The Lectures of Carl Wernicke Robert Miller

Home , Carl Wernicke, Globus pharyngis

An Outline of Psychiatry in Clinical Lectures

The Lectures of Carl Wernicke

Robert Miller · John Dennison Editors Translated by John Dennison · Robert Miller

123 An Outline of Psychiatry in Clinical Lectures

Robert Miller • John Dennison Editors

An Outline of Psychiatry in Clinical Lectures

The Lectures of Carl Wernicke

Translated by John Dennison and Robert Miller

Editors Robert Miller, ONZM, B.A., B.Sc., Ph.D. John Dennison, J.P., M.Sc., B.A. Freelance Researcher, and Honorary Research Fellow Fellow Department of Anatomy Otago University Otago Medical School Department of Psychological Medicine Dunedin , New Zealand University of Otago School of Medicine Wellington , New Zealand

ISBN 978-3-319-18050-2 ISBN 978-3-319-18051-9 (eBook) DOI 10.1007/978-3-319-18051-9

Library of Congress Control Number: 2015942521

Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) Dedication for This Translation

We want to dedicate this edited translation ﬁ rst to the memory of Valentin Braitenberg, still a source of inspiration. We also dedicate it, a triﬂ e late perhaps, to the many persons whose lives at times of crisis are depicted so graphically in Wernicke’s accounts of his patients. Robert Miller and John Dennison

F o r e w o r d

1894 Foreword

It was not originally my intention to let the present introduction to the clinical presentation of mental illnesses stand-alone. While its primary aim is to describe the organ within which such illness is expressed, it also conveys opinions that have developed very gradually, infl uenced by many years of clinical experience. Therefore its foundation and its integration lie within the facts taught in Pathology. Through the infl uence of an advocate of theoretical natural science, I let myself be persuaded to compile a stand-alone volume. His opinion, that the broader scientifi c community might take a lively interest in it, must be acknowledged as authoritative, compared with my own more reticent opinion. Thus, when this revered man of undoubted competence, and perhaps great foresight, sets his eyes on these apologetic intentions, may he at the same time receive my thanks for his stimulation and guidance over the hours and days of a chance encounter.

Breslau, August 1894 Carl Wernicke

F o r e w o r d

1906 Editor’s Foreword

In the middle of preparing this second edition, Carl Wernicke was overtaken by sudden death. His revision had proceeded only to the end of the second section. It was limited to a large number of small alterations and additions, entered in pencil alongside and beneath the text, without the form and content undergoing any other major metamorphosis. The review copy underwent a collaborative revision by Senior Physician Dr. Knapp, Wernicke’s fi rst Adjunct in Halle, and myself, and obviously private notes, not intended for publication, were removed. During this task I submitted our output to the widow of the deceased. As for the third, unrevised section, the unchanged copy came from the author himself. That Wernicke had nothing major to alter, and that this section still corresponded with the position of his previous opinions, was testifi ed by some few words, those of the mortally wounded man, worried about the fate of his life’s work, uttered on his deathbed: ‘Second edition as is’. Any introductory words about the work are superfl uous. It speaks for itself.

H. Liepmann

Preface to This Translation

This translation of Wernicke’s Grundriss der Psychiatrie grew from the long friendship one of us (R.M.) had with Valentin Braitenberg, born in 1926, and who died in October 2011. Valentin visited Otago, New Zealand, in 1993, and both of us (R.M. and K.J.D.) knew him and recognized in him a person of great generosity, wisdom, and integrity. On his bookshelf in Tübingen were many interesting volumes, some of historic signifi cance. One of them was the 1900 edition of Grundriss . The process of producing this translation was as follows: K.J.D. who is fl uent in German produced, lecture-by-lecture, a very literal translation of what Wernicke wrote and sent his versions to R.M., who has basic German, but wide knowledge of many areas of psychiatry and neuroscience. His task was to render these initial versions into fl uent modern scientifi c prose, aware of some of the scientifi c and clinical nuances which might not emerge in a literal translation. Sometimes, at this stage, words or concepts were unclear, so there were further exchanges of messages between the two of us to resolve uncertainties. In translating and editing Wernicke’s text, it has also been necessary to learn a great deal about the life and times when he was writing, and the existing knowledge upon which he drew. In the end, we both contributed to resolving uncertainties about concepts. As we went through Wernicke’s text, a number of editorial comments were inserted, initially as footnotes, to convey such understanding as we could gain, but which might not be obvious to today’s reader. These comments varied in length and subject matter from one lecture to another. We soon realized that many themes in the lectures recurred in successive lectures, gradually evolving and being developed. This makes his thinking appear fragmented, if the lectures are read sequentially. This is inevitable, given the context in which any series of clinical lectures has to be delivered, where the lecturer’s ideas must be presented in coordination with clinical cases as available (which may arise somewhat opportunistically). The fragmented appearance may also refl ect what was certainly a very pressured existence for the author, who probably preferred to spend his time on the ward, talking with patients, and analyzing clinical records, rather than perfecting the write-up of his ideas. We gain this impression from inaccuracies in some of his cited references, inconsistencies in his reasoning, and what seems to be a continuing struggle to fi nd adequate defi nitions for concepts which accounted best for what he saw in the clinic. As delivered, the lectures probably were not so fragmented for his original audience, for whom, we guess, each lecture would

xiii xiv Preface to This Translation have been followed by discussions which are not recorded. Nevertheless, the 1906 edition of Grundriss was a ‘work in progress’, which sadly never reached completion. It is plausible to suggest that he might have intended to write a comprehensive textbook of psychiatry, to fulfi l what was latent in Grundriss, just as his thought on the entire fi eld of neurological disorders was presented as his 1881 textbook, Lehrbuch der Gehirnkrankheiten. The fact that most of his thoughts on psychiatry are contained in the sometimes diffi - cult pages of Grundriss , rather than in a textbook, may have contributed to the neglect of his work, but it is also the reason why we have felt it necessary to write the extended editorial commentary, which follows the translation of Wernicke’s 41 lectures. To give what we hope is a clearer account of Wernicke’s thought, we decided that the editorial comments on each lecture should be re-grouped according to their subject matter and coordinated into this substantial editorial essay. This begins with a series of synopses about the subjects dominating each lecture, followed by discussion sections dealing with the numerous matters arising across the lecture series. These topics move from the medical scene in which Wernicke worked, clinical concepts of the day, Wernicke’s clinical, didactic, and personal style as far as we could discern it, the scientifi c concepts he used, his views on underlying philosophical issues, and, most important, a lengthy section on his unique clinical concepts. After that we move to Wernicke’s approach to classifying mental disorders and his style of reasoning, including what we identify (from a modern perspective) as fl aws in his reasoning. Later parts of the essay give details on his contemporaries whose work is cited, comments to clarify allusions made (mainly by his patients) to matters which would have been familiar in their day, and lastly, to clarify specifi c issues of terminology. This section came together at the very end of our work, when we compiled a long list of ‘problem words’ in both German and English and discussed how we could render them in a way which conveyed most accurately Wernicke’s intended meaning. To ensure that anything we write in our editorial commentary can be traced back to their source in Wernicke’s text, we identify the lecture in which each point is made (indicated as ‘L.’ plus a numeral, and our fi nal pagination). In addition, in indexing, we include not only items in Wernicke’s 1906 index (translated, and re-alphabetized, with our own pagination in bold typeface) but also, in the same index, items referring to this commentary (non-bold). Wernicke also gave many cross references between lectures in Grundriss , as footnotes. We retain these, but include them in the text, with our fi nal pagination. Occasionally, in our commentary, we cite other works, followed by corresponding page numbers (both within parentheses). To make our version fl ow well, we often condense superfl uities in Wernicke’s text. We often replace ‘the patient’ by a personal pronoun (‘his’, ‘her’ etc.). Abstract nouns are frequently replaced by concrete ones or verbal equivalents, and passive by active verbs. There are innumerable re-orderings of ideas within a sentence (inevitably, since sentences are constructed in different ways in the two languages), while retaining the original sense. Sometimes long sentences are split into two or more. When terms are used which are now part of today’s technical vocabulary, we use the familiar terms, Preface to This Translation xv

although, in our commentary, we sometimes discuss concepts, words, and how we choose to render them in English. We are alert to the possibility that concepts do not match words in equivalent ways in German and English. Sometimes, the same word is used in German, for what appear to be two different concepts. These may be related, but differ subtly, and can sometimes be distinguished as different words in English. The German word Krankheit is a case in point. Conversely we identify some German words (notably Ratlosigkeit, often rendered as ‘perplexity’) for which no truly equivalent word exists in English. In addition, inevitably, where Wernicke formulates new concepts, with no precedents, and no established terms, he resorts to analogies. In uncharted territory, use of analogy or metaphor is the only way forward, especially in mental abnormality. This necessity is discussed by R. Mojtabai in his 2000 article in History of Psychiatry (‘Delusion as Error: The History of a Metaphor’). When translating analogies we prefer abstract to concrete images, as having greater generality. As a priority, we have tried to capture Wernicke’s reasoning as accurately as possible, this being more important, we felt, than verbatim translation. Consequently, our translation is sometimes rather free. However, for some words, where we struggle to capture the meaning (perhaps when it is indeed ambiguous), we stick to a more literal translation (perhaps clarifi ed in our commentary). An example is the German noun cluster Organempfi ndung. (Noun clusters in German are not fully captured by adjective-noun pairs in English.) Of course, our attempt to convey Wernicke’s meaning depends on how well we understand his work. We have tried hard to grasp the subtlety of his reasoning but, at times, may have missed signifi cant points. At the time of fi nalizing our translation, our understanding still has some way to go. We apologize therefore for inaccuracies in our rendition. Wernicke’s text uses various forms of emphasis: italicization, quotation marks, and occasionally a third form of emphasis, not familiar in English— the ‘spacing out’ of letters which make up a word, and with slightly larger typeface—especially when introducing one of his favoured terms. In addition, to make his reasoning as clear as possible, we also often found it useful to add our own emphases, not present in the original. This again is perhaps inevitable, since infl ections in German as altered word endings can convey relationships within a sentence, which need to be conveyed in other ways in English. Sometimes we also add emphases to draw attention when the author introduces a new specialist term. Because of this, for all emphases, we have indicated those in Wernicke’s original as ‘[W]’, those which were editorial additions as ‘[Ed]’. All emphases involving ‘spacing out’ of letters are rendered as italics. In translating a work over 100 years old, we are aware of changes in sensitivity over terminology. We prefer a fl exible style, avoiding stereotyped ‘politically correct’ terms, but we do try to avoid some terms, such as the generic form, ‘the mentally ill’—and we usually prefer ‘psychiatric patient’ to ‘mental patient’. We have nevertheless tried to retain some of the fl avour of the time when Wernicke was writing. We see no need to adopt a ‘gender neutral’ style when using personal pronouns (this being a historical document); and for latinized terms based on Linnaeus’ binomial system, we retain the xvi Preface to This Translation upper case initial character for the fi rst word in the pair. In addition, we have tried to preserve an informal style, of lectures as they might have been delivered, rather than a more scholarly style, as might be found in a journal article. Wernicke’s original text gives references in footnotes to sources upon which he drew, but bibliographic details are often sketchy by modern standards and sometimes inaccurate in detail. In this edition, footnotes are not used. In Wernicke’s text, we indicate his citations by number, using the Vancouver system, with a list at the end of each lecture. Since his referencing is often incomplete, we have supplemented the references he gives in footnotes, with relevant publications of contemporary authors he often names without citing their publications. Sources referred to in our Editorial Commentary make up another reference list, appearing at the end of our commentary. Wernicke also used footnotes to make comments, which would break the fl ow of his argument, or to summarize the eventual outcome for a patient he has just presented. These comments are incorporated into his text (in parentheses, usually at a paragraph end) or in our editorial essay (identifi ed as ‘note’), and we omit some of the minor footnotes. Some of his cross references give no page numbers and are hard to identify, and some cross references are clearly to cases presented elsewhere to his students, rather than in earlier lectures of Grundriss . Sometimes these appear to be other lecture series (perhaps at a more elementary level), which his students would have attended. There are also many references to published clinical reports (Krankenvorstellungen aus der psychiatrischen Klinik in Breslau ).

Acknowledgments

We acknowledge, with thanks, insights we have gained on Wernicke and his ideas, either in correspondence or in personal discussion with the following: German Berrios, Eric Chen, Gerhard Heim, Andrzej Kiejna, Mario Lanzcik, Michael Molnar, Andrew Moscovitch, Almut Schüz, Surjo Soekadar. RM thanks Stephen Duncan for help at the proof-reading stage.

Wellington, New Zealand Robert Miller, ONZM, BA, BSc, PhD PhD (Glasgow) Dunedin, New Zealand John Dennison, JP, MSc, BA Introduction to This Translation

Carl Wernicke: Biographical Sketch

Carl Wernicke was born on 15 May 1848 at Tarnowitz, now south-central Poland (Silesia, at that time part of Prussia). His education included classical languages, since he sometimes uses Latin phrases, and in one instance a Greek one in his text, as if they were common knowledge for educated people. In 1870, he obtained a medical degree from the University of Breslau (Wrocław, to give it its contemporary Polish name), after which he studied for a year with Theodor Meynert (1833–1892) in Vienna. He is well known to English speakers as a pioneer of neurology. When newly trained as a physician, he made major contributions to the emerging concept that specifi c regions of the cerebral cortex served different psychic functions. He defi ned an area, now given his name, in the superior temporal gyrus on the left side, in which sensory memories of speech sounds are represented. This was documented by him in 1874, based partly on experiences gained in 1871, as a military surgeon during the Franco-Prussian war. In addition, in the late 1880s, he anticipated fi ndings of Sergei Korsakoff, in defi ning an amnesic syndrome found mainly in patients with chronic alcoholism, now known as the Wernicke-Kosakoff syndrome (Korsakoff’s psychosis or Wernicke’s encephalopathy). After his early success, he held various positions in neuropsychiatry— under Karl Westphal at the Charité Hospital in Berlin (1876–1878); in a private neuropsychiatry clinic he founded in Berlin until 1885; and from then until 1904 in Breslau, fi rst as associate professor, and from 1890, holding the chair in psychiatry at the university there. Patients he met early in his career in Breslau and in the Berlin period are mentioned in his clinical lectures. In later years his relationship with municipal authorities at Breslau became diffi cult, to the extent that, for some years, he was prevented from using patients for teaching purposes. In 1904 he moved to a chair at Halle. The psychiatric institute there had opened in 1891 explicitly for research and education, was administratively autonomous, and was the fi rst in Prussia to combine psychiatric and neuropathology wards [1]. Sadly, Wernicke died prematurely in 1905, from injuries sustained in a bicycling accident. His lectures on psychiatry were fi rst published in 1894, as Grundriss der Psychiatrie, a revision being produced in 1900, and he was revising another edition at the time of his death, published posthumously in 1906.

xvii xviii Introduction to This Translation

The original publication ran to only 176 pages, the fi rst 17 lectures of the fi nal version. In a footnote in the very last lecture of the 1906 edition, he writes, commenting on the outcome for a patient, ‘I must now put right these lines, written about ten years ago…’ The words ‘about ten years ago’, as in the 1900 edition, imply that drafts of even the last stage of Grundriss were being formulated before the partial edition of 1894. Grundriss is still read in the German-speaking world and indeed is republished from time to time (most recently in 2012). However, English speakers still know little of Wernicke as one who saw neurology and psychiatry as parts of a single discipline (as indeed they were when he was practising), and as a pioneer thinker about mental disorders. Several histo- rians of psychiatry who know Wernicke’s work well believe that had Wernicke lived longer and been able to develop his carefully considered, but incomplete ideas closer to the point where their full fruits were evident, psychiatry in the last century would have developed along very different lines, a view also expressed by Karl Leonhard, a successor to Wernicke of a later generation [2]. The idea that mental disorders should be defi ned in terms of categorical diagnoses, along the lines of diseases in general medicine, was not strong at the time of his fi rst edition, grew stronger in the mid-1890s with the publication of the 1896 edition of Kraepelin’s textbook of psychiatry, and was becoming a new orthodoxy by the time of Wernicke’s death. He himself was sceptical of contemporary attempts at classifi cation of mental disorders, and, although working within a medical paradigm, appears to struggle with the idea that the ‘disease model’ borrowed from general medicine dealt adequately with realities of mental disorders, as he saw them daily in his clinical practice. Wernicke was clearly exceptionally talented in both the detail and exact- ness of his observations, and his continual attempt to render those observations comprehensible within a wider conceptual framework. However, many basic facts about the nervous system (not least about the basic electrical and chemical signalling by nerve cells) were unknown at the time. Thus, any attempt at theorizing would necessarily often include imaginative leaps based on scanty evidence and vivid analogies. His theories and inferences, while often well ahead of their time, were sometimes far-fetched and lacked empirical support. For this reason his ideas were scorned by some, not least Karl Jaspers from Heidelberg, as Hirnmythologie (‘neuromythology’). Nonetheless what is presented in Grundriss includes such a bounty of ideas, some of which, in our view, are in advance of today’s psychiatry, that it is important that his work be better known to English speakers. A hundred years ago, an English translation by W.A.McCorn (Superintendent at Elizabeth General Hospital, N.J.) was produced, but is little known. According to a brief obituary of McCorn in 1904 [3], all 41 lectures were translated from the 1900 edition, and many appeared in Alienist and Neurologist . However, we have been unable to identify where many of the lectures were published (if indeed they were). In addition, the fi rst eight lectures were translated recently by Gage and Hickok [4]. In producing this complete edited English version of Introduction to This Translation xix

Wernicke’s 1906 edition , we feel immensely privileged to reveal to new readers the observations, ideas, and thought processes of one who was not only a superb clinician but also a profound scientiﬁ c thinker. In his day, there was of course already more than a century of careful observation and thought about the realities of mental disorder, yet we discern in Wernicke’s writing a freshness of approach, from an acute observer, and careful analyst, encountering many things as if for the ﬁ rst time, with an ‘innocent eye’ and freshness of mind, unburdened by the weight of a long, unassailable tradition. Thus, he impresses both of us, as an intrepid pioneer, in one of the most challenging areas of inquiry, where few others, before or since, could claim continuity with the broad sweep to the natural sciences. Although his work in psychiatry has been neglected, especially in the English- speaking world, its enduring impact is seen in several terms, now part of psychiatric vocabulary, which started with him, and in a distinct tradition, the Wernicke-Kleist-Leonhard school of psychiatric thought, especially in some European centres. We hope we have done justice to his work, bringing an up- to-date perspective on Grundriss, such as McCorn could not have achieved; that we have not imposed on Wernicke’s German text too much of our own perspective, which undoubtedly has its biases; and that we have not have not made too many misinterpretations.

Masterton, New Zealand Robert Miller Dunedin, New Zealand John Dennison

References

1. Engstrom EJ. Clinical psychiatry in imperial Germany. Ithaca: Cornell University Press; 2003. 2. Lanczik M, Keil G. Carl Wernicke’s localization theory and its signiﬁ cance for the development of scientiﬁ c psychiatry. Hist Psychiat. 1991;2(6):171–80. 3. Hughes CH, Hughes MR. Death of Dr McCorn. Alien Neurol. 1904;25:238. 4. Gage N, Hickok G. Multiregional cell assemblies, temporal binding and the representation of conceptual knowledge in cortex: A modern theory by a ‘classical’ neurologist, Carl Wernicke. Cortex. 2005;41(6):823–32. 5. Mojtabai R. Delusion as error: The history of a metaphor. Hist Psychiatry. 2000;11:3–14.

Contents

Part I Psycho-physiological Introduction

1 Lecture 1 ...... 3 2 Lecture 2 ...... 9 3 Lecture 3 ...... 15 4 Lecture 4 ...... 21 5 Lecture 5 ...... 25 6 Lecture 6 ...... 31 7 Lecture 7 ...... 37 8 Lecture 8 ...... 43

Part II The Paranoid States

9 Lecture 9 ...... 53 10 Lecture 10 ...... 59 11 Lecture 11 ...... 65 12 Lecture 12 ...... 71 13 Lecture 13 ...... 79 14 Lecture 14 ...... 85 15 Lecture 15 ...... 91 16 Lecture 16 ...... 97 17 Lecture 17 ...... 101

Part III Acute Psychoses and Defect States

18 Lecture 18 ...... 111 19 Lecture 19 ...... 117 20 Lecture 20 ...... 125

xxi xxii Contents

21 Lecture 21 ...... 133 22 Lecture 22 ...... 139 23 Lecture 23 ...... 145 24 Lecture 24 ...... 153 25 Lecture 25 ...... 165 26 Lecture 26 ...... 171 27 Lecture 27 ...... 179 28 Lecture 28 ...... 185 29 Lecture 29 ...... 195 30 Lecture 30 ...... 203 31 Lecture 31 ...... 215 32 Lecture 32 ...... 223 33 Lecture 33 ...... 235 34 Lecture 34 ...... 243 35 Lecture 35 ...... 259 36 Lecture 36 ...... 271 37 Lecture 37 ...... 279 38 Lecture 38 ...... 293 39 Lecture 39 ...... 301 40 Lecture 40 ...... 309 41 Lecture 41 ...... 321

Editorial Commentary ...... 331

Index ...... 459 P a r t I Psycho-physiological Introduction Lecture 1 1

• Mental illnesses are brain diseases; neverthe- attitude, medical knowledge of diseases did not less, they differ from them in practice go far beyond knowledge currently found among • Projection system and central fi elds of the lay public, when it treats coughing, palpita- projection tions, fever, jaundice, anaemia, and emaciation as • Association organ actual illnesses. This is precisely the current atti- • Brain disorders to be defi ned as diseases of the tude towards psychiatry, at least amongst the projection system; mental illnesses as propa- majority of ‘mad doctors’—its proponents. Even gated illnesses of the association organ for them, some specifi c symptoms form the very • Difference between primary and secondary essence of the disease—for example a depressed identifi cation in the case of speech mood, in the broadest sense, is the essence of melancholy; an elevated mood with excessive movements, that of mania, and so on. People now distinguish many such types of putative disease. Lecture However, since in Nature combinations of symptoms are far more diverse and complex, it has Gentlemen! been necessary to construct an artifi cial frame- Our subject here, learning about mental ill- work, sometimes more widely, and sometimes nesses, is essentially a branch of internal medi- more narrowly, accomplished by different cine which, because of its practical signifi cance observers in very different ways. Despite all and for other reasons of a more external nature, efforts to bring the cases of illness artifi cially into has required—and has received—special treat- one form fi tting within the framework, very many ment from time immemorial. Sadly, at the same cases remain that cannot be correctly assigned, time, it is an area that is backward in its develop- and in no way fi t the framework. Indeed, anyone ment: It presently stands at the point where the who can judge without bias, and has the neces- rest of medicine was, about a 100 years ago. You sary experience, will fi nd that the great majority will be aware that at that time an evolved pathol- of cases do not conform to the normal viewpoint. ogy in the modern sense, that is, one supported I readily concede that psychiatry has demon- by pathological disturbances in individual organs strated substantial progress in more recent times. of known function, still did not exist, and that, Work of men like Griesinger, H. Neumann, accordingly, people ascribed the status of disease Kahlbaum, Meynert, Emminghaus, and many classes to certain frequently-occurring symptoms, others has not been in vain. Yet even these out- albeit in widely varied groupings. Given such an standing researchers all still gave in to the

temptation of confusing individual symptoms organic brain diseases are examples of diseases with the essence of the illness; and the low level with mainly general symptoms in their clinical of average grasp of psychiatry even today can be picture. However, they are really characterized assessed by the prevailing doctrine of lunacy, the by the fact that focal symptoms occur along with merits of which are realized by a convenient general ones. Indeed, one can probably say that nomenclature. Psychiatry today enjoys more these focal symptoms are never totally absent. general recognition, and this would have been Mental illnesses in contrast present no such focal welcomed as progress by a thinker like Meynert symptoms. Accordingly, mental illnesses would [1 ] in his time. represent general diseases of the brain of a par- Under these circumstances, the teacher of psy- ticular type that are never accompanied by focal chiatry is strongly advised that if he wants to symptoms. apply standards of another discipline, he should Gentlemen! According to this defi nition, the stay just with symptoms. However his task is signifi cance that focal symptoms provide for our clearly predetermined for him: He should pro- subject matter makes it advisable to examine ceed as in the sister disciplines of medicine: their essence more closely. We learned from Symptoms must be deduced from familiar fea- Meynert that voluntary muscles and sensory tures of the diseased organ, in order to treat the organs are linked with the cerebral cortex by con- illness—in our case from features of the brain. ducting pathways that extend, in physiological Only in this way do we have the prospect of continuity, through the brain, the spinal cord, and obtaining a classifi cation and overview of symp- the peripheral nervous system. Meynert named toms which is both natural (i.e. based on the the aggregate of these pathways, where the ‘law nature of things) and, at the same time, of isolated conduction’ [Ed] predominates, the exhaustive. projection system [Ed], thus emphasizing the fact The assumption that mental illnesses are brain of physiological continuity, if not anatomical diseases is probably not contested by any special- continuity. More recent investigations have ist today. If we start from there, we must soon proven this to be valid in every respect—shown expand, by indicating brain diseases of a particu- clearly and unequivocally. Corresponding with lar type, and at a particular site, for they are in no the division of the cerebrum into two hemi- way identical with so-called organic brain dis- spheres, the projection system is also divided into eases with which we are far more familiar. Let us two halves, recognized by the connection of recall the division of brain diseases into focal motor control and sensibility of each half of the disease processes and general diseases; mental body with the opposite cerebral hemisphere (at illnesses will certainly not be subsumed under least generally speaking). The expression ‘pro- the former, but possibly under the latter. As is jection’ [W] is clearly borrowed from optics commonly known, two general diseases can be where, as here, the path of beams is traced pre- classed amongst organic brain diseases: meningi- cisely through a lens system: Despite all inter- tis and progressive paralysis. Nothing would stop vening nuclei along these projection pathways, us from proposing mental illnesses as a third cat- physiological continuity remains, and isolated egory of general disease. However, the question conduction is preserved throughout. The major- then arises: What are the fundamental character- ity of focal symptoms can easily be traced back istics that distinguish this third category of gen- to local lesions, or stimulation of conducting eral diseases of the brain from the other two links within these projection pathways. so-called organic diseases? A second series of focal symptoms can be To approach this question more closely, we traced back to the fact that the termination or ori- must focus for a moment on symptoms of brain gin of pathways in projection pathways is also diseases. All symptoms of brain diseases are, as localized to different points of the cerebral cor- we know, either focal or general. The two general tex. The law of isolated conduction prevails in diseases of the brain just mentioned amongst this way until these pathways join with 1 Lecture 1 5

corresponding regions of the cerebral cortex. Gentlemen! So far we have only incomplete Such end sites of afferent pathways—we will call information about the extent and exact location them projection fi elds [Ed]—are known to of projection fi elds in the cerebral cortex. include the optic tract in the occipital lobes; the However, as knowledge increases in this area, we acoustic tract in the temporal lobes; motor con- may well fi nd that the entire cerebral cortex is trol and sensibility of the leg, arm, and linguo- occupied by such projection fi elds. In searching facial region in the so-called upper, middle, and for a location representing the site of disease, will lower thirds of the pre- and post-central gyri; and we not then be led outside the brain and into the the motor speech pathway in Broca’s gyrus. It transcendental? Not by any means. Beyond the goes without saying that, for the type and manner projection fi elds there is another anatomical sub- of projection within this region, virtually the strate of great extent, to which we would quite same confi guration exists as is found in fi bres of reasonably attribute the seat of mental illnesses— a peripheral nerve. However, we know that in the system of the association fi bres, which serves projection fi elds of the cortex, regions lying far to connect projection fi elds one with another. If from one another in the periphery often become this applies, then mental disorders are the partic- united centrally to serve a common function. The ular diseases of this association organ. most familiar example of this is the projection Furthermore, certain focal illnesses of the fi eld of speech in Broca’s area. As we shall see brain already force us to assume that there are later, the principle of function must therefore disturbances in such association pathways; govern the type and manner of projections in the indeed they form a natural bridge to mental ill- cerebral cortex, because only a functioning ner- nesses. A case of this kind exists in certain rare vous system achieves connections with the cere- examples of the so-called transcortical aphasia. bral cortex. This is closely linked with a second Gentlemen! From time immemorial, people feature of the projection fi elds of the cortex: have hoped that aphasia might be a starting point These are also the sites where memory traces of which leads to an understanding of mental ill- the various functional products of the nervous nesses. That we have not been misled, and that system are located. Localization of such memory there are, on the contrary, actual cases of aphasia traces thus follows the same principle, so that, at closely connected with known mental illnesses, once, the occipital lobe forms the site of the is shown by the patient who we will now meet. visual memory traces; the temporal lobe that of You see before you a patient [2 , 3 ] who, even the acoustic memory traces; the so-called middle now, discernibly bears traces of a severe mental third of the central gyri (the arm region) contains illness that he survived in the years 1885–1889. memory traces of tactile impressions acquired by He stands and moves with a fi xed gait, which, the hand. Impairment of such predetermined however, does not stop him from working as a classes of memory traces also determines focal cabinetmaker, readily providing for himself and symptoms of brain diseases. his family. Any questions that we direct to him Focal symptoms appear consistently in the remain unanswered or are answered only by ges- form of disturbed functioning of the projection tures. In fact, he is completely mute, and for system—in its pathways, or in the projection 5 years has not been capable of uttering a sound. fi elds of the cortex. Therefore, given that focal He understands everything that I say to him, as symptoms of the brain can be collectively traced you can clearly see from his gestures and his per- back to functional disturbances of the projection forming instructions given to him. However, if I systems and their destinations in various projec- ask other questions or requests of him, he clearly tion fi elds of the cortex, then mental illnesses are indicates that he does not understand them. He distinguished from the other two so-called thus shows quite explicitly the extent (within a organic general diseases of the brain because in certain range, yet always the same) to which he the latter the projection systems and projection understands speech, while he has totally lost the fi elds are not [W] affected. motor ability to speak. 6 1 Lecture 1

This condition of total motor aphasia and par- of normal brain function? There is only one tial sensory aphasia has developed out of a cer- explanation—the function of those nerve path- tain mental illness that I will provisionally call ways, which are activated between the two pro- motility psychosis [Ed]. This has remained as a jection fi elds, must be disturbed. Thus, the mental lasting defi cit. In the course of this illness, mut- disorder appears to us as a disease of the associa- ism and verbigeration—two psychotic symptoms tion organ. However, I remind you that, in the that likewise arise in the speech area—had tem- common account of aphasia which we already porarily occurred earlier in the course of his use, such association pathways (the sensory illness. speech pathway as , and the motor speech path- Now, if we seek a more detailed understand- way mb ,) are thought to continue beyond the cor- ing of this relationship, we must target the vari- tical sites (projection fi elds), s and m , to a ous forms of aphasia established by clinical supposed Conceptualization Centre B . The trans- observation. To this end, follow me for an instant cortical pathways sB and Bm are nothing but into the related area of the so-called organic brain association pathways, and so the site of malfunc- diseases. tion must be in their region, betraying itself by Two projection fi elds of speech are known to the patient’s inappropriate answer. Nevertheless, us—one motor, and the other sensory. The motor each mental disorder, insofar as it comes to light (m ) is the origin of the motor speech pathway through a patient’s incorrect spoken words, is, for (mb ), part of the projection system that leads to us, an example of transcortical aphasia. The the nerve nuclei of the extended spinal cord remarkable case of aphasia as a consequence of a needed for speech. At the same time it is the site mental illness, from which I started, immediately of memory traces of movements taking place suggests the hypothesis that in some circum- during the act of speech or of conceiving speech stances all the Bm pathways and a great part of movement. The sensory speech fi eld ( s ) contains the sB pathways may be interrupted during the the central ending of the sensory speech pathway course of the illness. Then a genuine aphasia, of ( as ) and thus of the auditory nerves; but it is, at the same type as in our patient, can result. the same time, the site of memory traces of Nomination of a Conceptualization Centre B speech sounds or, as they have been called since in the aphasia schema has often been misunder- Helmholtz, acoustic traces of words. The clinical stood. However, the impossibility of avoiding it, picture of motor or sensory aphasia arises accord- and why it is necessary, is demonstrated as fol- ing to whether the motor or the sensory projec- lows: Sensory aphasia by destruction of the pro- tion fi eld is destroyed. jection fi eld s —cortical sensory aphasia, as I call However, if we now stand aside from our it—is characterized by memory traces of speech patient who, after all, is unique, then generally, sounds having been misplaced by the patient and, mentally ill persons are not aphasic. Normally, in as a consequence, words heard are no longer rec- psychiatric patients the sensory speech pathway ognized. However, for understanding speech, and the sensory speech fi eld are intact—they can obviously more is required than just recognition understand everything that people say to them. of word sounds: This must be connected with the They are also in full possession of their motor corresponding meaning. If we distinguish speech ability, insofar as it depends on integrity between a word and its conceptualization, then of the motor speech pathway and the motor pro- we can only hypothesize that some pathway leads jection fi eld. Nevertheless, we do encounter the via the cortical centre s to other cortical regions remarkable phenomenon where responses of that represent the associated concept. In truth, mental patients are often nonsensical, and appear this supposed Conceptualization Centre is dis- to bear only a remote or non-existent relationship tributed amongst cortical sites far removed from with the question posed. How is this to be one another. Consequently, for understanding explained, if we still assume that the correspond- speech, we need to distinguish two totally differing correct answer refl ects the usual expression ent processes. One, the recognition of word- sound References 7 images, is based on known functions of the pro- predominantly transcortical character of the dis- jection fi eld s ; we shall call it primary identifi ca- ease is valid. tion [W]. The other process, the sound of the Gentlemen! Comparison of aphasia with word by which the concept is identifi ed, is based speech symptoms in this mentally ill patient on functioning of association pathways and that teaches us that disturbance of secondary identifi - of the supposed Conceptualization Centre. We cation can be a feature common to both mental will designate it as secondary identifi cation [W]. illnesses and certain cases of aphasia. If we compare the whole process to the forward- Concurrence of the two diseases can be explained ing of a telegram, as others have done, then s is by changes in the same site in the transcortical or the station where the telegram arrives, although association pathways; but we take note of their the actual recipient is envisaged as B . The rela- difference: Mental illness selectively affects such tionship between B and the motor projection fi eld pathways by themselves, while focal disease proof speech at m is exactly the same: Here too B is cesses destroy just discrete portions of these the actual sender, while m is the telegraph station pathways. In exceptional cases, the sum total of that transmits the telegram. In other words: The individually affected pathways may achieve the meaning—the conceptualization of the word— same effect as focal processes, and a transcortical comes fi rst, and this requires transmission along aphasia may then proceed out of a mental illness. anatomical pathways to the motor projection Our patient demonstrates that such a case can fi eld m , so that the word is spoken. actually occur. If we designate the reciprocal connections Thus we postulate that, apart from the particu- from B to m as secondary identifi cation, which lar site, there is a particular type [W] of illness. we can do by analogy, then we can conclude that As in degenerative neuritis, this type of illness expressions uttered by a mentally-ill person, distinguishes individuals to some extent by other which seem strange to us, are signs of disturbed concomitant symptoms, and, by analogy with secondary identifi cation. degenerative neuritis, according to the principle Progressive paralysis must be assigned a of differences in function. totally exceptional position among mental illnesses; here, it can even be classed amongst organic brain diseases. However, it is undoubt- References edly also a mental illness. In the most common cases, where it shows clear-cut focal symptoms, 1. Meynert T. Klinische Vorlesungen über Psychiatrie auf wissenschaftlichen Grundlagen für Studirende und discrete lesions are also demonstrable in which Aerzte, Juristen und Psychologen. Vienna: Braumüller; an otherwise-diffuse disease process spreads to 1890. the projection system and the projection fi elds. 2. Verhandlungen des Congresses für Innere Medizin; Occasionally however, there are cases of pro- Neunter Congress; 1890 Apr 15–18; Vienna, Austria. Wiesbaden: JF Bergmann; 1890. p. 273. gressive paralysis where there are no more than 3. Heilbronner K. Aphasie und Geisteskrankheit. hints of such focal symptoms; in these cases, the Psychiatr Abh. 1896;1:33. Lecture 2 2

• To replace the Conceptualization Centre in initial stage of our understanding. In the last the speech schema by arbitrary, localized lecture, I was able to take you back to its true apperceptions meaning, but only in outline. Let me explain this • Registration and objective in the speech allusion in more detail. schema As already mentioned when discussing the • Generalization of the speech schema central projection fi eld, we can take it as estab- • Types of movement: expressive, reactive, and lished that memory traces and ideas are localized, initiative movements that is, they are linked, according to their content, • Disturbance of secondary identifi cation is with different locations in the cerebral cortex. induced by psychosensory, psychomotor, or Apart from such localization in the aphasia intrapsychic means schema, one can reasonably regard the receiver and sender of those telegrams as being linked to the notional Conceptualization Centre B , that is, with all the rest of the cerebral cortex and, as we Lecture shall see, its system of association connections. This would artifi cially separate the two projec- Gentlemen! tion fi elds s and m from the totality of all other So far, restricting our attention to the area of projection fi elds. Such separation within the cor- speech, we have contrasted brain disease and tex is the basis for differentiating the areas for the mental illness. Speech pathology is one of the two projection fi elds s and m (whether we stress best understood topics amongst brain diseases. their subcortical links or their transcortical links Likewise, spoken expressions encompass so beyond the projection fi elds). In this illustration, many of the symptoms of mental illnesses that by the anatomical view was that the aggregate of themselves they entitle us to view mental patients transcortical pathways sB and mB formed dis- from this sole perspective. Nevertheless, I hope crete pathways vulnerable to discrete lesions that in the following more extensive discussion, localized to the neighbourhood of the two projec- your understanding will be aided by starting from tion fi elds, while beyond there the pathways had the simplifi ed conditions of our example. to be seen as radiating out to many disparate We must examine further the (arbitrary) fi c- areas of the cerebral cortex. The discovery of the tion of the notional Conceptualization Centre B . clinical picture of transcortical motor and sen- As our knowledge of aphasia has developed, sory aphasia seemingly relied by sheer chance on this preliminary term was clearly essential at an the fact that these lesions appeared to occupy

precisely the postulated site. It is easily grasped the entire symptomatology of mental illnesses. that these rare cases were initially attributed to Instead of projection fi elds of speech, we have focal diseases of the brain. On the other hand, only to insert any other projection fi eld. In place observation of the patient I already introduced to of spoken expression, substitute any randomly you proved that such clinical pictures can arise expressed movement, and m represents the pro- during the course of a typical mental illness, thus jection fi eld in question, depending on whether forming a natural transition to mental illnesses. the movement takes place in arm, leg, trunk, etc. It is essential for our purpose that we go As is generally known, central projection fi elds beyond such rare occurrences. However, if we for such movements are contained in the so- called stay with that initial example, and hold fast to the motor zone of the cerebral cortex. Instead of the principle of localized representation, then we can sensory speech fi eld, the projection fi eld for any conveniently split the centre B into two localized arbitrary sensory awareness could take its place. representations linked by an association path- Just the same takes place in vision, for example, way: We shall call them A and Z. A , the source as in understanding the speech sounds a person representation [W], is linked with the sensory utters. By this means, primary identifi cation speech fi eld by an association pathway sA. Z , the occurs in the central projection fi eld of the visual destination representation [W], is linked with the system, in order to comprehend what is seen; but motor projection fi eld for speech by an identical transmission is required to other projection fi elds pathway Zm. AZ is the association pathway (for secondary identifi cation). Without this sec- between A and Z . Altering the schema in such a ondary process, the visual impression is lost to the way corresponds to some extent to processing of recipient, remaining unintelligible, just as in the an arithmetical problem presented to a patient: case of transcortical sensory aphasia for the sense Understanding the problem takes place as regis- of hearing. The same is true for all sensory impres- tration, in A ; the solution corresponds with the sions, as a little thought will confi rm. destination representation Z ; and only when the We quickly see that such a generalization is solution is found does activation of m take place. permitted—indeed recommended—by a more Between task and solution, complex thought pro- detailed look at our original example. The answer cesses can proceed, from which it becomes clear that I expect from the patient need not be spo- that the association pathway AZ itself can be ken—it can be given to me in writing or through regarded as subdivided many times over. We silent facial expressions and gestures, or by need not assume that the entire process normally employing any arbitrary response. Depending on follows a set pattern, virtually in preformed path- the muscles used for performance, the projection ways, so that the result is predictable. However, fi eld m will have different impact, and correspond we can tentatively assume that it behaves in just with different cortical sites. In other words, my this manner in response to any random question; question and my task can be carried out without a understanding the question is represented in A , word being uttered, whether in writing, or the meaning of the answer by Z , and the interme- through the spoken word, by expressive hand diate in-series pathway AZ makes sense of the movements and so on. case, so that the answer develops from a more or I said earlier that our schema, with its modifi - less simple deliberation. If we do not expect a cations, can be used to derive the entire symp- speaker to lead us astray, then we must recognize tomatology of a psychiatric patient. I should have that in this case, in a normal person, answers will expressed myself more precisely, by referring to arise in a totally determined manner, to be pre- symptoms just in so far as they are shown in dicted with approximate accuracy. The regularity that patient’s movements. However, this limita- hereby observed is based, as we shall see later, on tion is necessary only if we subtract from those the principle of ‘well-worn pathways’ [Ed]. movements (admittedly using layman’s terms This example provides opportunity for expan- and manner of understanding) speech, facial sion, which can become a founding principle for expressions, demeanour, and all those gestures 2 Lecture 2 11 included in such an expression. Yet even in those this classifi cation clearly has the advantage of cases, everything can be reduced to movement, encompassing the totality of all possible move- by which we assess the internal processing of a ments, and is thus preferable to Meynert’s [ 1 ] patient; and for scientifi c observation, to disre- classifi cation (however far-reaching and fruitful gard this fact might be a real error. The more the latter proves to be in other ways) into move- experience you have with psychiatric patients, ments of defence and attack. However, our clas- and come to recognize their symptoms, the more sifi cation fails in one respect and needs you become convinced that, in the end, there is improvement, in that sharp separation of the three nothing else to fi nd and observe, than movement, different types of movement is often impossible. and that the whole pathology of the mentally ill Inevitably some movements in one area fall also consists of nothing more than peculiarities of into another area, so that, depending on the their motor behaviour; for obviously, in a given observer’s point of view, there is dispute over the case, a breakdown in movement can be just as class to which a particular example of movement characteristic as previously intact movements. belongs. Despite this, we provisionally retain the We exclude here only intentional movements classifi cation, because it proves useful in the psy- of which other people are aware before they chiatry clinic. reach the consciousness of the patient himself or By the term ‘expressive movements’ [Ed], we herself. If these movements amount to speech, mean, above all, movements through which peo- we face the same situation although more tangi- ple’s Affect and frame of mind can be recog- bly and obviously than for other movements. nized. Indeed, speech movements primarily serve Symptomatology of psychiatric patients there- this purpose, although not exclusively; and inso- fore has movements as its focus, insofar as they far as they serve such a purpose, we should appear to be functions of the organ of conscious- include speech movements in the broadest sense, ness, in other words, the organ of association. for example, wails and moans of pain. Most Here we encounter the only limitation on the gen- exclamations, as is well known, are words that erality of the above sentence: Of course, some serve this purpose very well. Laughing and whin- movements are independent of consciousness, ing are specifi c expressive movements, as are all such as those controlled by the autonomic ner- facial expressions. Moreover, expression in the vous system, those of the heart, respiration, ves- face, even when it is not [W] in motion, arises sel walls, and viscera; and most refl ex movements from particular muscle actions; likewise posture belong here. As we will see later, these move- of the whole body, by the same token, is expres- ments can also be affected in mental patients, sive, just as are words or facial expressions, in although they do not form the actual focus of revealing a person’s state of mind and emotional observation. We will further fi nd that, in odd state. Movements of the entire body serving to cases, shifts of body temperature and, in almost express joy, cheerfulness, high spirits, satisfac- all cases, of feeding pattern as expressed by body tion, scorn, anger, fear, grief, anguish, despair, mass are important symptoms. However the hope, hatred, and love are familiar and suffi - exceptions are minor, and should be seen as sec- ciently expressive that it would be superfl uous to ondary sequelae [Ed], which consistently depend describe them here. Normally the face of an alert on the patient’s movements. man is continually enlivened by an expression; so Provisionally then, we can draw an abstrac- we recognize lack [Ed] of expression as a signifi - tion from the numerous exceptions, and can thus cant symptom. focus more closely on movements as functions of ‘Reactive movements’ [Ed] are those arising the organ of consciousness. This requires us to from actual external stimuli. When a person classify movements in a pragmatic way. We can answers a question, apart from the content of the conveniently differentiate between ‘expressive reply, the answer can always be viewed as a reac- movements’ [Ed], ‘reactive movements’ [Ed], tive movement. Moreover an answer that is not and ‘initiative movements’ [Ed]. As we shall see, made up of words but of other gestures—when, 12 2 Lecture 2 for example, the person questioned puts his fi n- Nervous excitation, which takes place along ger to his lips in a meaningful manner—comes the pathway sAZm can be likened to a refl ex pro- under the defi nition of a reactive movement. cess, and we can designate this pathway as a Failure to answer can, in many cases, be taken as ‘psychic refl ex arc’ [W]. The movement activated a signifi cant symptom. Amongst reactive move- from m then appears as the result—a discernible ments of particular importance in the psychiatric consequence—of this activation. Clinical meth- clinic are behaviour of patients: during a physical ods in psychiatry consist of studying the end examination; towards the minor services of the result in order to reveal the process from which it waiting staff; to requests of any kind; to the originates. approach and reception of the doctor; and to the You will notice at once that it is actually only whole unfamiliar situation in rooms of an institu- reactive movements that can be compared with tion—these merit particular consideration. In refl ex processes in the manner outlined. These addition, expressions of movement that are may, as in the initial example, be a spoken word essential to gratifying bodily needs (even when or other arbitrary movement; it is always taken as they can be traced back to internal stimuli) must completely spontaneous, yet still the conse- be regarded as reactive movements. It may, how- quence of an external stimulus—one based again ever, be equally valid to include the last-named on motor processes. However, one can ask: What class of movement amongst initiative move- is the situation for the other types of movement— ments, and again, many previously mentioned expressive movements and initiative movements? movements can be classed as expressive move- Obviously, these can be seen from the same per- ments. In any case it can be reiterated that, in psy- spective; for, quite apart from the question raised chiatric patients, absence of reactive movements about initiative movements, whether they arise is often just as characteristic and valuable as a totally without external triggers, we can fairly symptom, as their aberrant modifi cation. replace external stimuli by memory traces of past Amongst ‘initiative movements’ [Ed] we refer stimuli. When an external stimulus is absent, we to all movements driven by personal motives, can regard such memory traces as initial links, rather than by an external stimulus. This negative with movement as the terminal link in the psy- defi nition includes some expressive movements, chic refl ex arc. We can even go so far as to regard and some reactive movements. In consequence, movement in progress as evidence of this assump- for expressive movements, we should always tion. Movement without any [Ed] kind of cause is assess the extent to which they belong with initia- inconceivable; yet a visible cause is [W] clearly tive or reactive movements. One might ask absent. Therefore only a form of ‘energy’, accu- whether there are [W] actual initiative move- mulated somewhere, can induce movement that ments, that is, ones which arise without any does actually arise. As we will see later, memory external stimulus, since usually some kind of traces are [W] such sources of accumulated external trigger can be found for virtually any energy. spontaneous action. However, since such events From these preliminary remarks we can add to often are no more than opportune moments con- our learning about aberrant disturbance of move- nected to prevailing internal motives, identifying ment observed in mentally ill people. They are all them as initiative movements can be justifi ed. based on disturbance of secondary identifi cation, In general, initiative movements tend to consist as demonstrated above. However, I remind you of whole series of individual movements, and that we have considered not only the relationship can then be referred to as actions. The whole from s to A , the projection fi eld nearest to regis- behaviour, demeanour, and ‘the doing and the tration, but also the activation of Z to the motor allowing’ [W] of an individual in given situa- projection fi eld m , operating in the reverse directions—collectively, all his expressions by means tion. We were justifi ed in this shift because the of movement—insofar as they are neither expres- pathway Zm is an association pathway, as is sA , sive nor reactive movements, belong amongst the and the physical processes taking place through initiative movements. such association pathways should always be the Reference 13 same, regardless of their direction. In like man- We will always be forced, on practical grounds, ner we can also include the relationship between to distinguish two totally different aspects of A and Z for secondary identifi cation. speech: active movement as such, and the content Since all these are nerve pathways, abnormali- of the spoken words. However, since there may ties of excitability or ability to conduct signals are be abnormalities of active movements or, as we always the sole basis for disturbance of secondary can label it, the formal part of speech, then it is identifi cation. Three cases cover all possibilities: more accurate to use the word parakinesia only in reduced excitability or conduction ability; this narrower sense. Examples are the symptom increased excitability; and aberrant excitability. of compulsive speech and the monotonous word We label the pathway sA as psychosensory; Zm as repetition—the so-called verbigeration. The psychomotor; and ZA as intrapsychic. The possi- same refl ection that the content portion must be ble cases can then be summarized as follows: differentiated from the formal part of a movement applies to all expressive movements, and Psychosensory Psychomotor Intrapsychic also to reactive and initiative movements. Since Anaesthesia Akinesia Loss of function patient s may gabble a great deal of nonsense Hyperaesthesia Hyperkinesia Hyperfunction using formally correct speech, then the feelings Paraesthesia Parakinesia Parafunction expressed, despite having quite correct form, can still be aberrant; and so can their actions be for- One could dispute this tabulation on the mally correct but incorrect in content. In these grounds that these are nothing more than distur- cases therefore, we need not assume any disturbances of movement we encounter in mental bance of psychomotor identifi cation, but are patients, as I myself emphasized, and that there- forced to seek disturbance further back in the fore, the totality of symptoms is exhausted just refl ex arc. This corresponds to common idiom, by three cases—hyperkinesia, akinesia, and para- and the habit of completely ignoring a patient’s kinesia. This objection is partly true, and requires mechanism of sharing his or her internal thoughts, a thorough explanation. The easiest way to do expressing feelings, and so on as self-evident. this is to return to our starting point, the example After this discussion, it becomes comprehensible of speech. When a patient is silent and we would that, among mentally-ill persons, we frequently expect him or her to speak, we can interpret this see symptoms of disturbed content identifi cation, symptom as a circumscribed form of akinesia even though the movement mechanism itself is restricted to speech. If the presenting symptom is fully intact. an urge to talk, then by the same token this is a circumscribed form of hyperkinesia. If, on the other hand, his or her response is nonsensical Reference speech, we could rightly regard this as a symptom of parakinesia. Here, however, one would 1. Meynert Th. Sammlung von popular- wissenschaftlichen Vorträgen über den Bau und die need a more detailed account for each of these, Leistungen des Gehirns. Vienna; Wilhelm Braumüller; because misunderstanding is to be expected. 1892. Lecture 3 3

• Nature of memory images principle of localized memory images: These are • Retinal after-images and remembered visual clinical instances of sensory and motor aphasia, images and cases of the so-called tactile anaesthesia of • The hypothesis of special sense cells and the hand. The former are probably well known memory cells is insuffi cient as an explanation by now, so I need not go into detail; but the • Local signs in the retina importance of the latter is debated. Two related • Visual representations sets of facts provide support. On the one hand, cases have been seen where circumscribed cortical damage in the middle third of the two central gyri leads to permanent defi cit, where the hand Lecture fails to recognize objects by touch, although disturbance of sensation itself can barely be Gentlemen! detected. On the other hand, there are cases of Before we look more closely at symptoms of spinal or peripheral disease where sensitivity, mental illnesses we must revisit the aforemen- and—I stress—also muscle and position sense, tioned Conceptualization Centre or, more pre- is most severely disrupted, with only minor dis- cisely, those localized memory images. I hope turbance of tactile perception. The last-named that, on refl ection, you conclude that this is not cases demonstrate to some extent that even a the alleged ‘Conceptualization Centre’ [Ed] said very weak and patchy projection system can still to have a defi nite localization, but probably the conduct messages to the brain suffi cient to sup- concepts themselves. port primary identifi cation, provided the central In introducing my fi rst lecture, I presented as a projection fi elds and therefore the remembered statement of fact, confi rmed in pathological images—tactile images, as we can call them cases, that central projection fi elds are localized here—are preserved. However, cases of the fi r s t to different areas of the cerebral cortex. We must [Ed] type can be based only on loss of primary recognize that such fi elds are also sites of remem- identifi cation itself, since disturbance of projec- bered images; and it follows from this that these tion pathways themselves is clearly minimal. memory images also have defi nite locations. The principle that remembered images are local- However, let us examine these memory images ized to corresponding projection fi elds is estab- more closely. lished beyond all doubt by such facts, and thus First, I want to touch briefl y on clinical this principle can be fairly applied to all projec- facts which, in my opinion, totally validate the tion fi elds.

If we return to our example of the organ of visual agnosia occurs. Just as for an individual speech, we fi nd that the process of recognition born blind, so too for one born deaf, the content [W]—primary identifi cation (see above)— of consciousness totally lacks an entire category requires solid ownership of memory images. The of memory images originating from the sense of question then arises: How should one view such hearing. In partial cortical defi ciencies, as ownership? Evidently this concerns a special observed from time to time in those who are characteristic of the nervous system, that it under- mentally defective from birth and also have sen- goes lasting change in response to temporary sory defi cits such as deafness, there is a similar stimuli, a property we call memory [W]. Such lack of remembered images due to abnormal memory is seen, for example, in the fact that development of central projection fi elds. No less Faradic excitability of a nerve can be increased instructive in this connection is a comparison by frequent electrical stimulation [ 1 ]. The same with animal brains. Humans have only a vestigial stimulation then becomes more effective if it has olfactory bulb, whereas many mammalian spe- often been administered previously; and there- cies have an olfactory bulb occupying a signifi - fore lasting change exists in the nerve as a result cant part of their cerebral hemispheres, with a of the previous history of transient stimulation. separate ventricle and separate surface gyri. All training is based on the same principle, for Everyday observation shows just how different is any form of learning: ‘Practice makes perfect’ the consciousness of such animals, for example [Ed]. Pathways that are initially hard to access that of a dog from our own. It appears to be full become more fi rmly trodden in with each new of remembered olfactory images, and the animal, training experience—you could say that they are snuffl ing here and there, revels in all its joyful ‘moulded by experience’ [W]. Thus when a frame of mind, like the gourmet at table, or the memory of this sort reaches a person’s awareness eye of an artist beholding beautiful forms. The via nerve pathways, it occurs specifi cally in nerve content of consciousness shown in this way cell bodies. A refl ex in the spinal cord mediated depends on the state of the projection system and via its neuronal cell bodies takes place more eas- central projection fi elds, a relationship suggest- ily the more frequently it has previously been ing the following principle: Consciousness is a elicited; and it has been demonstrated by studies function of the central projection fi elds. If the of Ward [ 2], Jarisch and Schiff [ 3], and others assumption—that projection fi elds occupy the that this is a special property of the neuronal peri- entire cortical mantle—is confi rmed, then the karya. It would be reasonable to relate after- corollary follows: Consciousness is a function of images of the retina mainly to their ganglion the cortical mantle. cells. Similarly, in the cerebral cortex you would We can get a better grasp of the notion of a ascribe changes persisting long after instanta- memory image if we use a defi nite example, neous stimulation, which we call memory such as a remembered image of a visual sensa- images, primarily to neuronal cell bodies. tion. For this, comparison with retinal after- After this, it appears obvious that possession images is particularly instructive, since these of such remembered images—contents of con- belong to the same sensory modality. How far is sciousness [W], we might say—depends directly the comparison accurate and justifi ed? As men- on the projection system and sense organs by tioned, we can trace retinal after-images specifi - which those images were obtained. The con- cally to long- lasting excitation of retinal ganglion sciousness of a person with poor eyesight, or one cells by a stimulus; and, by special arrangements with generally defi cient senses, is thus quite dif- of such excited cells, an image is formed and ferent from that of a normal person. An individ- referred to a particular position in space. This ual born blind will certainly have no remembered image is of limited duration. Let us assume that images of visual sensation. Were his sight to be similar cells—call them ‘perception cells’ [W]— surgically healed, this would provide a situation are also to be found in central projection fi elds of we otherwise see only when the pathology of the optic nerve, where projection fi bres end. 3 Lecture 3 17

Could this assumption—that the memory image differentiating between perception-related and exists in resonating excitation of such perceptual recall-related cellular elements, and ascribing cells—be suffi cient to explain the apparent dif- the feature of memory only to the latter. Only ference from retinal after-images? Many things those elements in the cortical projection area contradict this. In my experience at least, the serving perception should correspond to points characteristic referral to a preferred position in in the retina. However, it is not just this assump- space is totally different from that of remem- tion which raises diffi culties. The difference bered visual images. The latter seem to be spa- between a perceptual image and a remembered tially referred only insofar as they always occupy image arises not so much from the diversity of a defi nite position in a particular person. They active elements but from the fact that the pat- also appear to be of unlimited duration, a differ- terning [Ed] of retinal elements or the form of ence that is especially diffi cult to explain. You retinal excitation [W] in the various examples is would hardly imagine that the same perceptual different, while mainly the same retinal elements cell, once recruited, would maintain its long- cooperate to create a memory image. It is just the lasting state of activation, but rather that it could memory of that previous patterning of function- soon be sensitized by a totally different stimulus. ing elements, that is, the form [Ed] of activation, You would expect it to be held in the same man- which makes up the psychological concept of a ner as a retinal image, and, at least, subsequent memory image. I agree entirely with Sachs [4 ] activation would always wipe out the preceding and Goldscheider [5 ] that only by assuming that activation. Let us assume for example that we functional links are acquired between simultane- are dealing with the sensory memory image of a ously excited perceptual elements using existing letter or a number. Assume also that retinal connections can one explain the specifi c mem- images falling on the position of clearest vision, ory for respective forms of retinal images, or close to it, will mostly be those leading to defi ned by patterned stimulation of retinal development of such remembered images. points. When the same pattern of stimulation There, not only is the greatest number of sensory returns, and the retinal image, is again detected, elements to be found, but, in this region, photo- one can envisage, as did Ziehen [6 ], a process receptors for images are also laid out with par- whereby the remembered image is reactivated ticular precision, so that the sharpest images from perceptual elements, because only this arise there. Correspondingly Nature has arranged combination of cells has been ‘tuned in’ [Ed], to it such that, for visual impressions that attract some extent, to this pattern of activation (some- our attention, we locate the point of clearest what like sound resonators respond only to cer- vision quite involuntarily by appropriate eye tain tonal combinations). However, this analogy movements—a compulsion which, even for still requires us to explain this ‘predisposition’ adults, makes it diffi cult for anyone to exert total [W]; and for this we need connection formation conscious control over their eye movements. As between perceptual elements by nerve fi bres, a consequence of this, many retinal elements that that is, the process of association. We shall see previously represented the image of the letter are later that association of various sensory impres- soon engaged in forming a new image, e.g. of the sions is always concluded when they take place number, and correspondingly so also are cells of at the same time; in exactly the same way we can the central projection fi eld serving perception. assume here that simultaneously excited percep- Assume (as highly likely) that the point of clear- tion cells serving sensation become associated est vision in the retina corresponds to a consider- with one another; and because renewal of the able area in the central projection fi eld. Under same sensory impression repeats the same pat- these circumstances, the diffi culty of explaining terning, these perception cells remain associ- the memory of the image by a particular cellular ated. A remembered image might then be nothing memory therefore remains unchanged. There other than an acquired association of perceptual have been attempts to avoid the diffi culty by elements of the central projection fi eld. 18 3 Lecture 3

You see, gentlemen, that with this concept, we incorporate the brilliant hypothesis of H. Sachs. need not assume the existence of any special According to this, so-called ‘local signs’ [Ed] of memory cells. We can reach the same conclusion retinal points are determined by two measures, in a totally different way: Here I stress only that it namely the meridian on which they lie, and their would not be a convincing account of the discrep- distance from the midpoint. A specifi c combina- ancies between sensory activity and memory tion of muscle activity is required for each half of images if only perceptual elements were involved, the retinal meridian; through interaction of mus- and always corresponded with certain points in cles, rotation of the eyeball brings the macula in the retina. The fact that remembered images have register with the light source. This combination no defi nite projection in space, as do after- of muscle activation remains the same at all images, would remain incomprehensible. Finally, points on the same half-meridian, but the inten- one can take the structure of central projection sity of nervous activity varies, and increases with fi elds in the cerebral cortex as a counterargument. the distance of the retinal point from the fovea A simple layer of ganglion cells, all linked to pro- centralis [W]. On the other hand, for different jection fi bres, might satisfy the current assump- half-meridians the muscle combination is always tion. However, in the cerebral cortex we fi nd such different. Differences in image size for fi xed a large number of nerve cells layered one over objects therefore require no more than shift in another in the visual projection fi eld of the occip- intensity of nervous activity; the anatomical fac- ital cortex—more than anywhere else—that they tor, the specifi c combination of different muscle far exceed the number of projection fi bres. All activations, stays the same. In turn, this behavior these thoughts will have to be examined in the expresses itself and is transferred to relationships future. In the meantime, we should note that we within the cerebral cortex. Visual cells of the cen- have fi nally proved a difference between mem- tral projection fi eld for retinal points of each half- ory images and retinal after-images; namely that meridian all have similar associative connections the long duration of the former and the transience with specifi c points of the central projection fi eld of the latter can be traced back to an anatomical for eye movements. We must think of the latter as difference—that the cerebral cortex has associa- broken up into as many different muscle combi- tion fi bres, while the retina has none [W]. nations (‘eye movement representations’ [W]) as If the strength of remembered images is to be there are half-meridians of the retina. Naturally, explained in terms of repetition of patterned stim- this must be taken cum grano salis [W], since we ulation, and this statement is applied to the par- are dealing with a continually graded series of ticular case of visual memory images, we soon muscle representations, rather than discrete encounter diffi culties. Retinal images, which are points. If this concept is taken into account, defi ned by solid objects in the external world, are visual memory images (some of whose proper- sometimes big and sometimes small, depending ties we already know) are distinguished, in that on whether they are near or far; yet their remem- those visual cells of which they are made up are bered images [Ed] are taken as whole units. In linked with precisely localized movement repre- fact the relationship of retinal points remains the sentations of the central projection fi eld of eye same, and their respective images can be regarded movements. By repetition of the same visual pat- as perfectly congruent, so that psychological tern, associations form not only amongst visual requirements that we place on a memory image cells themselves, but also amongst matching, are still met. However, there are always a number similarly localized movement representations. of retinal points whose patterning must be pres- We shall call the widened concept of the visual ent on any one remembered image. Even with the memory image ‘visual perceptual [Ed] represen- simplest assumption that the object is fi xed, each tation’ [W]. We now see that, despite change of memory image would still include countless sub- image size, the latter components of visual repre- images which, even though congruent, are of sentation remain the same, if they are related to various sizes. The diffi culty disappears if we the same object; they therefore characterize References 19 remembered images rather than visual sensory down! Even though a few diffi culties are raised images. Similar considerations apply also to reti- by these facts, nevertheless the vast number of nal images, positioned asymmetrically to the cell groups needed to accommodate just visual midpoint of the retina, as you will see from read- memory images may still seem astonishing. ing Sachs’ book. (I cannot recommend that book Experience teaches us that a healthy brain can strongly enough, as an introduction to our topic.) always acquire new memory images; there must A second, undeniable diffi culty is the different therefore still be an abundance of elements for vantage points for objects from which clear this purpose. However, I draw your attention to a images are seen. An equilateral triangle or a cross miscalculation that makes us exaggerate the dif- can be recognized whether the triangle is stand- fi culty: As I demonstrate later, we tend to overes- ing on its base or its apex, or whether the cross is timate the number and variability of solid objects standing, lying, or standing at an angle. How in the outside world; and we correspondingly could the same memory image be derived? In underestimate the frequency of recurrence of the reply one can say that by far the greatest number same impressions. of objects in the outside world (and consequently their retinal images) do not present such a diffi - culty: They provide a fi rm viewpoint for our References eyes. Compared to these, those objects which move and change their position or their retinal 1. Mann L. Über Veränderungen der Erregbarkeit durch images are fi rstly in the minority, and secondly den faradischen Strom. Deut Arch klin Med. have mainly a defi ned, habitual position in rela- 1893;51:127–40. tion to our body. In addition, if we count on the 2. Ward J. Über die Auslösung von Refl exbewegungen durch eine Summe schwacher Reize. Arch Physiol. ability of our eye to adapt itself in such a way that 1880;72–91. a familiar image reappears, then the diffi culty 3. Jarisch A, Schiff E. Untersuchungen über das caused by the changing position of objects will Kniephänomen. Med. Jb. Vienna: Wilhelm seem only small. However, we cannot deny that Braumüller; 1882. p. 261–307. 4. Sachs H. Vorträge über Bau und Tätigkeit des in some situations remembered images are insuf- Großhirns und die Lehre von der Aphasie und fi cient to identify objects in strange locations. We Seelenblindheit. Breslau: Preuss; 1893. do not recognize inverted letters; several familiar 5. Goldscheider A. Über zentrale Sprach-, Schreib- und optical illusions are based on the same failing; Lesestörung. Berl klin Wochenschr 4, 1892 6. Ziehen GTh. Leitfaden der physiologischen and how strange appears the image of a person, Psychologie in 14 Vorlesungen. Jena: Gustav Fischer; when viewed through a convex lens, upside 1891. Lecture 4 4

• The concrete concept: an ‘association of images. If, for sake of simplicity, we restrict memory images’ [Ed] ourselves to solid objects, which by themselves • Awareness of the outside world make up central aspects of sensory perception, • Number of concepts the content of consciousness is made up of the • Requirement of causality sum of such remembered images of these solid objects. Clearly, within this sum, certain fi xed groupings can likewise be differentiated, always corresponding with the features of a particular Lecture solid object. One and the same solid object usually contributes to several sensory perceptions, Gentlemen! always recurring in the same manner. The simul- Study of remembered visual images taught us taneity of these several sensory inputs leads to that they are acquired associations of perceptual their remembered images remaining in associa- elements of the central projection fi eld, and that, tion. In this manner an acquired association of for these, the form [Ed] of the stimulus is crucial. memory images from different senses corre- You would be justifi ed in transposing this princi- sponds with each solid object, and the association ple to central projection fi elds of any sensory is progressively consolidated the more frequently region. Acquisition of such memory images is the same solid object is perceived by our senses. generally based on a feature of central projection Thus we fi nd an anatomical basis for those psy- fi elds—their perceptual elements, that is, those chological dimensions that have traditionally nerve cells connected directly with projection been used to describe ‘concepts’ [W]. We are fi bres and also interconnected by association now in a position to differentiate the ‘strength’ fi bres, separate for each projection fi eld. We shall [Ed] and ‘extent’ [Ed] of the concept; however speak in future about olfactory, acoustic, tactile we will distinguish essential and non-essential and gustatory memory images without going into features of solid objects depending on whether further detail about their nature. I need not draw they always adhere to the object or are change- attention to the fact that each sensory area pres- able. Of course, the extent of a concept includes ents its own particular problems [1 ], and that its non-essential characteristics, since these these simplest mental components, the remem- always show a degree of constancy depending on bered images, can be more complex in form. the nature of the object. For any item, we can Recognition—or primary identifi cation—is then easily plot a curve with Extent (‘circumfer- produced by virtue of this property of memory ence’ [Ed] of the item), entered along the x -axis

© Springer International Publishing Switzerland 2015 21 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_4 22 4 Lecture 4 and ‘Intensity’ [Ed] (or strength) of the concept/ undoubtedly, Shakespeare; accordingly, his item on the y -axis. vocabulary is also uncommonly comprehensive: We have just seen how secondary identifi ca- extending to 15,000 [2 ]. How much should we tion differs from primary identifi cation, in that subtract from this, if we want to restrict ourselves when each individual component of a concept is to solid objects of the outside world! Not every- excited, the sum of all the rest, making up the one is a Shakespeare, but you will be surprised whole concept, can be excited. The anatomical when we soon pass to the other extreme (amongst basis for acquiring such related functional group- civilized nations!): The vocabulary of an English ings of cellular elements is the availability of seaman does not exceed a few hundred. The num- association fi bres between the various projection ber of concrete items is, in fact, not so great, nor is fi elds. We shall call these ‘trans-cortical associa- their diversity so signifi cant, as we can easily tion pathways’ [Ed], in contrast to intra-cortical appreciate, especially when we realize that the intrinsic fi bres. The content of consciousness, as number of nerve cells in the cortex is about a we now recognize, therefore includes the concept Milliarde [W] by Meynert’s count. We can now [Ed] of solid objects or, as we will call it, con- grasp that indeed the same solid object must crete concepts [Ed]. We can also identify the sum impinge on our senses quite often, if such a fi rm of such concepts as consciousness of the outside connection is to exist of particular remembered world [W], for in these concepts we in fact pos- images with what we call ‘concepts’ [W]. sess a true picture of the outer world. Perhaps by now it is obvious that conscious- As you will notice, also included in consciousness of the outside world has defi nite dependence ness of the outside world is the apparatus for on the outside world, or, we might say, is ‘a func- ‘simple circuit operations’ [Ed]. This process is tion’ [Ed] of it. Even quantitatively, the above the same as that which also serves for secondary examples show this beyond doubt. However, we identifi cation. From audible speech, from the should keep in mind, as opposites, not only barking of a dog, or from a certain fragrance I can extremes such as Shakespeare and the sailor, but acknowledge the presence of a man, a dog, or a also the generalized consciousness of urbanites, certain fl ower. Virtually all circuit operations probably educated, living in complex civiliza- which relate to concrete features are similar, and tions, and the man-on-the-land, the fi sherman, therefore, as we have seen, are only isolated and the hunter—growing up in secluded isolation examples of secondary identifi cation. with little education. Yet the qualitative variation The content of consciousness thus consists not in awareness of the outside world must also be only of memory images, but also secondarily of surprisingly great. Think of the contrast between fully-defi ned complexes [Ed] of such images an inhabitant of the tropics, growing up amidst fi rmly linked to one another through associa- lush fl ora and fauna, a world rich in colour, and tion—concrete concepts. The number of concepts the polar inhabitant, who experiences only traces depends on the number of solid objects. Perhaps of vegetation during a short summer. you are astonished that I have so far presented it It is worth dwelling for a moment on these as though only a few (and always the same) remarkable facts of association and their essen- objects would enter our sensory world. You might tial natures. Most associations that might interest ask: Do not things in the outer world come into us so far are based on simultaneity of impres- the realm of our senses in almost infi nite number sions. Admittedly there is no explanation, yet it is and indescribable multiplicity? Fortunately, a spe- undeniable that memory images of simultane- cifi c answer is possible. The number of words ously received sensory impressions remain asso- gives us a clue to the number of concepts. The ciated, whether the interaction was brought about number of concepts that a particular individual by a deeper connection or the loosest random possesses is shown by the number of words with occurrence. However, random occurrences will which he functions. One of the most comprehen- not be so easily repeated, so their association is sive spirits who ever lived, or will ever live, is, not as fi rm as that for clearly related events. 4 Lecture 4 23

The association of various remembered more recently Ziehen have made similar images to one another is a second example of the comparisons. In any case the fact of association occurrence of the so-called preformed pathways can be explained by assuming the existence of [Ed]; that is, the connection among them is so pathways connecting the anatomical locations at fi rm because these pathways have been called which memory images for individual senses are upon so often. localized. Since myriad fi bres are detectable as Apart from association through simultaneity, much in the white matter under the cortical man- we know of another type of association: that by tle as in the cortex itself, whose sole function is to succession. I need only recall that for each connect various cortical locations, then an ana- attempt to learn something useful, this plays the tomical basis for this is also undoubtedly avail- main role. There is a whole series of associations able. When two cortical sites in the same central which, impressed upon us at early age, remain projection fi eld contribute to the process of pri- with us for our entire life: I remember the alpha- mary identifi cation, or when different projection bet, multiplication tables, the Lord’s Prayer, etc. fi elds contribute to secondary identifi cation, and Through succession alone, this association makes are simultaneously excited by external stimuli us aware of the regularity of things. Always, from afferent pathways, the connecting pathway when a certain sequence of events recurs without between them is likewise set into sympathetic exception, we believe that a law is operating, and vibration. Resistance which stood in the way of are particularly encouraged in this belief when propagation of the excitation process along such we succeed in arbitrarily evoking the initial event, pathways becomes progressively eliminated the and then observe the subsequent one. Such an more often the process is repeated, and the path- experiment has an irresistible persuasive power way becomes ‘well trodden’ [Ed], or as I over us. However, clearly, this reveals no deeper described earlier, ‘well blazed’ [Ed]. This does connection between the two events—it proves not mean that the pathway is continually needed, merely the presence of that pathway which was but we can claim only its physiological continu- claimed earlier in the same processes [3 ]. Our ity, just as for pathways of the projection system. need to infer causality, in short, is an inborn error On the contrary, the fact that it provides a unique or a bias of our brain. Phenomena of the outside layer of nerve cells to the cortex, that of fusiform world are too far apart to have any kind of con- cells, which by their form and location seem to nection among themselves; the bond that links belong to the association system, indicates in a them exists only in our brain, and is not used to specifi c way that such cells too are activated in link the objects themselves, but only the tracks the association pathways. In general, it indeed they leave behind in our brain. contradicts our intuition to accept nerve fi bres We shall see later that simultaneity of sensory that cannot prove their origin from any nerve cell. perception is not possible, on account of the It is simplest therefore to assume that each cell, property designated as the ‘one-ness’ [W] or per- or association cell, sends out two nerve fi bres haps as the ‘unity of consciousness’ [Ed]. In truth, projecting in opposite directions, which, with we always experience only one sensory percept at their terminal dendrites, enter into association once; any second, apparently-simultaneous per- with nerve cells of the projection fi elds. There is cept happens either earlier or later. Association no diffi culty in imagining that nerve cells of a by simultaneity therefore appears to be but a spe- central projection fi eld which took part in pri- cial case of generic association through succes- mary identifi cation are all linked to one another sion [ 1 ]. by such association fi bres, each in turn provided Having spoken so much about association, with an association cell, even though in some there is no wish to conceal the diffi culties in situations, depending on the number of percep- understanding the processes involved. On an ear- tual elements involved, calculated according to lier occasion [3 ] I compared it with a wave their combinations, an enormously large number motion in an enclosed pipe system. Meynert and of such association pathways may be required. 24 4 Lecture 4

But as soon as you go beyond this initial physio- cells. There is absolutely nothing improbable in logical unit, the memory image, and envisage just thinking that excitatory processes (made up of the next higher level of visual images (see p. 19 multiple elements) in a particular cortical layer above) or even association between visual images are combined to some extent into a unit with the and remembered images from another projection nerve cells of an adjoining cortical layer. You fi eld, the diffi culty of conceiving the process could also consider that, for our consciousness, increases enormously. Recently Goldscheider [4 ] remembered images are not perceptions that quite rightly emphasized this fact. However, we remain associated, even though acquisition of the still should consider available options. It seems association is based on simultaneity of the per- impossible to apply the same scheme that is conceptions. You might consider also how slowly, ceivable in a projection fi eld, namely for each and with diffi culty, fi rm associations between dif- sensory element to be anatomically connected ferent sense modalities are acquired, but, once with any other by preformed pathways, nor is it acquired, with what security they are then uti- possible for memory images to be connected one lized. Initiation of these pathways may present with another. Great as the number of fi bres at our quite specifi c diffi culties. disposal may seem, it is quite inadequate compared with the almost infi nitely large numbers resulting from calculation of combinations in this References case. There follows from this the absolute necessity of making some other assumption that sim- 1. Ziehen GTh. Leitfaden der physiologischen plifi es the conditions for association. For reasons Psychologie in 14 Vorlesungen. Jena: Gustav Fischer; 1891. already indicated, but above all the last men- 2. Meynert Th. Sammlung von popular- tioned, one can fairly view the psychological unit wissenschaftlichen Vorträgen über den Bau und die of a memory image as corresponding to some Leistungen des Gehirns. Vienna; Wilhelm Braumüller; kind of anatomical unit. For example, it could be 1892. p. 5. 3. Wernicke C. Der aphasische Symptomencomplex, that cells of a certain layer of the cortex receive eine psychologische Studie auf anatomischer Basis. fi bre processes from the association cells men- Breslau: M. Cohn und Weigert; 1874. tioned above while at the same time being con- 4. Goldscheider A. Über zentrale Sprach-, Schreib- und nected with the perception cells or projection Lesestörung. Berl klin Wochenschr. 1892:4,5,6,7,8. Lecture 5 5

• The body is a part of the outside world and we should now examine this process more • Awareness of physicality is a function of the closely. central projection fi elds Given that sensory impressions and hence • Organ sensation and sensory content of information from the outside world reach our sensations brain only by means of the projection system, • ‘Feeling tone’ [Ed] of sensations then most basic considerations teach us that the • The large intestine represented in bodily same is also true of our body parts. Only via awareness nerve pathways which link a particular body part, such as the arm, with the brain, is the brain brought into connection with it; if the pathway is divided, as seen frequently after physical inju- Lecture ries, something quite unrestrained may follow in that body part—it can be pressed, punched, Gentlemen! rolled, crushed, or burnt, without the slightest I can best show you how important to our sensation being transmitted to the brain and topic are the intuitions gained so far, by again reaching our consciousness. Incidents of this confronting you with a tangible example: nature are most commonly observed in the arm, Suppose that someone awakens from deep sleep because the brachial plexus lies relatively super- or morbid unconsciousness. His organ of confi cially and therefore is most commonly exposed sciousness is functioning again, enabling him to to external forces. recognize the outside world and note the normal Since this example applies to all other regions occurrence of a ‘behavioural loop’ [Ed]. of the body, it is a universal principle that integ- Consciousness of the outside world had been lost rity of the nervous system is required to give us to the sleeper, or rather had not functioned during perceptions of our own physicality. An uncon- the time when consciousness was lost. After it scious person in whom the brachial plexus is returns, how does the person who has lost con- destroyed, upon waking, can no longer identify sciousness behave? We observe that he corrects his arm as his ‘property’ [W]. Thus conscious- the uncomfortable position that he had adopted, ness of physicality appears to be a quite general and feels his body, in order to convince himself function of the entirety of our sensory nerves, in of its integrity, and we note that his interest is other words, of the projection system. Meynert’s apparently directed towards his own body. statement, on the signifi cance of a transverse sec- Consciousness of corporeality [W] has returned; tion through this projection system at the level of

© Springer International Publishing Switzerland 2015 25 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_5 26 5 Lecture 5 the cerebral peduncle, also applies to conscious- important central projection fi elds of those body ness of physicality: Were that procedure to be parts. Human pathology provides irrefutable evi- carried out, sensation would then arise only from dence that such experimental results apply to the the retina and the olfactory organ. Let us imagine human brain, even if we still await precise delin- that, instead of such a transection, which cannot eation of corresponding regions in humans. Also, actually be carried out, another procedure is car- in my view there can no longer be any doubt that ried out which is even less feasible but just as each region represents the total sensibility and easy to envisage: The skull cap is exposed, and motility of the designated body part, the arm the brain is gently lifted from the fl oor of the cra- region, which thus constitutes the central projec- nium and, with no collateral injuries, raised high tion fi eld for sensibility and motility or, in other above the cranial cavity: Blood vessels, nerves, words, the entire nervous system of the arm. Here medulla oblongata, and spinal cord would not we face a relationship calling for our full atten- have suffered any damage in this stretching pro- tion: All these body regions are covered by the cess. Then the brain appears to us for the fi rst tactile organ—the skin—and corresponding cen- time, in its true form, as a fully sentient and mov- tral projection fi elds also contain representations ing entity, one equipped with a mechanism for of these sensory surfaces. On the other hand, registering sensory stimuli, and for executing representation of the body will not give us com- movements; yet, in relation to the brain it amounts plete ‘awareness of corporeality’ [W] if central to a part of the outside world, even though it is projection fi elds of the special senses are ignored, inseparably connected with the brain. Sensations since the olfactory mucosa, the retina, the audi- would, as before, reach consciousness, but with a tory organ, and the lingual and pharyngeal mucosa slight delay caused by the longer pathway; move- serving taste, although mediating specifi c sensory ments would likewise be possible, as before, functions, at the same time themselves constitute except that here too delivery of a command most important parts of our body. We must there- would take longer. The brain might then, as in an fore put to one side awareness of the physicality example already given by Meynert, be compared of these [Ed] sense organs, even if a special pro- with a mollusc, bearing both ‘sensory tentacles’ jection is not detectable (as for example for the [Ed]—the sensory nerves—and ‘capture tenta- olfactory and taste mucosa via certain trigeminal cles’ [Ed]—the motor nerves. The fact that the branches) at their already familiar central projec- former tentacles are armed with a complex sen- tion fi elds. Therefore, in the cerebral cortex, we sory apparatus, and the latter with a special are often made conscious of both the outside movement apparatus—the skeletal muscula- world and of our own physicality. Here we meet ture—does not detract from the analogy. more complex relationships, forcing us again to Observations made earlier with regard to sensa- resort to basic operations of simple sensation. tions will therefore also be useful with respect to What we have so far learned for familiar sen- our physicality. Also, consciousness of our own sation, and which provides material for us to con- corporeality is initially acquired, just as is construct our awareness of the external world, can sciousness of the outside world, by messages also be described as the sensory content of stim- from the most widely varied parts of the body uli. However, we know that any sensation has yet reaching their central projection fi elds in the another quality, which we have ignored so far, brain, and leaving there, as residues, memory generally identifi ed as the ‘feeling tone’ [Ed] of images. the sensation as opposed to its sensory content. Some of these projection fi elds are already This ‘feeling tone’ [Ed] of sensation, as I hope to known to us in broad terms, localized to specifi c show, is particularly closely related to conscious- sites in the cerebral cortex. There is no doubt that ness of corporeality in that it has a different col- cortical regions demonstrated by Munk—which oration depending on the site of the applied he called arm region, leg region, head region, stimulus, and thus to some extent emits a ‘local ear region, and trunk and neck regions—are sign’ [Ed] for consciousness—a sign indicating 5 Lecture 5 27 which part of the body has been affected by the tions may be acquired by each individual; they sensory stimulus. Stimuli linked to strong feeling involve at least those regions of grey matter to tone are closely related to motor responses which which only refl ex activity can be ascribed; they appear to serve protective functions for the body. are doubtless functional as innate refl exes; and We usually pay no attention to these organ sensa- they serve protective functions even amongst tions [W], which pass us by, our attention being humans, as in lower animals with predominantly directed to the sensory content of the stimuli. spinal organization. Within this organization the However, slightly stronger stimuli reach our lowest vertebrate can show more than simple awareness to such an extent that we ignore the refl ex movements in that, like the decapitated sensory content and focus instead on the organ frog, it has a capacity to make appropriate adap- sensation of the affected body part. Already, tations. However, where a large cerebral hemi- however, appropriate defensive movements have sphere is present, as in mammals, and more so in taken place. A few examples illustrate this: humans, we see similar mechanisms of move- Imagine that your arm is unexpectedly touched in ment transferred to central projection fi elds of the a crush of people; depending on the type of touch, cerebral cortex (as shown experimentally by you immediately consider whether the touch Munk for eye movements). In both cases appro- came from a person or an object. But if you priate modifi cation of the movement is observed, receive a solid blow, such that the assault is pain- depending on the part of the body affected. This ful, you immediately pull your arm back and try demonstrates that organ stimuli have the immedi- to protect it from further injury. Your attention is ate aim of protecting the body. directed to the affl icted part of the body. The ‘Local signs’ [Ed] in the retina, already dis- same response applies to loud noises: Everyone cussed in relation to visual perception, now recoils when a shot is fi red unexpectedly close to appear in a new light. They originated apparently their ear, and nobody remains in the immediate from organ stimulation of the retina, since we vicinity as an express train rushes past, even saw that receptive elements, depending on their though they know that there is no real danger. location in the retina, control movement mecha- Here too the ‘racket’ [Ed] is the essential compo- nisms in the cortex in such a manner that the nent eliciting the powerful organ sensation and fovea centralis [W] always faces the stimulus. involuntary rebound. A simpler protective reac- They can therefore be considered in Meynert’s tion, namely closing the eyes, is seen on exposure terminology as defensive or offensive move- to bright light, especially immediately following ments. In fact, in the animal kingdom, they must complete darkness; and in those situations pain prove equally effective in defence and attack. We can also be felt. When the eye initially focuses have already anticipated when this can be used to on a point source of light, using mechanisms explain formation of visual images. However, for of movement already discussed in the context of this action to proceed, a spatial image of the ret- visual processing, this also is an example of ina has to be acquired in our own consciousness organ stimulation. All such examples of move- of corporeality. Thus if receptor cells of the visual ment, some simple, some complex, must be con- projection fi eld assigned to retinal points are to sidered under Meynert’s idea of defensive or be matched with various points of the oculomotor offensive movements, and we remember that projection fi eld along the retinal meridian (with their origins are innate functional refl exes. I recall the level of oculomotor activity depending on the Pfl üger’s famous experiment where a decapitated distance from the centre of the retina), there is an frog could produce not only protective move- immediate need for a fi xed orientation of the ments, but even adaptive modifi cation of them, location of retinal points, thus achieving a solid such that, in the attempt to wipe off an area of image of the retina itself. This arrangement skin dabbed with acid immediately after its leg would be achieved through association. The pro- on the stimulated side had been amputated, cess would be the same as that for acquisition of recruited the other leg to assist. Such modifi ca- visual memory images: Through simultaneity or 28 5 Lecture 5 succession of excitation of adjacent retinal points Gentlemen, I cannot avoid the concerns you a fi xed association arises between corresponding might have about my view—it could be a more or sensory cells on the one hand, and accommodat- less arbitrary construct, and might not stand up to ing movements of the eye (between the latter and rigorous scrutiny and evidence; but allow me to the points of the motor projection fi eld) on the mention briefl y those facts, which I am forced to other. By constant recurrence of the same behav- accept, as essential to the view I have just pre- iour under the same conditions, the associations sented to you so vigorously. One fact is that in achieve the necessary stability and attain a degree cortical diseases, whether in the occipital, or of ‘solidity’ [Ed]. Evidently consciousness must parietal lobe, persisting defi cits have been be initially focused on the retina before the observed: in the former case in the visual fi elds, images derived from it can be used spatially. in the latter in sensation of skin over the limbs. In This spatial sense of the retina—that the retina my opinion, occurrence of such defi cits provides comes to be viewed as forming part of the body irrefutable proof that adjoining retinal points surface—is derived by reasoning similar to that must project to adjoining cortical elements in the which applies to the tactile organ of the skin, with occipital lobe; and adjoining cutaneous areas of the associated optical apparatus of the eye merely the limbs must have similar projections to adjoin- providing support. Likewise in the skin, a spatial ing cortical elements of the parietal lobe. sense can only develop from the fact that con- Occurrence of localized and thus continuous def- sciousness is already informed about the sequence icits of this type would otherwise be quite inex- and location of the sensory skin points. Moreover, plicable. The most direct and therefore the most this information can only be obtained by rehearsal likely assumption is that this projection relates to of the associations between sensory elements or the most immediate endings of projection perception cells that correspond with points on fi bres—those on the ‘perception cells’ [Ed] serv- the skin and mechanisms of movement in the ing perception. motor projection fi elds of the thorax, the eyes, The second fact consists of the secure orienta- and the limbs. However, we must regard the latter tion, which we maintain in relation to the retina as being much more complex than the combina- and the entire skin surface. I need not present this tions of movement produced by eye muscles. Just for the retina. Yet we know this also for the skin think how relatively easy the movements of the of the body: We know it for certain for any cho- eyeball seem, freely moveable around a centre of sen part of the body capable of fi ne spatial dis- rotation within a defi ned space, compared with crimination. Any person with closed eyes can the multi-branched tactile organ of the hand. If immediately indicate a skin area that has been we focus solely on the simplest tactile move- touched. Not only can he describe it, or point it ments, such as fl exion and extension of the fi nger, out with his fi nger, but he can also correctly and we have known since the time of Duchenne that without hesitation fi x his eyes on the point that these cannot take place without reciprocally has been touched. At locations with a very fi ne directed movements of the wrist, which clearly spatial sense, such as the palm of the hand, he provide fi xation for the forearm. The forearm can, from the sequence of touching the skin, must in turn be fi xated in relation to the upper reconstruct a letter, a number, and even a pattern arm, and the latter to the shoulder; however, the drawn there. Similar experiments are successful latter fi xation in turn involves corresponding acti- in most people, even for a number of other areas vation of the thoracic musculature, without which of skin. the torso might lose its balance during hand use. Gentlemen, if you have followed me so far, Thus, before the hand can be used as a sense you have gained only the most essential building organ, it must acquire certain regular relation- blocks for building up an awareness of our own ships between many separate motor mechanisms. physicality, but you will still fi nd it incomplete, This task seems so diffi cult that we might doubt in need of some increment to make good the defi - the possibility of solving it, were it not for the cit. It still lacks representation from three most evidence before our eyes. important sensory areas, for hearing, taste, and 5 Lecture 5 29 smell. There is no diffi culty transferring the point Localization of these intestinal sensations is of view that we have acquired to these senses as always quite vague, even though the sensation is well. At least this may be clear for the sense of distinct: Think of stomach pains, gallstones, renal hearing, because there the sensory content of the colic, discomfi ture from an overfull bladder, etc. sensation—think of speech sounds—achieves an Thus normal and impaired function of these importance dominating one’s entire mental life. organs contributes most to our general state; in Nevertheless we have already seen an example of other words, consciousness of our own physical- circumstances where organ stimulation of this ity clearly depends on the state of our large intes- sense is so powerful that it induces a defensive tine. We should actually defi ne the aforementioned withdrawal response; and not only the intensity, ‘feeling tone’ [W] of sensations generally, as but also the quality of auditory sensations can affl ictions of our consciousness of physicality. bring about similar effects. For example, it is We should then assume that consciousness of common experience that some noises create feel- corporeality also contains special projection ings and movement of shuddering, or are regarded fi bres from the large intestines, an assumption as a pleasant or unpleasant tone. We know that that gains strong support from some hypochon- apart from specifi c spatial sensibility, the organ driacal symptoms in people with mental illnesses. of hearing is unique, in that the source of an audi- With regard to the location of these projection tory sensation can be specifi ed. However its fi ne fi elds, admittedly, we are at present in ignorance, development appears only in abnormal cases, apart from Meynert’s hypothesis that the ganglia although it does demonstrate that certain local of the striatum would participate in this. Seductive signs indicating the location of an applied stimu- as this might seem, obvious considerations, both lus are also present within the auditory sensory anatomical and morphological, leave the idea surface, quite apart from the organ of Corti, still fl oating in mid-air, and allow no practical which conveys to us the pitch of a tone. applications. In taste and smell, organ sensations and sen- The entirety of memory images of all organ sory content are so closely connected that any sensations forms the content of our consciousness separation of the two is quite artifi cial. As you of corporeality, just as memory images of sensa- know, these two exquisite senses for chemical tions constitute consciousness of the outside analysis, important for both nourishment and world. We can now attempt to defi ne psychologi- protection of the organism, lie openly exposed. cally the viewpoint we have acquired, realizing Also included among organ sensations are that the former refers to location [Ed] of stimuli, sensations emanating from the muscles, joints, and the latter to the their form [Ed] or the mutual and large intestines. The last named show best organization of their stimulated elements. that organ sensations can have an independent We can also now defi ne, in a few words, the role, and can occur with no sensory experience. essential difference between a sensory percept Such organ sensations have little impact on our itself and its memory image: Sensory percepts consciousness when we are in a good state of are always accompanied by organ sensations and health, although hunger and sense of repletion, are therefore projected to certain spatial loca- the urge to urinate or defaecate, sexual sensations; memory images, on the other hand, are not. tions, etc. are familiar to us all. Nevertheless, Apparently it is the ‘perception cells’ [W] imme- intestinal illness demonstrates that these senses diately connected to retinal and to cutaneous possess a highly labile sensitivity, and contribute points, which convey organ sensations. most to our feelings of well-being or malaise. In I have already indicated that all projection fact this is the element that you can always iden- fi elds, which encompass consciousness of bodily tify as the ‘feeling tone’ [W] of any sensation, i.e. sensitivity, must be considered as intimately con- its accompanying feelings of pleasure or pain, nected with each other by association pathways. with organ sensations from the digestive tract Since the messages that the body itself transmits dominating all the others—even those relating to to consciousness are always the same, under the location of sensations. same conditions, this results in a permanent link 30 5 Lecture 5 from bodily sensations to memory images, world, they are also evoked by internal stimuli. because the former can never be thought of as Think of warmth or coldness of the skin due to memory images of the outside world. Various vasomotor processes; perverse taste sensations parts of bodily physicality are quite immutable in during catarrh of the oral mucous membrane; their relationship with one another; in contrast, subjective tinnitus—so-called noises in the ear; external entities are more variable. We can more light fl ashes that are unrelated to the retina during or less cut ourselves off from the external world; total darkness, etc. None of these organ sensa- by contrast, sensations provided by our body are tions relate to the outside world. The reciprocal always with us. During sleep, the effects of the relationship that exists here is that although sen- outside world seem to pass us by, virtually with- sory perception is inconceivable without corre- out trace; however the body surfaces, on which sponding organ sensations, the latter occur only we lie, continue to send their signals to our con- when stimuli lack connection to the outside sciousness. Whatever posture we adopt when world. Perception has organ sensation as a pre- awake, we cannot escape the continual pressure cursor [W]; but, decisively, organ sensation has and our perception of it on some part of our skin. no corresponding links to perception. This also Such awareness of bodily physicality accom- suggests that the idea of central projection fi elds panies a person throughout their waking state, that I already developed—namely, that con- and is seen unmistakably in their behaviour. If a sciousness of corporeality is represented by per- person’s attention is attracted to an object in the ception cells—implies also that the fi rst station in outside world so strongly that, at times, he is the cortex must be no more than an intermediate deeply entranced on hearing a melody, the body port of call, to be passed before a sensory stimu- still maintains its upright position, continues to lus conveys consciousness of the outside world. walk, avoids obstacles, adapts unevenness in the The laminar layout of nerve cells of the cerebral terrain, makes widely varied defensive move- cortex favours this assumption, according to ments, etc. which the cortical layer (or layers) immediately It is now clear that, from any organ sensation, adjacent to white matter would represent con- the entire complex of memory images of the sciousness of corporeality. body’s organs is brought to consciousness. Thus, At certain times a person’s body—already if we adhere to the analogy based on ‘conscious- well developed—can still undergo noticeable ness of the outside world’ [W], then what is built change—the time of entering sexual maturity, or up here is, so to speak, simply one large concept, puberty; the climacteric; pregnancy; puerperium; that of corporeality. This refers at least to those and senile involution. In our opinion it is no lon- defensive movements with which we are familiar ger strange that these are times of special vulner- through powerful organ sensations, since virtu- ability for development of various diseases of ally the entire body musculature can take part. In consciousness. the formation of concepts of specifi c body The relative immutability of our conscious- regions, defi ned as fi rmly as befi ts concepts of the ness of corporeality explains why our body outside world, these seem not to encroach on appears as constant in size, compared with other consciousness of corporeality, or only incom- contents of consciousness—as one unit, as pletely so. Since sensory perception is not possi- opposed to the impressions of the outside world, ble without evoking relevant organ sensations, which are subject to changes. Through experi- consciousness of corporeality in toto [W] is also ence, our consciousness learns that corporeality evoked by any sensory perception. Consciousness is indivisible; the outside world however can be of corporeality therefore also arises from every more or less broken into its component parts. act of sensory perception. Thus our body comes to form a ‘primary ego’ Organ sensations certainly then have two [W] (Meynert), under which we comprehended sources: In addition to stimuli from the outside our consciousness of corporeality. Lecture 6 6

• Concept of spontaneous movement ‘motion machine’ [Ed] which supports the brain. • Distinction from refl ex movement This operates by refl ex mechanisms of the spinal • Position sense and position representation cord, which, right from the start, bring sensory • Sensations of nervous activation of muscle, and motor apparatus of the same transverse level and their memory images into mutual relationship. This is probably why a • Sense of motion and movement imagery both gentle prick applied to the plantar surface of the derive from organ sensations toes immediately elicits a plantar fl exion refl ex. • Also, tactile sensations and touch representa- This metamerism not only determines the struc- tions from the hand’s tactile organ are derived ture of the spinal cord, but also, as shown in from organ sensations Pfl üger’s ‘irradiation of refl exes’ [Ed], recruits larger muscle areas, according to the stimulus strength, even almost all muscle groups, involving connections which are presumably built into Lecture the grey matter of the spinal cord. These refl exes have no immediate link to awareness; they are Gentlemen! innate, taking place even in the absence of con- You may already have noticed that so far I sciousness, as in deep sleep or coma. However, have completely ignored a group of phenomena later, when awake, we become aware of them. that have close connection with our awareness of That mollusc, by comparison, receives informa- physicality, namely our entire apparatus for tion from refl ex movements based on innate char- movement. I have avoided this until now, because acteristics of its body. Without immediately it is quite complicated. How can we understand prejudging more detailed statements, we can call that any comparative mollusc learns to master its these messages ‘sensations of movement’ [W], muscular system so completely—as is indeed the and their residual memory images ‘representa- case—if we avoid consideration of its innate abil- tions of movement’ [W] or motor memory ities? We now examine this point more closely. images. Now, let us try to understand those ‘sen- It is known that humans like all vertebrates sations of movement’ [W] in greater detail. still bear the clearest traces of their lineage from In refl ex movement, a whole series of different the invertebrates, in that the spinal cord preserves sensations arise. First, let us denote the joint a segmentation, designated by the numbered ver- which is moved, by g . Joint sensation depends on tebrae. We must also remember to take this meta- the excursion of a given joint movement, and is meric structure into account along with that associated with a certain skin sensation h ,

© Springer International Publishing Switzerland 2015 31 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_6 32 6 Lecture 6 because, on the fl exor side of the joint, skin sur- than sensation linked with nerve cell activity z , faces are shortened to a specifi c extent, and which can be taken as the origin of nervous acti- approach one another; on the extensor side, on vation of muscle at the moment of the refl ex. the other hand, surfaces are stretched and move Muscle contractions which occur at this moment apart. Thus there is a constant relationship trigger certain muscular sensations m 1; and these between g and h , which applies if the joint stand in constant relationship with activity in reaches the same position passively. However, nerve cells z , thus m 1 :z . We can then designate the muscles are also demonstrably involved, since message which reaches consciousness, as the during fl exion they are relaxed on the fl exor side, sense of nervous activation i , and then i = z :m 1 . and elongated and stretched on the extensor side, The movement sensation b , taken as a whole, the opposite occurring during extension. then contains both components of the refl ex Observations from pathology demonstrate that movement—the sense of nervous activation— these muscle sensations m are independent of— and the position sense—and these, as is readily and can sometimes occur in the absence of—skin apparent, stand in constant relation to each other: and joint sensations. The highly specifi c ratio of b = i :l . these three sensations to one another, that is, Muscle sensation m 1 can also be tested g : h : m, we call ‘position sense’ [W], l , so that directly, by electrical stimulation of the muscle. l = g : h :m . In this case, the most that can be determined is We can call memory images formed from this the current strength that can be perceived, and ‘position representations’ [W] L . The same posi- whether changes in this measure are perceptible. tion sense must arise when the joint is moved The resulting joint movement requires a separate passively, and is in no way linked exclusively to position sense, perceived like any other in normal refl ex action. awareness. However, a regular connection A subject’s position representations can be between muscle sensation and position sense examined clinically, because a person passively does not exist in this experiment, because iso- adopts some arbitrary position for his joints. A lated contraction of one muscle never occurs nor- healthy person is then in a position to either imi- mally, the experimental conditions thus being a tate these positions, or to make some alteration; novelty for conscious awareness. at least we recognize that he has full control over Sensations of movement which reach con- the position of his limbs. This investigation is sciousness in this way, and which, through their particularly relevant for easily moveable joints of content, always recur in like manner, develop fi ngers and toes. Successful testing of position into movement representations, as robust fea- sense depends on total exclusion of the subject’s tures of consciousness, which we can denote as own activity, that is, elimination of his own motor B. Although they give rise to memory images impulses. This, of course, is not equally possible limited to refl ex movements, defi nite patterns of for all individuals, because it presupposes the muscle activation are nonetheless represented, person to have a degree of control over his since refl ex movements are undoubtedly coordi- movements. nated, in the sense described by Duchenne. Muscle sensation has previously, and incor- According to Duchenne’s classifi cation of mus- rectly, been given a dominant role in position cle coordination, as impulsive, collateral, or sense, and therefore presence of position represen- antagonistic, refl ex movements are impulsive and tations as a unique sense has been called the ‘mus- collateral. Refl ex movements are not lacking in cle sense’ [W]. We prefer not to use this word, usefulness, and can be considered more clearly as since it can lead to further misunderstanding. protective reactions, which defend against a stim- Suppose now that position sense l is generated ulus, or remove part of the body from the vicinity by refl ex action; this creates the sensation of of a stimulus. These two occasions can be movement b; but another feature must be added regarded as the most important preconditions to what has gone before: It may be nothing more leading to spontaneous movements. A person 6 Lecture 6 33 recalls that during refl ex movement a message ity to bright light, in eliciting eyelid closure, is reaches consciousness not only from the move- another indication of dominance of bodily sensa- ment itself, but also from the sensation e , which tion. Amongst spontaneous movements, those elicited the refl ex. The memory image E of this which are overwhelmingly dominant in the fi rst stimulus, whether it be tactile or directly painful, years of life are defensive movements [W], as will consequently remain associated with the more or less faithful imitations of refl ex move- movement representation B . We will then only ments, again based on bodily sensations. There speak of spontaneous movement, when the mem- are also very complex combinations of move- ory image E evokes the movement representation ment persisting throughout adult life, such as the B through the association pathway EB in such a combined response to a shock, including jump- manner that the movement actually takes place. ing backwards and leaping sideways, controlled A necessary assumption is that a centrifugal path- mainly by bodily sensations, as we already know way p stretches from B to the nerve cells which from earlier examples; and if you accept a heredi- went into action previously during the refl ex tary infl uence on development of language— response. This pathway has, in fact, been demon- which is hard to deny—you should trace the drive strated: It is the pyramidal tract. to imitate audible sounds back to bodily sensa- Two examples will illustrate in more detail the tions from the auditory nerve. In other words, essential difference between refl ex and spontane- you must assume that excitation of the auditory ous movement. A needle applied to the sole of nerve at a given moment is connected with a the foot is followed by refl ex fl exion of the lower pleasant feeling, and that a child’s discovery that limb at all three joints, thereby removing the foot they themselves can produce sounds can be used from the sharp point. In spontaneous movement to create such pleasant sensations by its own we only see [Ed] the needle; the memory image E vocal gestures. Bodily feelings in the visual sense of the tactile sensation e thereby is brought into are still detectable in adults when they acknowl- consciousness and, via the association pathway edge pleasurable sensations hinting at titillation EB, elicits the movement that had previously in the play of colours, where various saturated taken place by refl ex. The pathway Bz, which is colours follow one another in rapid succession. still required, is the pyramidal tract. It behaves in We can hardly doubt that, in the auditory sense, the same way if the eyes were to be closed as the pleasure provided by producing a particular tone needle approaches: Initially visual perception has a similar basis. occurs; this is associated with the memory image This simplest scheme for spontaneous move- E, as is the latter with movement representation ment, as just described, can soon be applied to B. We can now defi ne spontaneous movements in the active acquisition of tactile representations. general as responses to external stimuli mediated As in refl ex action, a movement follows a stimu- by memory images. In reality most spontaneous lus, for instance when visual perception of a nee- movements throughout life are constructed from dle leads to eye closure mediated via association all kinds of external stimuli, although we cannot pathways; so, undoubtedly, visual perception of exclude the possibility that external stimuli are an object may trigger tactile movements—‘attack totally absent; thus spontaneously emerging movements’ [W] in Meynert’s sense. Given that memory images are the start for association pro- our entire skin surface functions as a passive tac- cesses which end ultimately in movement. tile organ conveying obscure tactile perceptions The fi rst spontaneous movements a child in the absence of any bodily movement, we still makes are apparently under control of organ sen- possess specifi c moveable tactile organs, actual sations. Suckling movements, which are refl exes feelers [Ed] for discriminative sensation in the in the newborn, later become spontaneous move- limbs, and also, in the fi rst stages of life, the ments brought about by bodily feelings of hun- mouth. A child examines by touch every object ger. Later still, the sight of the nipple is suffi cient that he sees, with hand or mouth. For the retina, to elicit suckling movements. A child’s sensitiv- as described above, each memory image was the 34 6 Lecture 6

residue of a particular spatial arrangement of the fact that each component of the series b 1 + e 2 excited retinal elements, and this principle must is itself already a composite integral, as I just dis- also apply to memory images from the passive cussed: Remember that b = i :l , implying a partic- tactile organ. For the retina, there was a defi nite ular relationship between position sense and point of clearest vision which we can then use as feelings of nervous activation; and now comes an the site for acquiring memory images. For the added association with passive tactile sensations skin, there are also places of greatest sensitivity, of the series e 1 + e2 …. We can call this complex such as an infant’s mouth and the skin of hands integral t , the tactile sensation of an object. We and fi ngers. We may still suppose that such a lim- then denote as T , a memory image, tactile repre- ited skin area by itself can give rise to memory sentation, or probably a tactile image. In practice, images; but they can also be acquired from any we test for tactile representation by requiring a skin surface. With certain limitations this is of person to recognize specifi c objects merely by course also true of the retina, since objects per- touch, using their hands, with eyes closed. A nor- ceived outside the fovea can be recognized accu- mal person solves this problem with ease, for rately, and one can postulate that, for the retina, every object he knows. memory images acquired in this manner will Gentlemen, by more detailed examination of gradually become associated with images this topic it should have become clear to you how obtained in central vision. A similar association important are the unique body movements in our between memory images applies to the various sensory perceptions. Memory images from the skin surfaces, once it is grasped that they origi- sense of touch which, when we started our nate from the same objects; and one can consider enquiry, could be traced back to a type of passive them to arise in central projection surfaces of a projection process (like other sensory percep- passive tactile organ. Nevertheless one cannot tions) now appear to be assembled simultane- deny that fi ner representations of touch are ously from memory images of spontaneous acquired through the movable [Ed] tactile movements. However, these motor memory organs—the hands and fi ngers. Let us take a images must correspond to consciousness of our closer look at how this happens. own corporeality—our body form—so here we If a solid item such as a penknife is touched, enter an area where awareness of the outside assuming this to be done with only one hand, and world and that of our own physicality lose their we let palmar surfaces of the fi ngers, with many fundamental separation, refuting the proposition changes of position, play over it to convince us of that only changes in our own physicality give us the consistency, smoothness or roughness, sur- knowledge of objects in the outer world, and face temperature, and overall form and dimen- reverting to the most obvious: The similarity sions of the object. We then consider all these between the outside world and our own physical- sensations together, as a single unit, which recurs ity, in their sensory connections, shows that all only on subsequent occasions when a penknife is spontaneous movements give us mastery over the felt—but for no other solid object. If we call this outside world (‘attacking movements’ [W], unit the ‘tactile sensation’ [Ed] of an object t , according to Meynert). Each skill or adroitness then it is made up of a series of skin sensations amongst our known movements, from walking

e1 + e 2 + e 3 …, and a series of motor sensations and speech movements to the most complex

b1 + b 2 + b 3 … standing in simple—yet also com- movement sequences of a creative artist, must be plex—relationship with the former. Simple, in learned laboriously. All these occur only under the sense that any major muscle contraction rein- continual guidance from the sense of touch: They forces the pressure sensation from the object; are made possible only by our possessing a large complex in so far as a series of successive move- repertoire of most complex tactile representa- ments is required, under conditions of constant tions. If we undertake to test such varieties of pressure, to sense the object’s shape. Just how movement representation, we tend to concentrate complex the integral t = e + b must be comes from on the simplest evidence of manual dexterity. 6 Lecture 6 35

For example, a patient is given the task of unbut- seen defi nite localization of function made possi- toning his clothes and then buttoning them up ble through the fact of projection. As visual mem- again with eyes closed, or sharpening a pencil, ory images are explicitly localized in the central winding a clock, writing numbers or letters in the projection fi eld of the optic nerve, and acoustic air, or writing in the normal way. With few excep- ones in the central projection fi eld of the acoustic tions, handling one or more objects is always nerve, we cannot doubt that the tactile representa- required, and, in order to carry out the required tions of solid objects are localized in like manner. movements, tactile representations must be Simple fi gures, such as numbers, a cross, a circle, available. and a triangle, can be recognized by touch, when Since in the tactile representations just dis- drawn on the skin surface with the subject’s eyes cussed movements are linked to skin sensations, closed. Therefore central projections of the pas- there is a quite complex muscular apparatus, sive tactile organ—the skin—develop a space whose movements are under control of impres- [Ed], like the retina, wherein reciprocal arrange- sions from the retina. If the form of an object is to ment of skin points aroused by a stimulus infl u- be perceived precisely, then, with familiarity and ences the resulting memory images. by appropriate eye movements, the point of clear- As stated above, these cutaneous memory est vision is scanned across the contours of the images become tactile representations through object, a process entirely analogous to scanning their association with movement representations by that tactile organ, the fi nger, and to be of the tactile elements. described just as for scanning by the macula The same tactile images thus reach various lutea [W]. The intricate eye movements required projection fi elds, but are connected with one to leave behind motor memory images form a another not only by secure associations, but also, series of associations, very similar to those dis- above all, by visual representations held in com- cussed above, obtained by scanning with the mon. Tactile representations of solid objects hand. When these are merged with passively should be localized exclusively to the arm region, acquired memory images of principal sensations although, of course, in different hemispheres for E, then together they represent the complete tac- right and left arm because such tactile representa- tile concept of an object. The motor memory tions are acquired, in adults at least, exclusively images—so to speak—of scanning eye move- through hand movements. ments, are a new component which, when associ- It is also to be understood that we have no ated with those with which we are already innate orientation of the position of retinal familiar, constitute a single unit which we may points, these needing to be acquired. Orientation justifi ably call a ‘visual representation’ [W]. For ‘above’ [Ed] and ‘below’ [Ed] or ‘left’ [Ed] and eye movements it is unfortunately not possible to ‘right’ [Ed] refers exclusively to one unique analyze position sense and position representa- body, meaning no more than the acquisition of tions separately. Nevertheless their importance in strong associations between perception cells, spatial orientation can hardly be overestimated— associated with points on the retina, and the they are a further striking example of how organ ‘concept’ [W] (see above) of our own corporeal- sensations can be surveyed to build a coherent ity. This brings two kinds of movement sensa- picture of the outer world in our consciousness. tion into consideration: fi rstly those originating In conclusion I draw to your attention a similar as deliberate gaze movements upwards, down- relationship between tactile exploration and audi- wards, and to right and left. These could be tory perceptions: A child’s vocal gestures are ten- called mass eye movements. Second are those tative movements unrelated to skin or retinal serving to adjust the eyeball to the light stimulus sensations, but which are related to and guided by or rotating it—to be distinguished as adjustment auditory sensations. movements. The fact that such eye movements In so far as we have been able to survey the can occur refl exly at any time during life is a contents of consciousness, up to now we have necessary physiological postulate. The most 36 6 Lecture 6 likely movements are adjustments that, using element a particular form and particular degree appropriate preformed connections of primary (extent of excursion) of associated muscle com- visual centres with eye muscle nuclei, are trig- binations can be evoked. gered by a light stimulus. Sensations of nervous Trigger points found by Munk in the canine activation ( i = z : m1 , see above) arising in this occipital lobe, from which adjustment move- way have particularly fi ne sensitivity for eye ments can be elicited, evidently correspond to muscles in this situation, given that you might such muscle combinations. In the dog they cor- not want to assume a special position sense in respond in location with cortical projections of the eyeball (via the ciliary nerves?). Their mem- the retina and its centrifugal fi bres, Bz (see ory images are movement representations for above), and run conjointly with projection fi bres eye musculature. According to the manner of of the retina in the sagittal cortical bundle of the their acquisition, they become associated with occipital lobe. Thus far, they adopt a special perceptual elements in the projection fi eld of position, and differ from fi bres of the pyramidal the retina in such a way that, from each such tract. Lecture 7 7

• Consciousness of personhood, or individuality this is the possible existence of an unchanging • Is its localization accessible? sense of corporeality, in contrast to the ever- • The mystery of self-awareness changing environment, as we have already seen. As soon as a child begins to operate with the word ‘I’ [W], constraints are felt from these facts. If mental development were cut short before this Lecture time, the outcome would be an imbecile who would speak of his body in the third person. Gentlemen! Awareness of personhood therefore includes With the overview that I have given you of everything that you tend to understand linguisti- two great areas of awareness—of the environ- cally as intellectual ‘property’ [Ed] and intellec- ment and of our own corporeality, we have by no tual acquis [Ed]—everything introduced to the means exhausted the content of consciousness; child through teaching, education, and child- those areas are just the fi rst foundations of aware- rearing, so that the individual infant can be trans- ness we share with animals, albeit with quantita- formed into a person. tive differences. Higher mental development of The fi rst distinguishing hallmark of each humans must start from these fundamentals, but human is undoubtedly the social environment in extends far beyond them: It sets sail—so to which he grows up. Living examples have always speak—from the point where these basics have been the most effective means of education, the already been acquired. The normal unfolding of more so when they combine with the obvious mental development results in the formation of a implicit authority of parents towards their child. ‘personality’ [Ed], or an individuality. An uncon- Family life of parents is indubitably imprinted as scious individual, who we choose as a subject for the ultimate stamp on the child, his intellectual our study, must regain consciousness of his own personality, and his future character. personhood before we can consider him to be Consciousness of personhood thus includes all fully reconstituted: That is, he must remember those properties arising as instinctive regularities not only that he has the same body as before his in the social environment in which each individ- accident, but has remained the same in terms of ual grew up and lived. These properties include his whole mental status. A prerequisite for ‘con- notably all those so-called character traits, which sciousness of personhood’ [W], which we should develop in specifi c ways in each family environ- now consider in detail, is the possibility of devel- ment, according to whether it was a more brutal opment of an ‘ego’ [Ed]. The main condition for or a more refi ned ‘temper of life’ [Ed], and on

© Springer International Publishing Switzerland 2015 37 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_7 38 7 Lecture 7 which depend the predominance of more egotis- of a person’s memory we understand mainly the tical or more altruistic objectives of a person’s sum of his acquired knowledge; at least we usu- future actions. Such characteristics can also ally examine memory by inquiring about such develop quite strongly, even where the most acquired knowledge, and a person’s ability to powerful, even half-instinctive method of child- recall it, compared to what is accessible for most raising, the spoken word, cannot be used, as wit- normal people. The sum of such skills or knowl- nessed for example in deaf mutes. edge varies widely, not only quantitatively but Possession of language itself must in some also qualitatively, depending on each individual’s sense be associated with awareness of personal developmental processes. I need not explain the identity, insofar as it refl ects the style of the quantitative differences in more detail. environment in which each individual has lived. Qualitatively it is so great because knowledge The variety of language used by different nations gained in early stages of education consists has a special place within ‘intellectual property’ mainly of a series of associations devoid of any [Ed] differing from that used almost everywhere deeper connections—historical facts, memorized else, despite similar consciousness of the outside sayings and songs, the Ten Commandments, and world and of the body’s physicality. Within one even multiplication tables. As long as more new and the same population there may be differ- knowledge is acquired, it is assimilated into the ences in dialect, which remain with an individual existing repository of information, and is further throughout his life and betray where he has refreshed and reinforced in memory. However lived. An individual’s entire style of speech, this is not all of equivalent value since a child’s which differs quite markedly according to the brain is distinguished by its ability to retain what manner of his upbringing, and his level of intel- has been learned, and the knowledge needed and lectual development, adds to the evidence of per- most commonly made use of early in life. sonalized consciousness. Through language, the Reading and writing usually belong to temporary entire mental acquisition of an adult, and not acquisition of knowledge, although the acquired only of each individual but of countless genera- associations of letters with speech—associations tions whose intellectual heritage he has encoun- that are often interrupted remarkably by focal tered through language, is transferred to the lesions of the brain—are laid down very fi rmly. child’s brain. This is done with a certain logical To personalized consciousness belongs the order and structure, somewhat comparable to sum of experiences peculiar to each individual. skill on a musical instrument, yet not complex The individual we see before us always repre- enough to be considered as virtuoso perfor- sents this sum total—be it knowledge, or experi- mance. Orderly, logical thought and all fi ner ences—a sum having a defi nite value only at a intellectual operations undoubtedly have their specifi c point in time, but which undergoes new main roots in the comprehensive yet traditional growth every hour and every day. The current art of language. It is therefore also distinctive of state of the brain is always this fi nal summation the complete mindset of each individual—the of all previous states. Hence, after a person has language handed down from parents, whether recovered from a mental illness, it is required that poor and rough for a person of lowly status, or we ensure that he has achieved insight into the rich and more refi ned from highly educated par- abnormality of the state he has experienced, for ents. The altered manner of speech found in the sum must necessarily be inaccurate if it con- those with mental illnesses indicates a change in tains false elements. their intellectual personality. In like manner, personalized consciousness If we disregard the child-rearing medium of encompasses the range of each person’s interests, speech, then everything that an individual other- be they self-centred, showing interest in other wise learns is from instruction and what is handed people, family, etc., his occupation, or clinging to down—the sum of all knowledge—which he daily work routines. In particular, interest in adsorbs as part of his personality. When we speak family, friends, and other people while laying 7 Lecture 7 39 aside personal concerns often occupy centre on those processes of association, which, from stage in the contents of an individual’s conscious- the outset, have certain intrinsic individual ness—think of the intimate relationships between differences. mother and child, between husband and wife in The position that each individual believes he sexual love, etc. Willingness to go to one’s death occupies in a human society depends on his for others, or for an idea, a principle, or a prede- awareness of his own personality. If he is ill, we termined ambition to die on the one hand, and the may see relevant symptoms of grandiosity, belit- over-weaning, selfi sh world of interests of most tlement, persecution, etc. Later we will have people on the other demonstrate extreme oppo- much to say about such disease phenomena. sites and infi nite variety of intellectual personal- What spatial sense can we make of a personality types, all still falling within the normal range. ized consciousness? Or have we already reached Further varieties are added by illnesses. All this the limits of spatial representation, and confront explains how diffi cult it is to describe mental sta- the incomprehensible? tus—be it that of a normal person, or of a men- It seems that consciousness of corporeality is tally ill person; it also explains the slow progress most accessible to cerebral localization because of clinical psychiatry. it is most closely connected with the normal Personalized consciousness obviously arrangement of the projection system. Awareness depends on awareness of corporeality and of the of the environment likewise allows us to partition environment. A man with keen senses and a according to relevant projection fi elds, in which healthy body must also develop differently in his its components, the sensory memory images, are intellectual personality, compared with one presumably stored. In our consciousness of being endowed with dulled senses and a feeble body. a person, localization according to such norms of Character traits such as courage or cowardice, the projection system is out of the question. Does openness or concealment, vigorous action or it therefore remain totally inaccessible to the doleful shyness—these can often be traced back principle of localization? to those same fundamentals in consciousness of Clinical experience teaches us that this is not corporeality and of the environment. Adaptability so, because some mental illnesses draw attention to the outside world, which Herbert Spencer exclusively to a person’s awareness of their own identifi es as a normal mental condition, itself var- personhood, others almost exclusively to their ies according to such preconditions. One can awareness of the environment, or of their own express such a mutual relationship in this sen- corporeality, while yet others reveal some other tence: Personalized consciousness is a function combination, of disorder of personal identity of awareness of the environment and of corpore- with a person’s sense of bodily physicality or of ality. However, if you include impressions that his environment. Thus, the disease process come from the social milieu [W] within a per- appears to distribute itself in various locations. son’s awareness of the environment—which is Mental illness which develops progressively justifi able—this sentence is still quite illuminat- and perniciously κατ’ εζοχηv (to a prominent ing. It is then self-evident that such personalities degree), such as progressive paralysis, attacks in develop in civilized conditions, while on the turn an individual’s awareness of their own per- other hand antisocial personalities arise in crimi- sonhood, of their environment, and of their own nal families. You will clearly not take a mental corporeality, and seems to begin quite often with illness as an explanation of criminal tendencies, atrophy of fi bres in the outermost purely grey but can speak of such only when a person’s intel- cortical layer. Still other clinical experiences lect has developed in defi ance of the external present, and even suggest further localization for world, as in cases of the so-called moral insanity awareness of personhood. It so happens that in [W]. In any case, personalized consciousness is the wake of serious illnesses, including brain far more complex than consciousness of the envi- diseases, large fragments may disappear from an ronment and of corporeality, because it is based individual’s awareness of their own personhood. 40 7 Lecture 7

It may turn out that all ideas acquired recently— strongly multilingual, and this skill is lost, except a period ranging from a few months or years, and for their mother tongue. Quite recently such a sometimes up to half a lifetime—have been lost. case was published by Charcot. Unfortunately, Dr. Freund has published such cases from my the distinction between skill in speaking and in own clinic [ 1], under the heading ‘general weak- understanding language has not been suffi ciently ness of memory’ [Ed]. Patients in question have analyzed, so that localization of the lost function a fairly good memory—about as accurate as you in a strict sense is not possible. However, from would normally expect—for all events that took reported facts, this much can be concluded with place before a certain period of time, for instance certainty: that the loss is quite analogous to any before the age of 30 years; all those happening other focal symptom arising in a part of the later have vanished from their memory: Often brain. Now, suppose that a purely motor defi cit this includes their most important personal was the issue here, one that, according to all our events, such as marriage, birth of their children, previous knowledge, would be attributed to loss of assets, and the like, but also well-known Broca’s convolution: Then, from our above public events of the time, skills acquired during assumption, quite specifi c layers of this convolu- this time, etc. In a word, the loss encompasses tion would be totally destroyed as a result of the the entire chain of events that has become linked stroke, while layers immediately above or to awareness of personal identity after a certain beneath, and serving skills in the mother tongue, point in time. Consequently, one such patient, would be left completely unharmed. This seems who is an elderly woman, still behaves like a highly unlikely. By contrast, the following idea young, blossoming girl, thereby becoming prey has, in its favour, a whole series of other known to a mocking contrast with reality. To a lesser facts. Cells and fi bres of the cerebral cortex are degree, similar loss of memory is encountered extremely delicate structures, tending always to almost normally in advanced old age where, remain in an embryonic state until they begin to commonly, old memories can be preserved in function. Only through functioning do they every detail, while memory for daily events of obtain a certain resilience, which increases in recent days, weeks, or months may be totally proportion to their functioning. This hypothesis lost. The fact that experiences from a certain is completely analogous to that which Cohnheim period in time can be lost as a result of gross attributed to muscles—that they grow and physical illness allows a precise interpretation increase only during their functioning. Now sup- that the site of these complex memories is prede- pose that in the vicinity of focal brain damage, termined in the cerebral cortex from the time of there is a centre, like that of Broca’s convolu- their being laid down. From this, we can con- tion, where besides cells and fi bres that have clude, approximately, but most directly, that a been functioning for a long time and therefore kind of layered deposition of memories takes have a certain resilience, there are those placed place in the brain, similar to sedimentary forma- at risk by slight injury. It therefore seems quite tions of the youngest strata of the earth. You plausible that a side effect of acute focal damage might be tempted to assign the outer cortical spreads to surrounding tissue, and destroys one layer facing away from the projection fi bres to element while leaving others intact. The same awareness of personhood, this being the young- explanation also applies to cases of general est structure. Without letting the crudity of this weakness of memory. As with the circumscribed notion to make us recoil in alarm, other consid- location just described, it must be assumed that a erations stand in the way of interpreting such harmful effect spreads throughout the cerebral experiences in terms of layer-wise localization. cortex, where only resilient elements can sur- Occasionally we see circumscribed loss of vive, and it is then little wonder that the level of recently acquired memories after focal lesions of this resilience is a function of time; in other the brain. Cases are known, and well docu- words, only those memories laid down most mented, where a stroke occurs in people who are recently would disappear. Reference 41

Personalized consciousness includes a speciﬁ c other words, the perceiving individual, at the highest level faculty of the brain, which has moment of perception, is a certain mental person- always been considered the mystery of mysteries, ality, differentiated from the personality of the the phenomenon of self-consciousness [Ed]. In previous moment, by a signiﬁ cant value; so it can this aspect it appears that the same organ, the be no surprise that this latter value is capable of brain, in which you probably place your trust, is perceiving previous values from recent times in able to perceive, and at the same time, that it is that sum, as well as objects of sensory perception. also perceived. However, it seems impossible that In other words, the intellectual personality does one and the same being, or thing, which makes not perceive itself [W], but only that personality [W] a perception, could itself, at the same time, be that existed a few moments, hours, days, or years [Ed] the object of perception. We can already see before. It is mere self-deception to believe oneself from this comparison the lack of clarity about to have remained exactly the same. matters at issue here that prevails amongst philosophers, who still feel the need to warn us against overestimating the importance of anatom- Reference ical and physiological views on the subject. We 1. Freund CS. Klinische Beiträge zur Kenntniss der should remember that personalized consciousness generellen Gedächtnissschwäche. Arch Psychiatr. is a sum, whose value is a function of time; in 1889;20:441–57. Lecture 8 8

• The activity of consciousness dependent on we must acknowledge that this organ is composed the content of consciousness exclusively of nerve fi bres and nerve cell bodies, • ‘Preformed’ [Ed] organization of the connec- and that therefore we can demand no more from tions of thought it than the sequence of certain excitatory pro- • Narrowness of consciousness cesses, and, during its disease states, a morbid • Level of consciousness change in such processes. Moreover, in what we • Attention and will have considered so far, we needed no other pre- • Ability to be attentive condition, because the contents of conscious- • Affect ness—the sum of all acquired perceptions—had • Normal value of apperceptions no meaning for us other than that of permanent molecular alteration in purpose-built fi bre and cell masses, resulting from excitatory processes that had taken place. We referred to the ability of Lecture nerve elements to undergo lasting changes elicited by stimuli that had occurred as their ‘mem- Gentlemen! ory’ [W], a phenomenon with analogies in the Let us take a backward glance at our journey natural world of inanimate matter, since iron can so far. The organ of consciousness has been be magnetized. Thus we deal here with excitatory revealed as populated by a collection of potential processes in a complex organ, whose activity energies, remembered images in their various depends on excitation that it underwent in previ- groupings, from the simplest up to those of com- ous times. We should therefore examine, fi rst of plex dimension, for which the name ‘memories’ all, the nature of such dependence. [Ed] seems appropriate. For such contents of When a question from a particular fi eld of consciousness a natural division into three areas knowledge is addressed to a person who is unfa- emerged—environment, corporeality, and per- miliar with that fi eld he may fi nd the very ques- sonhood—an organization that, as we shall see tion incomprehensible. A fundamental principle later, is also required in practice for any obser- applies here, which should surprise no one, about vant physician. You will notice, however, that in newly acquired perceptions: Understanding the such ‘quiescent consciousness’ [Ed], as it were, question can be gained only on condition of pre- you face an inanimate machine. It is now our task existing acquired perceptions. If we refer to pro- to examine in greater detail the activity [Ed] tak- cesses currently playing out in consciousness as ing place in the organ so constructed. However, ‘mental activity’ [W] and activity triggered by

© Springer International Publishing Switzerland 2015 43 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_8 44 8 Lecture 8 the question as ‘registration’ [W], and the result properties of things that we learn to be relatively of mental activity included in the answer as ‘exe- constant and changeless are their relationship cution’ [W], then, in the present case, mental with other things, be they inanimate or animate, activity remains incomplete because the individ- and, in particular, with our own person. The fact ual cannot produce activity corresponding to that water becomes ice when cooled, and ‘registration’ [W]. If we bear in mind that mental becomes water vapour when heated, is an expe- activity is, as a rule, connected to an external rience that we take as valid because of its con- stimulus, that is, any sensation, then sensory per- stant occurrence. In our brain this is refl ected by ception in general depends on such stimulation. association between the perceptions of water, Sensory perception that has never occurred previ- ice, and water vapour, and hot and cold, happen- ously and therefore cannot produce the usual ing in a completely regular way. The cold sensa- consequent mental activity remains not only mis- tion of the skin can then, by association, awaken understood, but also very imprecisely perceived: the perception of water freezing. The association This fact convinces anyone who concentrates on is somewhat more complicated when observa- the sounds of a foreign language. Thus if perception of a thermometer leads us to the same con- tion itself is to be precise, it requires certain pre- clusion. Here, visual perception linked to the existing ‘mental acquisitions’ [W]. Quite similar registration is learned, as well as its association to these simple examples of mental activity is with the other perceptions. Just as the simplest behaviour involving more complex thought pro- natural phenomena impose themselves in regular cesses, where registration is often merely casual order so to speak, so it is for more complicated sensory perception, which escapes our attention. associations of perceptions that we learn from Moreover, such complex thought processes usu- examples in our environment. Our innate drive ally take place along prescribed paths from which to imitate is analogous to the compulsion with emerge relatively rare ideas that are truly new. which natural phenomena impose themselves on Overall, mental activity shows itself to depend on our brains. From earliest years we are used to a long history of acquiring ideas, and arranging behaving always in the same way as others. For them in special ways; that is, it usually means example a person learns, in the crudest sense, simply repetition of the same excitatory pro- from the example of others, that you dig up cesses in the same order as have repeatedly taken crops, cook them, eat them, and thus satisfy hun- place in the past. ger. Even this simple example suffi ces—the per- What is the basis for the ‘order’ [W] prevail- son plants crops now [Ed], with planting of crops ing in these perceptions, which is expressed in itself as an objective, to satisfy hunger later routine mental activity? As you may recall, we [Ed]. This highly complex action is ultimately gave the name ‘association’ [W] to the network driven, after interpolation of a whole series of of perceptions; order prevailing in perceptions associations, by initial feelings of hunger. In the therefore allows us to unlock our cache of asso- simplest condition, every activity is driven by ciations, which are roughly the same for all indi- similar examples from the environment. The viduals. Our question can therefore be rephrased environment in which the person grows up, or in the following way: In what way are such uni- where he lives, therefore extends back to fi ll his versally valid associations formed? In part, I consciousness with a whole series of perceptions build here on what was said earlier, and is already in a very specifi c arrangement, and the more familiar to you. In speaking of consciousness of monotonous the fl ow of his life the more strongly the outside world, I pointed out that the natural and immutably is this arrangement of percep- order and succession of things represented in our tions fi xed, undisturbed by details of more com- brain are, to some extent, a refl ection, of what is plex living conditions. Collective consciousness present in the outside world. It is therefore legiti- requires that you should behave like everybody mate to link phenomena found there, to those else, and may often still be effective when men- also found in our consciousness. Amongst those tal activity is totally dislocated as a result of 8 Lecture 8 45 mental illness; so the otherwise inaccessible— we have emphasized individual differences; and and always reluctant—mental patient adopts the it cannot be denied that the traditional heritage examples of fellow patients. The entire institu- that we are given through sentence structure and tional treatment of mentally-ill people is based terms for abstract concepts in language is chiefl y on this principle. On the other hand, we can see responsible for this. Despite all differences in how deeply this herd consciousness is ingrained social milieu, and the epoch in which we live, all in us too, when we participate in a group gather- individuals in full possession of their senses have ing, or any kind of mass demonstration, intend- fi rmly laid down in their store of apperceptions ing to remain passive, yet being dragged into the combinations of identical thoughts. In this regard same feelings that inspire the crowd. Teaching therefore, we must guard against overestimating by example is also effective in deaf mutes who the diversity of individuals. This is defi nitely an have had no other instruction. If he has no other advantage for psychiatry, making clinical obser- defi cits, such a person may often be a useful vation possible. Here, the question mentioned in member of society within a narrow walk of life. passing was whether mental activity has to take However, the main way to acquire a particular place using words, and how far it depends on order to one’s perceptions is through articulated words. Renowned scholars have argued for such speech. Through this medium all fi ner and more dependence, and cited certain abstract concepts precise relationships are made with ease, not only as evidence that ordered thought cannot proceed among concepts of solid and fi xed objects, but without the abbreviations contained in language. also between these and events or activities—the However, these very abstract concepts are little latter in chronological order—and, by subtle more than a means of communication, and it nuances, the status of the personality in question seems inconceivable to me that anyone familiar is recognized. For more complex associations, with modern ideas of aphasia could entertain the abstract concepts [W] become familiar to us notion that a person with total aphasia has lost all mainly through language, and shorthand labels his concepts of faith, love, hope, fear, anxiety, are found, so that we learn to use a whole series hatred, grief, sorrow, and the like, or of the nation of perceptions; and just by using such abbrevia- state, society, religion, time, and space. The tions for various states of mind, everyone learns behaviour of such patients does not imply this in empirically about such things as love, hate, fear, any way. Each word may still be closely linked anxiety, hope, sorrow, etc. In such terms we have with a whole series of perceptions; yet we qualify at our disposal a whole series of experiences in this by pointing out that the associations are not summary form, comparable to our conceptualiza- just with the word, but include association of tion of solid concrete objects. The syntax of lan- each of these series of perceptions among them- guage, and its logical structure, gradually leads selves, even though the latter may have been and guides the run of our thoughts. At least it acquired only via the word itself. Language is may distinguish the educated from the unedu- only the means of training the disciplinarian, by cated, in that the former can follow every logical means of which perceptions are arranged, once nuance of expression. and for all, in rank and fi le. What I have just said requires further explana- What we referred to above as mental activity tion, since you might easily think that I wanted, probably coincides with processes that Fechner above all, to elevate the role of speech in relation called ‘psychophysical motion’ [W]. Fechner to mental activity. Far from it, I merely point out compared such psychophysical motion to the that an essential condition for understanding lan- passage of a wave of excitation, which we con- guage is not only our possessing the same lan- sidered to run between registration and execu- guage as that being spoken, but also the same tion. Thus we seem to be shifting our viewpoint ‘apperceptions’ [Ed] as those of the speaker. We on the course of excitatory processes from a therefore assume a degree of commonality specifi c nerve pathway to an entire system of between intellectual personalities, whereas so far interdependent fi bres and nerve cell bodies, 46 8 Lecture 8

interrelated in a manner dependent on various, the stroke of a pendulum when a star passes over already acquired associations. We would make the cross hairs of his telescope sees either the star the same mistake if we were to compare the fi rst, and then hears the pendulum, or he hears movement of a wheel with that of a whole, com- only the pendulum and then sees the star; and plex machine; yet in both cases, the processes of between the two moments, a measurable time motion are at least similar. Let us imagine, by interval has elapsed; this differs for different way of illustration, that we plot this excitation on observers, but remains a personal constant, to be rectangular coordinates: We are interested in the taken into account in astronomical formulae, shape of the resulting curve, and we think of spa- when results of different observers are compared. tially extended awareness of corporeality as the In this example, the peak must be thought to abscissa. On this, the curve must extend as a fl at migrate between central projections for visual plateau across its full extent, since awareness of and auditory perceptions. The fact of unity of corporeality accompanies us throughout our consciousness or intensity of consciousness leads waking state, albeit in only a moderate degree of us to assume that the volume of the curve, when arousal. We can then add the use of speech, by it can be calculated, remains constant; in other which, when we are conscious, we imply not words, there is always only a certain store of [Ed] only the content of consciousness but also its ‘life force’ available in the brain for psychophys- activity, or the level of arousal of the movement ical movement. Fechner illustrated this statement going on within it; therefore in this sense we as follows: A miller, who is used to sleeping must differentiate various levels [Ed] of con- through the clatter of his mill, awakens fully alert sciousness. The level of consciousness is plotted when the mill stops. It must be assumed that the on the ordinate by the height of the curve, while sleeper’s auditory perception of the mill’s equip- the ‘extent’ [Ed] of consciousness corresponds ment sets up sustained psychophysical motion in with distance along the abscissa. We gain quite a the auditory projection fi eld, which then, sud- low level of consciousness from our physicality; denly, disappears, whereupon psychophysical but, since external stimuli continually play on our motion at some other brain site undergoes such bodies when we are awake, it follows that ‘the an increase that the raised level of consciousness body’ [W] can be taken as such a solid unit that it awakens the sleeper. Numerous similar examples is always being activated in its entirety. A steep can be cited. A further conclusion can be drawn wave of activation can rise anywhere from this from these that the volume of the curve remains uniform plateau, indicating the position of the constant even in sleep, but the shape of the curve currently highest peak of excitation. It is charac- differs from that in the waking state, in that the teristic of the human brain that only one such aforementioned peak is not so pronounced. On peak can occur at any one time. That peak indi- the other hand, Fechner expressed his view that cates the highest level of awareness—the most sleep and wakefulness differ in the location of intense excitation—and, from experience, only a their psychophysical motion, which is correct if single peak at any given time. It was therefore one concedes that the shape of the curve infl u- totally appropriate that we envisaged the wave of ences its location. excitation in psychophysical movement as migra- If the peak designates the site of most intense tory, and it is the peak—that second elevated thought activity, then you can imagine that the component—which shifts its place, while the ini- most closely associated concepts would be con- tial plateau retains its overall extent. tained in ascending and descending limbs of the The experience that only a single peak is ever curve, which are in continuity for the sequence of present on each curve is identifi ed by the phrase thoughts between initial perception and goal. ‘unit or intensity of consciousness’ [W]. A per- We use various terms for the migration of son cannot think of two things at the same time, peak of activity—we speak of ‘attention’ [Ed] nor carry out two actions, nor even perceive two when referring to the act of perception or thought, things. An astronomer who records the time at and of ‘will’ [Ed] when we prepare for activity or 8 Lecture 8 47 a process of association. Let us take a specifi c be conferred more or less arbitrarily by its asso- example—contemplating a work of art. Prolonged ciations: The slightest hoarseness catches the attention is then focused on visual perception, attention of a singer, and the slightest damage to and so the peak must lie in the central projection the foot becomes the focus for a trekker. For all fi eld of the visual system. Guided by this peak of senses, the so-called threshold for sensation activity, all associated apperceptions are succes- depends on our general attentiveness. The fact sively brought into consciousness; indeed this is that it has a certain measure differing little the purpose of our scrutiny. Attention directed to between people, suggests that attention—in other an object thus corresponds to mental activity in words the height of the peak on the ordinate—is which, without our intervening at all, a large approximately the same in all normal people. The number of pre-existing associations rise ‘above threshold level can have a spatial extent seen the threshold of consciousness’ [W]. As we expe- when we assess visual fi elds; concentric narrow- rience this over and over again, we come to ing of the visual fi eld, as applies to the clinical believe that we can arbitrarily focus our attention, picture of retinal anaesthesia, indicates nothing a self-deception analogous to that of self- more than a reduction of awareness. In neuroses awareness. The more intensely a viewer directs following head injuries, railway accidents, and his attention towards the picture, the more does the like, reductions in awareness play a major awareness of the environment and of corporeality role, and do so no less among mentally ill and the rest of his personality retreat. Absorbed people. in contemplation he may forget who and where Gentlemen! You can see from this that in he is; yet consciousness of corporeality is never- determining the threshold value for sensations theless shown by the fact that he involuntarily we have a method to measure awareness, that is shifts his position, dodging about or making the ordinate height of the excitatory process, spe- defensive movements, etc., according to the situ- cifi c to each faculty of awareness we study. Even ation. The dominant peak of activity may even in neurology this fact should be taken into exclude from awareness parts of our own body, account, and methods set up so that patients when visual sensations are of great intensity; any direct their attention, as we examine them, further associations then become inaccessible. towards corresponding targets. You will remem- However, should pain or unpleasant sensation ber that I presented to you in an earlier lecture a occur in any part of our body, when attention is female patient in whom it was entirely my choice directed to a selected portion of the outside world, whether I demonstrated either total cutaneous attention is immediately defl ected and redirected anaesthesia for touch or normal tactile sensitivity, to our own physicality. Very intense pain, such as depending on the nature of the methods we used violent toothache, immediately signals to our for investigation. Let us bear in mind that a subconscious to redirect attention to our senses. reduction in such threshold values may, under The artwork that gave rise to our sensory percep- certain circumstances, imply a reduced level of tion is still there; associative processes come consciousness. together just as before, but they prove inexcit- A prerequisite for acquisition of new remem- able, because the peak is tuned into conscious- bered images and for sensations is the very pos- ness of our own corporeality, and to special sibility of normal awareness. In future we shall regions of it. Thus a severe pain prevents one refer to this aspect of the ‘organ of conscious- from thinking, despite the arguments against this ness’ [Ed] as ‘memory’ [Ed], including also the always given by followers of Stoic philosophy. normal use of language. To avoid misunderstand- The pain may be tolerable, yet one’s attention ing, in future I will speak of memory only in the certainly cannot be arbitrarily redirected to any sense of the long-acquired store of concepts, other object. Apart from the strength of a stimu- whereas under ‘retentiveness’ [Ed] we can under- lus which may be encountered by any body part, stand the ‘ability to lay something down in great importance to momentary discomfort can memory’ [W]. We can test the latter ability by 48 8 Lecture 8 giving a patient the task of recalling a multi-digit Graded levels of consciousness, right down to number, an Affect or Mood. Here too unfamiliar loss of consciousness, are usually taken to dif- word, etc. If it is lost or half-remembered, then ferentiate states of the sensorium, subdivided by this may sometimes be due to a lapse of attention. terms such as dizziness, somnolence, and coma. However, you will soon become familiar with However, this does not match our language for cases where memory is markedly impaired, small reductions in activity of consciousness, despite good attentiveness. In memory we can which we can call ‘drowsiness’ [Ed], whose therefore see a way to test independently the detection is possible only by special, focused activity of the ‘organ of consciousness’ [Ed] and investigation. Among psychiatric patients, only the neural elements in question, and only condi- exceptionally do we encounter marked drowsi- tionally of attentiveness. ness, although, by contrast, we frequently fi nd Between memory and the capacity for recol- reduction in attentiveness or retention in lection [W], we encounter a similar relationship memory. as that between attention and memory. The test of Gentlemen! We now come to a set of phenom- memory just mentioned showed us that a memory ena which until now I have intentionally avoided, defi cit [W] can sometimes be detected. In the but which very often have effects of slowing above test this consisted just of a patient forget- down the course of mental activity, which are ting a task he had been set. From my last lecture decisive and disruptive, in equal measure. These however, you saw that such memory defi cits can are the moods or ‘Affects’ [W]. People fi nd it dif- cover long periods of time so that all experiences, fi cult to defi ne ‘frame of mind’ [Ed], and the insights, and knowledge acquired in memory, same goes for pain; both are facts of inner experi- obtained along with those same impressions, ence, which we assume to be present in all peo- appear to have vanished. In particular we encoun- ple, because their utterances and behaviour ter the same phenomenon amongst mentally ill suggest it. We know that pain has a contrast: the people, or, after a mental illness has run its feeling of pleasure. We know also that the condi- course, for the entire period of illness, or for cer- tions in which pain can arise can be stated in a tain phases of their illness. If we tested the mem- general way, and that such pain-causing excita- ory of these patients, and memory was seen to be tion may exceed any useful performance of ner- lost or diminished, then the defi cit would have vous pathways—such as conduction of seemed to be a comprehensible consequence of sensations—and it may damage the nerves. We the reduced encoding, at the time when the mem- also know that pain then arises when isolated ories should have been acquired. In addition, the conduction is interrupted and the grey matter of conclusion that a memory defi cit is always based the spinal cord is brought into consideration. Pain on loss extending over a given period is not cor- is an Affect of such grey matter, without which, it rect. Without doubt there are mental defi cits aris- seems not to exist. In all this, no defi nition of pain ing from other causes. I remind you of the is given; however given that pain is a functional remarkable cases of the so-called retroactive property that can be ascribed even to the least amnesia in which head trauma, an epileptic sei- developed nervous system, not just in vertebrates, zure, or a stroke led to total loss of recall, not organisms seem to be endowed with a type of only for the subsequent period but also for expe- alarm signal, enabling them to avoid harmful riences immediately prior to the attack, that is, at effects that would cause structural damage to the a time of full mental clarity and health. Also, nervous system. The converse, namely nervous cases of general weakness of memory mentioned arousal that is benefi cial to an individual, seems in the last lecture allow us to recognize such ret- to apply to simple pleasures such as tickling and roactive effects of the illness that caused the erotic excitement. The same importance which impairment. In such cases memory acquired sub- attends feelings of pleasure and pain in the spinal sequent to the onset of illness is shown to be per- cord also seems to confer Affect to the ‘organ of manently and markedly diminished. consciousness’ [Ed]. Whatever is conducive to 8 Lecture 8 49 consciousness of personhood—the ego—evokes Suppose that a train of thought, whose content a pleasant state of mind; whatever is harmful to it is advantageous to an individual, is often evokes an unpleasant state of mind. According to repeated—a condition brought about deliber- the degree of this state of mind we speak of Affect ately, for instance for educational purposes and or mood. Here too, we see a protective or defen- character-building—then we meet in the intel- sive device that the brain may have acquired dur- lectual property of such an individual a group of ing its development. Normally, all more complex apperceptions associated with strong motiva- processes of association—‘mental processes’ tions. Other groups of apperception in the same [W] as we called them—are accompanied by a individual are acquired in such a way that a moderate degree of Affect, a kind of pleasant strongly aversive Affect is consistently linked ‘sense of self’ [Ed] (see Lecture 7 ), which with them. Apart from that, excitability of cer- Griesinger aptly named the ‘Psychic Tonus’ [W]. tain groups of apperceptions, and the ease with This nonchalant, slightly elevated mood of which they can be re-enacted, will also depend healthy people does not affect either mental on how often they have been used. Both condi- activity or other Affects when it remains within tions are especially clear for lines of thought moderate limits. We distinguish this uniform, which become individual motives for action. In smooth fl ow of mental activity as a state of equa- this sense, we come to realize that, with apper- nimity. During all stronger, or stormy Affects, be ceptions with normal links to personal values, they exuberant joy, or sorrow, anger, and rage, there may be a well-defi ned gradation of arousal such equanimity is lost: The fl ow of our mental relationships, which vary over a certain range in images can no longer follow through in their different individuals, but require in each indi- inherent predetermined order, but are dominated, vidual a preformed range. Content of conscious- without any check by certain overriding circuits ness in each person thereby gains richness and of mental activity, which might otherwise be individual colour. The diversity of personalities counterbalanced by opposing apperceptions. is mainly due to the different value of each per- Also, a form of unrestrained mental activity may son’s apperceptions, from which come their occur, such that hints of diametrically opposite actions in different circumstances. In the normal perceptions emerge in passing, without the line case, we expect that overvalued apperceptions , of thought being pursued; we call this ‘bewilder- [W] which might lead to action, cannot be ment’ [Ed]. accessed easily, due to opposing apperceptions, Gentlemen! Allow me again to connect this to and their requiring a loss of constraint before a fact that I just hinted at, that mental activity action occurs. The concept of honour, modesty, itself is usually associated with a slight degree of cleanliness, and the like are guiding principles Affect. After the somewhat teleological defi ni- for actions of civilized people. It is required that tion of Affects—as you may have found it— normal values of apperceptions should prevail which I have given, it will not surprise you that within conscious activity. Among mental patients the content of apperceptions in mental activity we often encounter deviations from such normal also exerts its infl uence on accompanying Affect. values of apperception. Part II

The Paranoid States Lecture 9 9

• Overview of clinical results The contrast is between stable conditions and • Mental disturbance diseases actually in the process of developing; • Mental illness and to understand the former intrinsically pres- • Paranoid states ents fewer diffi culties. This is just the same dis- • Unrecovered mental patients tinction as discussed earlier between the content • Patient demonstrations of consciousness and conscious activity: Dealing with alterations to the content of consciousness in the course of normal or near-normal conscious activity is a simpler task. On the other hand, Lecture when actual mental illnesses unfold, we are spectators of conscious activity whose actual course Gentlemen! is abnormal. Conscious activity shifts as a func- Before we approach clinical examination of tion of time, and its output is the specifi c content mental patients, we shall try to get an overview of of consciousness; thus we can defi ne acute men- the tasks we face. Taken altogether, we call the tal illnesses as the process of altering the content subject of our study ‘mental disturbance’ [Ed]—a of consciousness, which we see taking place in a term quite familiar to lay people, and well suited defi ned time period. Such changes are often to include all mental conditions deviating from linked with Affects and changing moods, just as the norm. Among such conditions it is useful fi rst they are under conditions of healthy mental life. to select the simplest ones for study, i.e. those Acute mental illnesses are therefore almost uni- that we might hope to understand with no prior versally accompanied by vivid Affects, and we specialist knowledge, but just on the basis of gen- note that these complicate understanding and eral notions, such as were discussed in earlier treatment of acute mental illnesses. The shorter lectures. The simplest are those with persisting the duration of the acute mental illness, the more alterations in the content of consciousness after stormy the accompanying Affects tend to be; and recovery from mental illness. These in turn are in the event of the outcome not being an actual divided into two major groups depending on return to health, the greater are the resulting alter- whether they are qualitative—falsifi cations of ations in content of consciousness, be they quali- consciousness, or quantitative—defi cit states of tative or quantitative. consciousness. We encounter far more complex We thus have to assume that equivalent nor- symptoms in ‘real’ [Ed] mental illnesses; the mal mental activity can take place within con- more so, the more acute and stormy their course. sciousness, despite the richness of content being

© Springer International Publishing Switzerland 2015 53 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_9 54 9 Lecture 9 of infi nite variety. You can hardly doubt this, to purely local effects of destruction. It is almost since, as mentioned earlier (see p. 22), amongst superfl uous to point out that, in exactly the same people who function with only a small number of way, content-related alterations after recovery concepts can be found individuals whose intelli- from acute stages of mental illness—with excep- gence matches that of people with extensive tions yet to be mentioned—represent incurable learning. conditions. Thus our clinical material will consist Gentlemen! Our immediate task might there- primarily of incurable, so-called old cases [W], fore be to get to know cases of mental disturbance and also of some patients with ongoing condi- which, after recovering from actual illness, carry tions who, in outward appearance and in expres- its residue in the form of altered or defective con- sions of their conscious activity, are very similar tent of consciousness. Activity of consciousness to cases that recover. Most long-term inmates of has returned to normal, and the strong Affects, large mental institutions are such patients, usu- which accompanied the emerging changes in ally without differentiating the two categories content, have disappeared. Patients therefore do based on their very different modes of origin. If not lack Affects, and their Affects are not gener- we eliminate conditions of defi cit from this mate- ally abnormal. Thus, the latter, even when related rial, we can summarize the still very large num- to altered content of consciousness, are not spe- ber of remaining cases under the heading cifi c signs of illness, and can be understood using ‘paranoid states’ [W] because they share the the same criteria as for healthy people. We come common feature—an aberrant alteration of con- across quite similar behaviour in many patients tent of consciousness, in other words, a falsifi ca- with very chronic mental illnesses. These reveal a tion of consciousness. The content of the falsifi ed very slow and gradually-occurring change in the consciousness may be either residual, if it is content of consciousness, a process also occur- retained after recovery from a mental illness, or ring when the organ of consciousness is healthy, may be an expression of a chronic, progressively but which here is due to internal morbid changes developing mental illness. in the organ. In fact, content of consciousness of The full range of ‘residual falsifi cations of mentally healthy individuals undergoes steady consciousness’ [W] will, of course, be relevant increase right into old age. This applies particu- for further classifi cation. We have already seen larly to consciousness of personal identity, since that we can speak of three different aspects of such awareness assimilates the entirety of indi- consciousness—personhood, the external envi- vidual experience. If the same is accomplished ronment, and the physicality of a person’s own by similarly slow disease processes, we observe a body; for a brief description of symptoms related very gradual change of personality, without this to each of these areas, I propose the names: auto- requiring the normal changes to have occurred in psychic, allopsychic, and somatopsychic. external conditions. Extreme Affects, from which ‘Residual autopsychic falsifi cation of conscious- the healthy are not spared either, are here not in ness’ [W] includes, for example, the many cases themselves abnormal, but are often built upon an who are discharged from institutions, following abnormal shift in personality. If we seek an anal- recovery from mental illness, as only ‘improved’ ogy with brain disorders, the gradual change in [Ed], yet unable to be classed as ‘recovered’ [Ed], the content of consciousness may be likened to because they have not achieved full insight into the gradual accumulation of focal symptoms in their mental illness (see p. 39). Misconceptions, the case of a slowly growing tumour substituting mostly false judgments made by these individu- for (and not just displacing) brain tissue. As in als, usually relate to the manner of their treatment such cases, symptoms of mental illness in and the necessity for their staying in the institu- extremely chronic cases thenceforth also bear the tion, to which they owe their relative recovery; hallmark of an incurable disease. In our case, this and since they are reinforced in their opinion by is due to complete amalgamation with the healthy similar false judgments about other patients dur- content of consciousness, and in the tumour due ing their stay in the institution, and believe that 9 Lecture 9 55 they have witnesses amongst the latter, it is in a subsequent episode, then the conclusion understandable that they complain about, and seems justifi ed to the patient, as to all lay people, discredit, the institutions more or less vigorously that merely the enforced admission to the institu- and constantly, according to their individual tem- tion, and the impressions gained there, would peraments. I remind you of the high school have caused the illness. Furthermore, lack of teacher with a doctorate, discharged only as insight into illness is not always an incurable ‘improved’ [Ed], who subsequently resumed his condition: Quite often, memory of supposed teaching activities, and the wine merchant treated experiences of illness and its associated effects here years ago who even now conducts a fl ourish- fade away progressively with the passage of time, ing business: They have both gone to highest especially when there is no lack of regulated authorities with their complaints over injustices activity in the patient’s normal experiences. suffered at the hands of the clinic. A portion of These same patients, who have previously com- these attacks, which in recent years have also plained bitterly, then tend to revisit their institu- been expressed in the press against our treatment tional experiences only reluctantly; they appear of lunatics, can be traced back to such sources. to have partly or completely forgotten them, and Gentlemen! As you see, the point just touched any aversion to doctors or staff of the institution on is of great practical importance. Not only the no longer has any practical consequences. You position of the ‘alienists’ [Ed] but also that of the will remember that we frequently used this fact to medical profession in general, and the public in enable patients, who could not gain full insight need of their help, have an interest in ensuring into their illness despite a long hospital stay, to that the explanation of this is expanded in the return to civilian life and take up an occupation widest circles possible. I will therefore go into appropriate to their abilities. even greater detail on this than I did when com- Gentlemen! A second major category of menting on consciousness of personhood in my patients unfortunately is not destined to return to seventh lecture. Lack of insight into illness is, in civilian life, even though their mental illness has effect, the same as an increase in the sum of a run a similar course, and quite favourably. These person’s memories by a body of data not corre- differ however from the fi rst group in that, apart sponding to reality, as we might gain from the from complete lack of insight into their illness, experiences of a dream. If we were to string these they exhibit fi xed delusions to be classed as often highly adventurous dream experiences onto ‘explanatory delusional ideas’ [Ed], which we our store of memories, what incalculable conse- will study later. As I already suggested, if such quences for our actions or our judgment of peo- patients regard their stay in an institution as an ple might it lead to! Yet this is precisely what injustice infl icted on them, this can only be seen happens in totally incorrect assessments of expe- as a logical consequence of their lack of insight riences subsequently preserved in memories of into their illness. A further inevitable step leads mentally ill people. I must quickly note that lack to the idea of persecution that the purpose of a of insight into an illness may be manifest to vary- period in an institution was to remove the patient ing degrees. In acute mental illnesses it is not from a profession, or even to harm him civilly; or uncommon that the peak of the illness declines to eliminate him temporarily or permanently; or shortly after its beginning, and the patients indeed even to make him insane by enforced mixing gain insight into the more severe phenomena with other mentally-ill people. Usually then, occurring at this most acute stage, but not for there are people who are perceived as persecutors subsequent occasions. It is in the nature of things and enemies, even though they are identifi ed as that special credence be attributed to accounts of some sort of ‘higher power’ [Ed]. More detailed such apparently insightful patients, which is development of this delusional system may differ indeed justifi ed with respect to their admission, widely, depending on a patient’s consciousness but not to their remaining in the institution. of their own personality (or individuality), just as Should insight be acquired about an acute stage the vigour of their action may be based on 56 9 Lecture 9

motivation obtained in this way. If the source of He is polite and accommodating without being persecution is sought among large organizations, obsequious; he evidently puts his trust in the doc- such as the Church, the Freemasons, or state tors in the institution; he is satisfi ed with his stay authorities, then those organizations may be in the institution and its activities and, indeed, excused, on the grounds that they are acting expresses his wish to be discharged, but he can under compulsion; however, the initial suspicion, easily be dissuaded by the opposing view that he and later the certainty about the source of perse- has a carefree existence here. His plans after pos- cution, is often directed at individual persons, sible discharge, to reestablish his position, seem depending on individual experiences, as in regu- quite reasonable. His answers come promptly lar cases where one spouse suspects the other— and their content is appropriate to his level of the real purpose of detention in an institution then education. Also his sphere of interests appears to being to enable an adulterous relationship. In be no more restricted than to be expected from such cases, the doctor is almost always saddled his now 24 years of life secluded from society. with the blame, and is the fi rst participant in the He reads the most important political information conspiracy to be identifi ed. In many cases the and daily news in the newspaper. Attention and fi rst explanatory delusion of persecution has a retention in memory are demonstrably normal. sequel in ones of subsequent explanatory delu- Therefore we appear to be dealing with a sane sions of consecutive grandiose delusions [W], person, one of the unfortunate victims of negli- followed by requisite cooperation of the authori- gence and recklessness by alienists, so often ille- ties, leading to the view that such an unseemly gally detained in institutions, if you believe process had probably been brought only against a reports appearing daily in the press, written by major personality, and that the power of the state well-meaning but untrained and therefore (at had been rendered subservient to the persecutor. least probably) imprudent philanthropists. I have None of these patients can be given their freedom, no doubt that a commission of lay people armed because they make no secret of their violent ten- with the right to discharge patients at their own dencies and danger to the community. The root of discretion—the familiar reformatory idea of their delusional system, namely their detention, those philanthropists—would declare the patient cannot be eliminated and therefore their system of healthy, especially since, towards strangers, he is delusions is constantly supported and reaffi rmed. extremely careful and cautious. However, once However, within the institution, over time, and he puts his trust in us, in the chatting stage, he especially as they become accustomed to useful regales us unreservedly with his experiences. At activity, their Affects can be moderated, and a tol- fi rst we are struck by the fact that he knows noth- erably peaceful existence brought about. ing about having overcome a mental illness; for Gentlemen! As a representative of a third cat- his part he might have come into hospital only egory of old institutional inmates, I present to you because of an acute febrile illness, and he actu- the 61-year-old patient, gardener Rother, who I ally considers it wrong—a mistake—that he has have known for the last 24 years, since 1871, as a been held for so long, even though he admits that past case of acute mental illness, and about whom the doctors had always been kind to him. Then he further information is unfortunately unavailable. tells of a confl ict with one of his gardener’s boys Since that time he has led an active life in the shortly before his admission to the institution. institution, and apart from temporary, short- During the struggle he had been thrown down the duration episodes of excitation occurring years stairs by this man, and had broken his neck. apart, connected mainly with external disturbances in his professional activity, he has shown I ask : ‘Who?’ calm, attentive behaviour and a normal physical ‘Well, me’. condition. He goes in and out freely, and has keys Question: ‘But aren’t you alive and sitting here?’ to the garden and his work area. As you see, his ‘Well, yes, but the other one is probably still appearance is quite appropriate to the situation. there’. 9 Lecture 9 57

Question : ‘What other one?’ America on a causeway that was about as wide as ‘Well, Rother’. an ordinary road. From time to time he came Question : ‘So, once you have been dead; is this across a guesthouse where he could spend the possible?’ night. To right and left he saw the blue sea and ‘Of, course, everyone has a double’. the most beautiful ships. Then once he walked around the Black Sea, in a few hours. People The patient then recounts how he had experi- were busy drying it up. enced other quite different things that no one Gentlemen! For the moment, let us leave the would believe: He had once been a bull and, as question unresolved as to how the patient arrived such, had been tortured in a quite inhumane man- at this enormous number of misconceptions; you ner and then been slaughtered. He describes how will concede in any case that we are dealing with they had drawn a ring through his nose and falsifi cation of content of consciousness on a dragged him along. He had also been crucifi ed grand scale. All three areas are affected equally, once, together with two robbers. but in such a way that the most contradictory ideas coexist without interfering with one Question : ‘Like Jesus Christ?’ another, and that things that are quite impossible ‘Yes, exactly like that’. are not considered to be contrary to everyday Question : ‘Then you are probably Jesus Christ?’ experiences of reality. It is, in a sense, a crum- ‘Yes, I am Jesus Christ’. bling of consciousness into fragments that you see before you, a state of ‘decay of individuality’ The patient goes on to explain that he had also [W], that totally eliminates any systematization. been Gottfried von Bouillon, describing the steel Therefore we cannot talk of any actual system of armour he wore, and had also been a brummer delusions in this patient. The absence of delu- [W] (meaning a blowfl y), and fl ew around sions of persecution and grandiosity coming into like one. existence as a result of logical thought activity We stumble here across most fantastic ideas, will seem only natural; but the surprising lack of in the realms of consciousness of bodily physi- judgment that he shows through his morbid con- cality and personhood, but this patient also car- tent of consciousness makes only a minimal ries around with him equally perverse ideas about impact in the rest of his life. In his profession, he the outside world. From the stately garden where presents even as though he is fully mentally com- he had just recently busied himself, a staircase petent. However, he judges his fellow patients for was alleged to lead down into vast underground the most part as fraudsters, in that he recognizes spaces. There you might encounter all kinds of only the disturbed and excited among them as fabulous monsters, great snakes, dragons, and mentally ill. The fact that such a patient cannot wild beasts. The underground space extends right live in a society, cannot care for himself nor under Breslau, and beyond there into the ‘stand on his own two feet’ [Ed] needs no proof; unknown. The sun shines above, and, around it he is dependent on hospital care forever. you can see the earth rotating, a respectable ball Gentlemen! The patient before you can be in itself. taken, in a sense, as the paradigm for all cases of extensive, residual falsifi cation of consciousness. Question : ‘Does it not then fall down, or is it The extent of the disturbance itself prevents the supported?’ development of a delusional system. However, ‘It rests on a big pointed stone’. the relatively complete recovery from the disease process enables him to develop approximately In his journeys the patient has travelled far. He normal mental activity within the boundaries of is on foot, and in 3 days has gone from Europe to his professional interest, and thus an active life. Lecture 10 10

• Patient demonstrations (continued) elevated self-assurance, she is persistently submissive by nature; she rises at each salutation and bows, doing this to every fellow patient, even to a very feeble-minded female paralytic patient. Lecture She often apologizes that she has not behaved in a seemly manner, and begs that her words not be Gentlemen! taken as too sharp. She regards her fellow patients The patient I present to you today is a typical as men of the cloth, usually high-ranking clerics example of slowly emerging ‘allopsychic falsifi - who are here in part for repentance. The doctor cation of consciousness’ [W]. She is a 45-year- too belongs to the clergy, although he may previ- old agent’s widow, Frau Reisewitz, whose illness ously have been a physician. She declares a developed gradually over the last 5 years, from 13-year-old girl to be the Duchess Arco, chief barely noticeable beginnings, and is expected to wardress to His Majesty Kaiser Friedrich, and develop further. She has already surprised you as others as guards for certain princes. All of these she enters, by her measured and somewhat digni- people had been around her in Dalldorf but would fi ed bearing, and her facial expression is simi- have made changes in their appearance since larly rather solemn. She says, when asked, that then. She alone remains unchanged. she had lived in Dalldorf, from where she was Gentlemen! The information we have just brought here, and that her surroundings there obtained suggests a so-called systematic delusion must have been brought with her here to Breslau. based mainly on recurring religious themes, and She does not recognize the building where she is an autopsychic falsifi cation has developed, lead- as a hospital; these are ‘sacred places’ [W], a ing the patient, having now survived the examina- ‘house of God’ [W], all bearing the stamp of reli- tion period, to play the role of a priest or gious solemnity. The purpose of her stay is prob- prophetess. Particularly striking to us however is ably to prepare for a future important position; her reinterpretation of people and the whole sur- she is still very unworthy, and great honour falls rounding to fi t this religious delusion. Given the on her by her being included here. Possibly she apparent prudence and the peaceful behaviour of owes it to a high priest, to whom she turned in her the patient, we cannot assume that her senses have misfortune. The fact that she has been through a deceived her, such that she could not observe great deal of misfortune and suffering is well objects and events in the outside world correctly; known; her name is known throughout Breslau. yet everything is identifi ed in a reconfi gured man- Apart from the interpretation she conveys of ner to match certain prevailing notions, and, as is

© Springer International Publishing Switzerland 2015 59 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_10 60 10 Lecture 10 often the case, within just such a religious frame- she maintains a roughly constant body weight; work. And so she presents us with a striking and her behaviour at today’s clinical presentation example of disturbed secondary identifi cation shows nothing remarkable. Her answers are resulting from delusional content of conscious- prompt and meaningful. She is fully orientated ness altered by mental illness. I intend to return with respect to her surroundings, her current situ- later to the amnesia very characteristic of such ation and her former illness, and also about all cases. With regard to her current mental status, it her personal circumstances; namely, she has was noted only that she was not entirely free from good memory for certain details of her illness. sensory deceptions. Very few auditory hallucina- The sum total of her knowledge is consistent with tions seem to occur, whereas olfactory hallucina- her stage and level of education; despite a degree tions and subjective skin sensations are fairly of malaise, her mood is elevated rather than common. The former are interpreted as audible depressed. On the ward, however, she does not blessings, perhaps the voice of God; in the latter always behave appropriately and comes only two sensory domains, the ‘vaporization’ [W] of from time to time to her occupation in the sewing chloroform and the ‘electrical treatment’ [W] are room, usually preferring to become involved in usually accepted patiently as tests, and leave all kinds of things that do not concern her, giving behind bodily weakness; but sometimes they pro- advice, and harassing her fellow patients through voke outbursts of anger and energetic ranting. A jokes and childish behaviour. For example she prolonged conversation is perceived as stressful; pulls the bedclothes off them, or throws water in but nevertheless you can obtain accurate informa- their face to surprise them, steals from them, or tion about personal details of the patient right up perhaps steals food she is not entitled to from the to the time of onset of her illness; memory defi cits kitchen. She is in the habit of disrupting clinical do not exist; attention and memory are approxi- rounds by interjecting. She disobeys doctor’s mately normal. orders, and if she is sent to bed for disciplinary You will observe the contrast between this reasons is unabashed to wander naked in the cor- case with such pronounced allopsychic falsifi ca- ridor. So you see, gentlemen, that the patient’s tion of consciousness and another patient, in behaviour is in no way normal, but, on the con- whom consciousness of the outside world is in no trary, requires so much patience and forbearance way involved over the entire course of the illness on the part of her surroundings that she can exist right up to the present time, while the main alter- only within the special confi nes of an institution. ations are in awareness of physicality, and, in due You will see later that many patients are in the course, also of personhood. We can take it as an same situation: After recovery from actual men- example of residual, mainly ‘somatopsychic fal- tal illness, they prove themselves incapable of sifi cation of consciousness’ [W]. This is a living anywhere else than in an institution, on 46-year-old female cook, Tscheike, who had account of their social incompatibility, and their been treated for 4 months in our clinic 5 years demanding and mainly egotistical behaviour ago, and was then transferred to the asylum in the requiring constant supervision. On closer investi- city of Berlin. She was discharged from there as gation our patient shows that she is also full of a relatively improved, but after multiple attempts vast number of misconceptions. At the time of to resume her employment fi nally came back to her illness she suffered from bronchitis. She was our clinic. The period of her fi rst stay could be so full of mucus at the time that she felt that a regarded rather as the most acute stage of a men- prehistoric man, a bloodthirsty man, or a lance- tal disturbance, which up until then had been let—she uses these three terms synonymously— gradually increasing over a 2-year period and had had entered her body. The prehistoric man been accompanied by all kinds of serious distur- disturbed her greatly—he had been housed in her bances of general health. Currently, she is entirely body as if a living child was therein. He was orig- free of such complaints and presents a healthy inally created in the diaphragm; he has a trans- appearance; her bodily functions are controlled; parent pink body consisting of phlegm—as might 10 Lecture 10 61 be seen in an aquarium—an angel’s head, and a Gentlemen! We will talk later about the processes pointed tail. He lies within her in such a way that by which such falsifi cations of consciousness— the head is in her brain, the body along her spine, partly somatopsychic, partly autopsychic—actu- and the tail above her anus. He often wanted to ally arise. I want to emphasize just one point get out, forcefully, which she noticed from here: That we have observed in these patients the stitches on top of her skull and below at her anus. time at which somatopsychic delusional ideas He lived on what she ate, but mainly on what she actually originate, and can thus provide evidence drank, which was why she had to drink so much. of their origin from abnormal physical sensa- Since that time she had doubled everything— tions. If such fantastic ideas could arise from double nerves, double heart beat, and even a dou- one’s own body, we need to remind ourselves of ble brain. From that time on she also had gained the peculiar situation in which these patients fi nd a very young face like that of a 15-year-old girl themselves: Patients experience morbid feelings with the head of an angel, and her pockmarked which are hitherto quite unknown, totally devoid skin had become smooth. (The patient actually of any analogy with normal bodily sensations, for has numerous pockmarks on her face.) At the which patients lack any vocabulary to describe time of her illness the right half of her brain had their experiences. Parables, similes, or analogies broken out on one occasion: She had suffered are then forced up to conscious levels in distinc- from severe headaches and nausea; the vomit tive ways for each patient, and are then used as a looked like brewer’s yeast; she felt that the right means of description. During the acute, Affect- half of her brain had suffered damage. The dis- laden stage we hear patients complaining all too eased half of the brain later replaced itself. often how indescribable, unspeakable, and Through the illness she had also received dou- unique are the feelings which affl ict them. The bled thought—‘on the one hand the epitome of bodily localization of these feelings—which may everything that had been my work, on the other be more or less defi nite—then provides the main hand politics and science’. In fact, she seems to evidence leading to the development of a delu- differentiate between her earlier mental status, sion, by way of explanation, whose building which corresponded well to her areas of interest blocks are then adaptations of each individual’s as a cook, and her mental activity since the onset scientifi c knowledge. Our patient was probably of her illness. She believes that she has ‘genius in infl uenced by Häckel’s undigested writings when everything’, and has apparently read a number of she conceived her delusional system. A further books, which aroused her interest but with no delusional explanation is based on the autopsy- comprehension. She mentions the book by chic notion that, due to the illness, she has come Häckel, ‘Urmensch oder Lanzettfi sch’ [W], but into possession of a new way of thinking, extend- believes that Häckel means something like binding to politics and science. In this, she expresses ing, or belonging together. According to her, a her own perception that her mental activity has person has 27 senses: profundity, combativeness, changed direction, due to alterations in the con- hygiene, sense of language, word meaning, sense tent of her consciousness, a point to which I shall of colour, and artistic sense; the others she just soon return. The nonsensical, apparently feeble- could not recollect. She writes treatises on politi- minded aspect of her thought processes, here cal conditions, of which I shall read you only the associated with elevated mood—a contrast with beginning of one: ‘The lowest class of people is the way her thoughts had formed previously— used to save the life of the higher. As a conse- can thus be fully explained. quence, the poor individuals receive an acute or Gentlemen! You will recall an even purer pic- the opposite of it. This stomach ache is related to ture of residual somatopsychic falsifi cation of chlorosis’ etc. She emphasizes that she under- consciousness from last semester. I presented to stands something of medicine, can treat fractures, you a 65-year-old woman about whose past we apply bandages, cure diphtheria, etc.; and it is could fi nd no detail. According to her own this that leads her to interfere during ward rounds. account she had been through a serious illness 62 10 Lecture 10

18 years previously, that left her entire body, ance. The suspicion we therefore had, that he was especially her outer body, permanently disfi g- still suffering physical sensations, was confi rmed ured. She complained about her horrible ugly when we examined him; for it revealed that the face, her plump ungainly limbs, her altered skin patient still felt an obstruction and constriction of shade, her imbecilic facial expression, and the the bowel immediately proximal to the anus, and like, while in reality she was a graceful, fi nely complained about extreme discomfort and all built, and relatively intelligent, introverted, sorts of abnormal sensations during defaecation, elderly lady. She had no abnormalities of sensa- albeit conveyed with a sense of hopelessness and tion, nor did her general condition reveal any dis- requested medical treatment for his actual turbances. Nevertheless, more extensive suffering. examination showed other severe changes, noted Gentlemen! The 57-year-old master mason’s as defi cits, which encroached principally on the widow, Frau Schmidt, who I present to you next, allopsychic and autopsychic domains. In addi- makes a perfectly healthy impression in physical tion, close scrutiny showed that her memory had terms; she does not complain of any disturbances decreased signifi cantly, from which we reach the in her general condition, and calmly and reason- conclusion of a residual falsifi cation of con- ably gives the following information about her sciousness, complicating mental disorder of the discomforts. The occasion for her forcible trans- elderly. The initially striking purity of the case fer here would have been the harassment to which was thus proved mistaken. she was subjected at home, and to which she had Far purer was the clinical picture in the other responded with threats against their families and example I presented at the same time of a residual other residents; she had mainly been sprayed and somatopsychic falsifi cation of consciousness. hosed, and shot at from all sides. But let her speak You will recall, this was the case of a young man for herself. ‘I felt as though I had been injected of 20 years age, Biega, who as a result of his ill- with a syringe in fi ne jets on my skin, usually ness claimed to have experienced a deformity affecting my head. It happened when I stood at a such that he had become a hunchback; his upper window that I heard a signal, and then received a ribs had become sunken, while the lower ribs had spray, often in my eyes as well, so that I could not expanded angularly, and his shoulders had see. At fi rst there was bone damage as well—they slipped down considerably. Objectively, nothing were red and infl amed, and I also heard shots could be seen of all these changes, and they no fi red, injuring my arm, chest and other parts of longer caused the patient any discomfort; but my body. Something had been painted on the probably he was recalling the time when the skin of my feet, the heel especially, so that I could change had set in, with pain and indescribable not walk for 8 days. Sometimes, when I went to sensations—a period that lasted for years. While bed I got sharp splashes, which stung me. this had opened up conversation with the patient, Anyway, the walls were hollow and passages had it demonstrated that he had no defi cits of any been dug out. I was sprayed from there. I do not kind; and by very careful testing it could be know who could be persecuting me in such a shown that attention and memory were normal. manner. I think it is a punishment but I do not Nevertheless, the whole demeanour and external know who has the right to punish me so’. appearance of this patient gave the impression of She then tells how the medical check-up that profound mental disturbance—his broken pos- would have preceded her transfer did not go prop- ture, his meagre responses, his ‘out-of-tune’ [W] erly. Somebody had put a woman in the clothes of face, cool extremities, and morbid complexion her well-known physician, Dr H. However; she surprised us right from the start. We also learned recognized from his beautiful teeth that it was not that he was quite reclusive in his behaviour on the a man but a woman. Here in the institution the ward, hiding away from other patients, eating enactments ceased, for the most part. Yet we inadequately, and severely neglecting his appear- learned from the case notes that the patient had 10 Lecture 10 63 complained of being harassed around her genita- and was a malign and quarrelsome person. She lia during the night and of having seen a shadow. had noticed soon after taking over the child that In the ward she has complained of other physical she must have been slandered in some taverns; abuse. At home someone had forcibly broken her amongst other things she had been accused of teeth and glued her lips together with a greasy sexual intercourse with Frau W.’s husband; at substance and closed them tightly. At times she every opportunity she had been insulted and complained of burning facial pains, which she harassed; on the street she had been told to her explained by somebody having poured a caustic face that she was a whore, etc. Emphatically, only substance over her face. Regarding the develop- Frau W. could have been to blame; this could all ment of the illness, we learned from the patient’s be attributed to her. In the end, after ‘years of son-in-law that she had felt herself persecuted in malicious persecution and deliberate enticement this way for 5 years, and a few years ago had of the child’, she had fi led a lawsuit, but did not became unsociable and distrustful, and did not go know what had become of it. Finally, to have out anymore. Occasionally she had complained of some peace, she had moved to the little town of voices emanating from a wall, without going into K., but had noticed that she was also abused by any greater detail. Out of mistrust she fi nally dis- people there. Apparently Frau W. had written to missed her housemaid and did the housework her- this place, and stirred up people there. She then self. She failed to recognize one of her returned to Breslau and found it worse than ever. grandchildren, and claimed that the child had She heard the words whore, mad bitch, and the been planted on them. Finally, she had threatened like even from small school children and, to smash every window pane in the house. undoubtedly, the midwife Frau W. was to blame. The patient was apparently suffering a slowly Three weeks ago the latter made a complaint developing paranoia, the basis for which could about her to police headquarters, upon which as be found mainly in a series of morbid sensations she correctly describes she had been visited by a and tactile hallucinations. She notices changes police medical specialist. She, the patient, how- in her body but, in contrast to the previous ever understood the process quite differently: She patient, attributes these to outside infl uences; believed that the police chief was engaged in an and thus she reaches allopsychic—in addition to illicit affair with Frau W., and had agreed with somatopsychic—falsifi cation of consciousness. her to bring her [the patient], a person with com- We will encounter a similar paranoia in the fol- pletely normal mental health, into the asylum. lowing case, but with a very different origin: You can see, gentlemen, that this woman The 50-year-old, fl ourishing, well-nourished regards her delusional system with a semblance gunsmith’s widow, Frau Reising, complained of probability. She speaks correctly in accord that she had been cunningly lured from her home with her level of education, and gives a smart and by a policeman and brought here. This involun- energetic impression. She has been hospitalized tary transfer to the asylum was obviously an act for 3 months. Initially she was most insistent that of revenge by Frau W., who was known to the she be discharged, became easily excited when district police chief, with whom she associated. this was refused, and frequently gave utterances This would have enabled her to involve the police indicating a continuation of her auditory halluci- in her plans. She had known this Frau W., a busy nations. Gradually, she became affable and midwife, for 6 years. Since she, the patient, was friendly, and auditory hallucinations appeared to childless, and had noted that Frau W. treated her have subsided. Moreover, she knows nothing of daughter badly—‘the kid got in the mother’s ‘voices’ [W], but apparently projects her halluci- way’ she interpolated—she had taken the child to nations onto people round about. raise herself. Two years later the child was taken She explains her detention in the asylum by away again, for no reason. In the meantime she the doctors having to act according to the instruc- had learnt that Frau W. led an immoral lifestyle, tions from the police. In addition, apart from 64 10 Lecture 10 occasional stomach pains, we have heard of no chronic progressive falsifi cation of consciousness. physical complaints. Her body weight decreased Auditory hallucinations of morbid and threatening by about seven pounds over the fi rst 2 months, content appear to form its basis, so that we can and has increased somewhat since then. formulate it provisionally as a particular form of Gentlemen! The patient, Frau Reising, is a typi- allopsychic falsifi cation of consciousness. Later, cal example of a commonly encountered form of we shall come to deeper understanding of the case. Lecture 11 11

• Interrelationship of lapsed so-called old cases defi nition, we might accept that, amongst cases I to chronic psychoses have shown, there are conspicuous differences • Explanatory delusional ideas of autopsychic, not only in terms of presenting fi ndings but also allopsychic, and somatopsychic origin of their histories and origins. The diversity of • Autochthonous ideas and hallucinations presenting medical conditions could easily be characterized in greater detail if we were to use the terms autopsychosis, allopsychosis, somatopsychosis, and their various combinations. For Lecture any material falsifi cation of consciousness covering all three areas of consciousness, the term Gentlemen! would then be ‘total psychosis’ [Ed]; but when it Before we make acquaintance with new was just a portion of this totality which had been patients, we should dwell for a moment on attacked, the name in question would be some patients we have already seen, while they are still appropriate combination of these terms. fresh in our minds. Firstly, let us face the ques- According to this classifi cation, the fi rst patient tion of nomenclature. According to current labels, presented, the gardener Rother, would be classed all those patients would be examples of ‘chronic as an example of a total chronic psychosis; Frau insanity’ [Ed] or ‘paranoia’ [Ed]. However, if we Reisewitz, a chronic auto- allopsychotic; the wanted to comprehend [W] it in this way—that patient Tscheike, a chronic auto-somatopsy- paranoia was a well-characterized clinical form chotic; the Biega case, a pure somatopsychotic; of illness—then the fl oodgates of greatest confu- Frau Schmidt, a combined chronic allo-somato- sion of concepts would be opened, for the cases psychotic; and Frau Reising, a chronic allopsy- show very great differences from one another. chotic. By addition of ‘residual’ [W] you could We can avoid this misunderstanding if we talk of emphasize the importance of that group of paranoid states [W], which include all those patients in whom the disease process had appar- chronic mental disorders where we encounter fal- ently run its course, with the patients returning to sifi cation of content of consciousness, while con- health, without their having gained any insight scious activity remains well preserved. In so into their illness. doing, we believe that we cater for the view, often The necessity of the latter distinction can, expressed by earlier authors, that we should however, lead us to introduce other, somewhat include under paranoia an overriding disturbance simplifi ed terms into the fi eld. It might, perhaps, of intellectual activity. Under this very broad be advisable to reserve the term ‘chronic mental

© Springer International Publishing Switzerland 2015 65 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_11 66 11 Lecture 11 disorder’ [Ed] just for residual cases, and apply concert. We came to recognize that the strength the term ‘psychosis’ [Ed], with appropriate com- of these functional links varied, depending on bination of words, only to those cases of mental how often they were used. However, since this disturbance actively in progress. If we were to strength was intrinsic to the most complex, high- prefer this nomenclature, then all cases which, est level of associative links, we were led to con- relatively speaking, have recovered (but without clude, quite generally, that there existed a insight into their illness), and the two patients balanced and regular organization in the fl ow of Rother and Tscheike, would be included in the mental activity in any normally developed per- area of chronic residual mental disorder. All cases son. So, let us assume that in the reverberations I presented—and others mentioned in passing— of the same combination of associative elements, belong in the area of actual chronic psychoses. All the same mental processes always take place. We psychotics who do not progress to full recovery would then not be too bold were we to conclude but reach a standstill fall in the group of chronic that, in this sense, the set of ‘specifi c energies’ mental disorder, under this classifi cation. [Ed] of sensory elements may be transferred to Gentlemen! If such a distinction (as we the entire organ of association. The way in which acknowledged is no more than a clinical require- such associative links are triggered into action is ment) still has to be made, you will ask whether thus somewhat irrelevant: Under some circum- it would not have been better to separate past stances it can be an aberrant internal stimulus cases and chronic psychoses from the beginning. which starts off various psychic processes, Now, it will still be fresh in your memory from depending on its localization. For purposes of my introductory remarks that we can recognize this analysis, all changes in content of conscious- falsifi cation of consciousness occurring in both ness can then be likened to focal symptoms, and categories of mental disturbance, and, as you will behave just as do more familiar focal symp- gradually get to know all inmates of our clinic, toms of brain diseases; but these naturally will you will fi nd many patients amongst whom it is have different clinical ‘weighting’ [Ed] depend- quite impossible to decide immediately which of ing on whether they correspond with the stimulus the two categories they belong to, since informa- state or the paralysis state. tion on their past is missing. But even when it is Let us take examples from neurology: A major possible to obtain detailed information, it is often cerebral haemorrhage of the well-known mar- so far back in the past that inaccuracies and dis- ginal artery of the lentiform nucleus or an embo- tortions are inevitable; and therefore, just as for lism of the f. S. artery generates during the period the obvious inadequacies of lay observations, one of acute illness not only hemiplegia, but also a can no longer reliably distinguish these two series of severe accompanying symptoms, to be groups of illness. Combining all such ‘old cases’ seen as secondary effects of local brain injury. [W] into a single large group, that of ‘paranoid Residual hemiplegia remains as a permanent out- states’ [Ed], therefore meets a practical need. come, while side effects of the focal damage dis- However, if we dig deeper, we come to appear. However, exactly the same fi nding of understand an indisputable connection between hemiplegia may come about when a slowly- the two. Allow me to suggest what is for me the growing tumour or chronic brain-softening critical aspect, even if I cannot now treat it with causes tissue destruction only very locally; at the breadth it deserves from a theoretical point fi rst (usually) there is a slowly developing mono- of view: plegia affecting for example the leg; then a bra- The content of our consciousness was pre- chial monoplegia may arise, then one involving sented to you in introductory lectures as some- the facio-lingual area, so that, fi nally, hemiplegia thing acquired, indeed acquired through emerges. Corresponding with such slow progres- functioning of the organ of consciousness itself. sion, there may be total absence of severe general Each new acquisition corresponded to a specifi c symptoms. However, the site of brain destruction pattern of associative elements functioning in is the same in both cases, so it is fair to compare 11 Lecture 11 67 a residual focus with a chronically developing explanatory delusional ideas to every single one one. In exactly the same way we can fairly equate of the acute symptoms that we will encounter residual alteration in content—as a localized pro- later. Here, only certain types of explanatory cess—with changes in content when psychoses delusions are evident. We follow the guideline progress slowly. that they should lead in part to understanding Gentlemen! The comparison we have made cases as presented, and in part to recognition of with brain diseases has proved so instructive that pathological principles, as necessary and essen- we should apply the analogy to another major— tial hypotheses in the psychiatric clinic. and unavoidable—question. When can a mental The area of somatopsychic explanatory delu- illness be considered to have run its course, apart sions [W] is almost indescribable in its variety. from cases of it actually having been ‘cured’ We met an example in the case of the patient [Ed]? When can it be regarded as still present, or Tscheike. Her conceptions arose at a time when increasing in intensity? For residual hemiplegia, supposed changes in the body would have been we have no doubts about this matter. For mental directly experienced; but seldom do they remain illnesses on the other hand there is often great as harmless as in this naïve admirer of Häckel. diffi culty in deciding this; and I have already More commonly, changes which the body has pointed out (p. 55) that in cases we might other- supposedly suffered are regarded as arising from wise deem to have run their course, new psy- external infl uences, and then become channels chotic symptoms have emerged, associated with for the patient’s resentment and hatred against explanatory delusions, and, in practice these can people or institutions—and I remind you here of be of the greatest importance. I must note here the patient, Frau Schmidt. Another patient of the that such explanatory delusions only rarely stay same type, who I presented to you recently, limited to the initial delusional ideas (usually of expressed his indignation in a more drastic way, persecution, see above) but often develop further in that he believed that this type of treatment had in the most consistent manner, forever giving rise degraded him virtually to a pig; he repeatedly to new delusions. Precisely this process, the so- called himself a pig, yet leaving no doubt that he called systematization [Ed], has always been did not mean actual change in his body but only seen as indicating that a patient is incurable— linking it fi guratively with the aforementioned albeit erroneously, as we shall see later. Should meaning. The real change in his body—his main we now believe that such progression of delu- complaint—was that his head had been divided sions runs in parallel with progression of the dis- by the impact of hammer blows; his face had ease process itself? As I already indicated, we slipped down; the cranial vault had been pushed should not assume this automatically; rather, we upwards; and thus his entire head had become should recognize that, once established, without broader. The entire alteration had taken place any new adverse processes needing to be in play quite rapidly, over one night. Somebody had within the brain, an alteration of content of con- imposed these changes on him; how this had sciousness can have most disastrous conse- been done, he left to the doctors, because he was quences for the entirety of subsequent mental life a layman. You will probably still remember the of the individual, possibly even in direct confl ict clarity with which this intelligent patient, a with it, because normal fl ow of mental activity 27-year-old merchant who had been mentally ill and strict logic has been preserved in the indi- for 3 years, developed his explanatory delusions vidual. We must soon duly consider this effect of in relation to their motive. This shifted between once-established change in content of conscious- three different assumptions. To him, the most ness—the emergence of explanatory delusions. likely one was that someone wanted to drive him Gentlemen! It would be going too far and take mad and so eliminate him. When I then asked up too much of this clinical lecture were I to dis- whether he was therefore insane, he responded, cuss here ‘delusions of explanation’ [W] more you will remember, by declaring that this was broadly. Suffi ce it to say that we can trace back highly likely. The other explanation to which he 68 11 Lecture 11 was inclined was that the physical abuses were patient, indisputable general malaise was blamed intended to test him and prepare him for a higher on the institutional administration—and all his calling. In particular, the disfi gurement of his thoughts and endeavours were then consequently head might serve to give him the outward appear- directed towards shifting to a different institution, ance of a high-ranking personage, the Duke of since he felt far too ill to do without institutional Sagan. He added indignantly, ‘However, I will care. not assume the name, because then I might actu- For autopsychic explanatory delusions [W] ally be a pig in my innermost heart’. A third pos- we have already found an example in the patient, sibility fl oated before the patient: The purpose of Tscheike. She claimed, since her illness, to be such manipulations was to entertain other people able to think ‘in double’ by her embracing a and have fun. ‘The whole thing is perhaps a newly acquired ability, enabling her to argue human game, or a fashion game, or pure theatre’. about learned, political matters and the like, in By presenting these three possibilities he addition to her kitchen duties. undoubtedly counted on the assumption that a One of the most important sets of explanatory whole conspiracy had been set against him. delusions of autopsychic origin is built around Gentlemen! I have no doubt that in a few semes- what we shall call ‘autochthonous ideas’. [W] ters I can present to you the same patient, in pos- Patients notice the emergence of thoughts which session of the same, well-preserved formal logic they consider to be alien to themselves, not per- and dialectics, and that he no longer ranges across ceived as normal, that is, probably not created by various possibilities but offers a fi rmly founded, the usual processes of association. Interpretation uniform delusional system. Whether this corre- of this symptom presents no problem, since it is sponds to one of the latter dubious possibilities or exactly what we would expect from aberrant stim- is rather a new, far more complex delusional uli acting at a particular location in the organ of structure cannot yet be determined. The second association. We assume that such an aberrant of these assumptions seems more likely, because, stimulus is stronger than normal excitatory pro- at present, we see the patient constantly revising, cesses involved in the act of association; that con- under the infl uence of new psychotic experi- sequently, such a stimulus occupies a peak of the ences. We do not always get the opportunity to psychophysical wave of excitation; and that it dis- see the very process of systematization itself, as turbs otherwise normal and ordered thought pro- we can in this patient, due to his level of educa- cesses. In any event, attention is forcibly directed tion, his well-maintained logic and prudence, and towards such autochthonous ideas, and others are willingness to share it with us. Usually we have perceived as annoying intruders. In this connec- to deal with explanatory delusions only as ready- tion such ideas bear close resemblance to equally made facts, leaving no doubt about their mean- annoying, so-called obsessional ideas, but differ ing. I merely make you aware of one of the most in that the latter are never perceived as foreign common somatopsychic explanatory delusional and alien to the personality, and consequently do ideas because it is of great practical importance. not attain the disastrous importance for the There is a predilection for people in the immedi- entirety of mental life as do autochthonous ate environment (e.g. family members), or the thoughts. Apart from that, disturbances of associ- institution’s administration to be blamed for the ation, brought about by autochthonous ideas, in physical agony. A patient of this nature, with many patients—especially those with more fi nely such a round-about description of the change in organized personality—are equally distressing, content of his consciousness, is seen by many often even so more than physical feelings and doctors as a hypochondriac, that is, suffering pain; they are almost always a fruitful source of from neurosis rather than psychosis. This patient autopsychic explanatory delusions. Hence, laid the blame on his wife, who in the end had to amongst mentally-ill people, only as an exception invoke a separation, to protect herself from his do you fi nd an ‘objective’ [Ed] observer who verbal and physical ill treatment. In another experiences just the ‘foreignness’ [Ed] of emerg- 11 Lecture 11 69 ing thoughts without attaching to them any far- religious beliefs, belief in miracles and supersti- fetched interpretation. Almost always, these tions ruled their minds, and corresponding con- thoughts are said to be ‘made’ [W], ‘looked for’ tents of explanatory delusions in everyday [W], ‘inserted’ [W], and probably also that they parlance, for which you can fi nd most telling ‘took it to be’ [W]; how and in what manner this examples, were extorted confessions of unfortu- occurs depends entirely on each patient’s individ- nate victims of numerous witch trials. uality, and his not-unrelated store of innate ideas. We fi nd similar dependence of specifi c con- Pious thoughts come from God; evil thoughts are tent of the delusions on prevailing ideas of the instilled by the Devil; more enlightened individu- period, these being specially prominent in allo- als rely on physical tools, for whose handling they psychic delusions of explanation [W]. The most usually put their trust in doctors. So it also was common bases for delusional ‘explanations’ [Ed] with the merchant, whose somatopsychic explan- are sensory deceptions, under which heading we atory delusions have just occupied us; he com- include both hallucinations and illusions. In our plained about ‘strange thoughts’ [W] affl icting his sense, sensory deceptions are defi ned as psycho- mind, especially those that disturbed his sleep and sensory hyperaesthesias and paraesthesias; fur- which, at the onset of his illness, incapacitated ther detail is reserved for a later lecture. The him in his professional role. He was also able to effect is always that content of consciousness is indicate the direction whence his thoughts ‘pur- increased by various false components in the sued’ [W] him; probably this was due to simulta- allopsychic area. They are usually construed by neous abnormal physical sensations: They came patients as ‘foreign’ [W] phenomena, which pro- from above, from the ceiling. At the most critical voke the explanation; however, for reasons that time, he actually revealed, insofar as he presumed we will come to recognize later, their reality is to explain his thoughts as being based on sugges- usually not doubted. The explanation is usually tion and hypnotism, that he had not noticed the act achieved by adopting some ‘physical medium’ of his being hypnotized, and it would have taken [Ed], for which any enemy and persecutor—in place against his will. You will probably still rare cases friends and patrons as well—can serve. remember how hard it was for me to get the The nature of the medium varies for each indi- patient to divulge information about these vidual, and the system based on it corresponds thoughts—only after prolonged pleading on my exactly to each patient’s level of education. To part did he deign to impart them. There was no explain auditory hallucinations, uneducated peo- need to give the reason for his refusal, his thoughts ple usually refer to a device similar to a simple already being known to me. We will come across speaking tube: Either holes are bored through the this phenomenon of ‘thought becoming sound’ wall, or the walls are hollow, or there are under- [1 ] [W] from other sources. One of the most com- ground passages, and so on. For a while, the tele- mon explanatory delusional ideas for the symp- graph played the same role, for all those for tom of autochthonous thoughts is that patients see whom it conveyed only sound, and now it is doctors as authors of their thoughts, and therefore almost universally replaced by the telephone. For assume these to be known already by them. The those with some education in physics, absence of response heard so often from quiet sufferers, ‘You visible wires creates no diffi culty since experi- already know that’ or ‘You know that much better ments on the heart have established that electric- yourself’, usually conveys this meaning. ity can be propagated without fi xed conductors. Gentlemen! You see from this example just False perceptions in the visual sense are attrib- how much the era we live in can infl uence the uted to more or less complicated optical instru- specifi c content in all appearances of explanatory ments; simpler mirror devices and projectors are delusions. We currently have no fewer than three popular here. Tactile hallucinations lead to the chronic patients in the clinic, whose explanatory idea of being sprayed or sprinkled, usually of delusion is built up from received ideas about course with harmful substances, and, if there are hypnotism and suggestion. In the Middle Ages, tingling sensations, most people know this to be 70 11 Lecture 11 due to electricity. The sensation of pricking, of same hallucinations can also be interpreted in a being attacked and touched on various parts of favourable sense, as a source of advice, a super- the body, etc. are projected externally by patients. vising agency, a treatment for the body to toughen Deceptions in smell and taste may vary, depend- or harden ones’ self against injurious infl uences, ing on the knowledge, the school of thought of etc. This cannot be based solely on individual dif- each individual, and the supposed effect; but ferences in coloration of the hallucinations, since these are mostly interpreted as harmful or toxic. we will gradually fi nd that this content is not The so-called physical persecution complex [W], itself a random selection but varies according to of which you saw an example in patient Schmidt, how the illness presents itself, and can therefore is based, as you can see, on just such attempts at be regularly codifi ed. explanation; we will therefore not evaluate it as a clinical form of illness, or at least only in the same sense as any other type of explanatory delu- Reference sion. To assign persecution complexes formed in this way to the correct place in the science of 1. Cramer A. Die Halluzinationen im Muskelsinn bei Geisteskranken und ihre klinische Bedeutung, ein disease requires totally different criteria. This is Beitrag zur Kenntnis der Paranoia. Freiburg: clear from the single fact that in rare cases the Mohr;1889. Lecture 12 12

• Sejunction hypothesis question is raised proves to you the diffi culty that • An attempt to explain pathological symptoms often confronts us in deciding between residual of stimulation mental disorder and chronic psychoses. • Delusional explanatory ideas resulting from We would do well to avoid answering, until I motility symptoms and from intrinsically nor- have introduced a hypothesis about language, mal functions which, on its own, in my view, can guide us to deeper understanding of the essence of all mental illnesses. Here I remind you of our fi rst patient, the gardener Rother who, incidentally, also suf- Lecture fers from sensory deceptions, albeit rarely and then only temporarily. How is it possible, we Gentlemen! wonder, that in the same head such a vast quan- In the previous discussion of allopsychic delu- tity of misconceptions and misjudgments can sions of explanation we could not avoid the fact exist side by side, in such contrast both among that a large proportion of chronic psychotic themselves and with reality, with well-preserved states, whether they be temporary or permanent, formal logic, apparent prudence, and totally are accompanied by sensory deceptions, admit- accurate appreciation of the reality of his situa- tedly—in the former case—just insofar as they tion? Well, gentlemen, compared with the indis- coincide with episodes of acute illness. In addi- putable facts seen after the origin of his current tion, sensory deceptions can persist, even in cases condition, the answer is undeniable: It was the of residual chronic mental disturbance, some- acute mental illness that created the gap in the times permanently, sometimes temporarily, or solid structure of his associations. We will give only on certain occasions. This appears to contra- this process of detachment an appropriate name dict all our preconceptions that conscious activity and call it ‘sejunction’ [W]; we cannot fail to see has returned to normal in residual paranoid states, it as a defi cit, a break in continuity, which must since it is notable that, for sensory deceptions, correspond with failure of certain lines of asso- there is a clear disturbance of conscious activity. ciation. The fact that, in the brain, different ideas If it has not returned to normal, then we ask our- and idea complexes are not merely juxtaposed, selves whether any defi nite signs of a more fl orid, but are normally combined into larger groups, evolving disease process remain, when chronic and fi nally into unity of the ego, can, in the fi nal mental disorder is accompanied by sensory analysis, be due only to associative processes. deceptions. Gentlemen! The very fact that this The very fact that this patient is unaware of

contradictions between his various misconcep- in many old cases. In other cases, unmistakable tions suggests that the combination of all higher progressive changes in content suggest the same associations into a single unit, the ego, has chronic progression, albeit less obvious. Whether ceased. This individual consists simultaneously, the disease eventually merges into a state of defi - as it were, of a number of different personalities: cit, namely dementia, depends on the extent of We could boldly call his condition a ‘disintegra- the sejunction. tion of individuality’ [W]. It is perhaps just coin- Gentlemen! We thus see that the sejunction cidence that this is so little evident in his outer hypothesis provides us with a key to understand- appearance, because of the small demands made ing the most important phenomena of such condi- on his whole personality by his occupation. A tions, which we can equate with defi cit symptoms gardener’s monotonous work is similar in this of brain diseases, equally for chronic as well as respect to that of an agricultural labourer, many for acute mental disorders. However, a number of factory workers, and even busy people whose other symptoms appear to have no explanation in work is single-mindedly manual, conforming to such terms, by which I mean ones we have defi nite patterns. If it were a profession requiring regarded as ‘irritant’ symptoms, such as halluci- development of a highly complex personality, nations. The better researched pathology of such as a judge, a doctor, or an industrialist, dis- organic brain diseases gives us no explanation integration of the personality would be revealed here, because the origins of even the most com- all the time in such occupations. mon symptoms of irritation—localized spasms Gentlemen! We will see later that most signs and contractions—are still totally unknown to us. of disturbed secondary identifi cation, which We learn only a little here from brain diseases: make up symptoms of acute mental illness, can that these irritant symptoms are almost invariably be explained by assuming the same sejunction linked to neurological defi cits, and only from the process. Changes in content of consciousness, latter do the former gain their clinical status. In remaining as consequences of errors in identifi - some way, therefore, we should assume a causal cation, can therefore be traced back to relationship between defi cit symptoms and irrita- sejunction. tion symptoms. But in our case, gentlemen, it is Nevertheless, we also know that, other than different, insofar as some irritant symptoms, such healing, or persistence of changed content, there as hallucinations, are the most important symp- is a third way in which acute mental illness can toms of mental illness, apparently often occurring develop: to varying degrees of dementia or on their own. Should we not try to fi nd some rela- feeble- mindedness. We can also derive dementia tionship to defi cit symptoms, as an example of from the sejunction process, as we shall see later, sejunction? This requirement is virtually forced because according to this, we defi ne it just as a on us by our clinical experiences, because we failure—or reduction—in associative activity. know of some mental illnesses which offer almost With acute mental illnesses, you can often exclusively—throughout their entire course— observe a shorter or longer stage, where, after a only such irritant symptoms, and yet result in the period of acute illness, a state somewhat similar same fateful outcomes, either falsifi cation of con- in form may be present, albeit with changes in tent or dementia. As irritant symptoms are extin- content, or with reduction in processes of active guished, defi cits, whose full extent was hitherto association, before a defi nitive return to full unsuspected, then become apparent. With all due health. This stage of acute mental illness, whether caution, you can at least say that the process of paranoid or demented, is therefore still accessible sejunction is accompanied by irritant symptoms, to restitution. and may be obscured by them. It is entirely within All such considerations compel us to see in the current framework of our ideas of disease pro- the sejunction process the real nature of acute cesses that destroy nerves that they simultane- mental illness. As the Rother example teaches us, ously act on nerves as a stimulus: The current prior episodes of sejunction can be readily seen theory of stimulation is indeed based on this. The 12 Lecture 12 73 same view probably prevails for ganglion cells. which in the case of compulsive ideas compel The time course of processes leading to death of them against their will, and ‘alien’ [Ed] thoughts, nerves would then be a critical determinant of the in the case of autochthonous ideas, for which occurrence of irritant effects. But perhaps also a they initially have no explanation. We might also purely mechanical concept of irritation, both be tempted to seek a distinguishing feature plausible and comprehensible, is possible: As related to sejunction, so that at one time—for you will recall, we have taken mental activity to compulsive thoughts—we might be dealing with be a form of movement, which progresses in a an excitatory process whose continuity is pre- closed chain of association sAZm in our schema. served, and at another time—for autochthonous Memory images were, for us, sites of stored ideas—with an excitatory process where it is energy, always being refreshed from the ascend- loosened. ing pathways, which access projection fi elds. This consideration throws light on the internal This energy is being continually drained away, relationship between hallucinations and autoch- we may suppose, as charge on the projection fi eld thonous ideas. Both are based on sejunction pro- m declines, in readiness for their being called into cesses; both appear to the patient as alien action. Such continuous balancing up of energy invasions, and are usually projected externally. can be inferred from the so-called unconscious We will have to look for the real difference mental activity, and from the circumstance that between them in the different locations where you always wake up from sleep with thoughts sejunction occurs: for hallucinations in the path- running through your head. According to general way sA and for autochthonous ideas in the path- principles of mechanics, you would expect that way AZ of the mental refl ex arc. disruption of such a fl ow of energy by sejunction We can now understand that these two acti- would result in a build-up of energy, and thus vation symptoms are also closely related clini- localized enhancement of excitatory processes. cally, and that transitions are found between Were this ‘nerve stream’ [W] to be readily com- the two. I can demonstrate this to you, for parable with fl uid movement, you could then example, in the case of the 24-year-old speak of a refl ected wave in the nerve stream; but mechanic who had interpreted his autochtho- even without this, you might expect in ganglion nous ideas near the beginning of his illness as cells—the main sites of stored-up energy—that promptings from the Holy Spirit. However, a voltage would increase, when run-off is impaired, few weeks earlier, he heard the voice of the but with continuation of infl ux, and this can eas- Holy Spirit speaking to him. Also, in the ily overcharge the psychophysical movement to patient Böhm, according to his own precise reach a wave peak (p. 46). In this sense it is prob- account, at one stage his autochthonous ably not too bold to speak of ‘accumulated ner- thoughts led to his hearing ‘voices’ [W]. vous energy’ [Ed]. Then the location of the Furthermore, the fi nding that patients them- sejunction process would be a critical determi- selves do not know exactly whether they hear nant of any resulting irritant symptoms. voices or only experience related thoughts cor- Occurrence of hallucinations would suggest that responds to a transitional state between autoch- sejunction on pathways sA would occur in a rela- thonous thoughts and hallucinations. Such tively confi ned range of pathways, or at least in uncertainty on the part of patients about their one of the sensory projection fi elds, for example own perceptions is commonly reported. in an area of their output representations A . A second implication of our study deals with In the case of autochthonous ideas, of course the status of hallucinations in the whole science they appear at fi rst sight to be a ‘pure stimulus’ of disease. If our hypothesis is correct, hallucina- [Ed]; but comparison with compulsive ideas tions may occur even without any actual abnor- shows this assumption to be insuffi cient to mal process being in place, merely by explain the phenomenon. In fact, patients differ- accumulation of nervous current at the point of entiate quite well between their own thoughts, sejunction. From this site of discontinuity, one 74 12 Lecture 12 may expect the perceived magnitude of the motor behaviour [1 ] fall in a position intermedi- stimulus to be amplifi ed beyond the norm, and ate between somatopsychic and autopsychic: For consequently, for excitation of sensory regions of the former, insofar as people’s motility is the brain in s to occur, even without an external expressed only through visible bodily changes, stimulus, especially if the same process has and for the latter, because movement makes an occurred often, and therefore become habitual. I increasing contribution to the entire personality, remind you of what I said in my introduction as levels of schooling increase. At least one can about memory, and ‘exercising’ [Ed] of the ner- say that so-called actions [Ed] (but also most vous system. There, I fi nally went so far as to simpler movements which are under conscious give you reasons to assume that under some cir- control) can be taken as functions of ‘conscious- cumstances hallucinations cannot claim to be ness of personhood’ [Ed]. We need not deal with intrinsic to any active disease process but are to fl orid hyperkinetic states here, because they be regarded as pure sequelae [Ed] of disease pro- occur exclusively in acute psychoses, or in the cesses that have run their course. A clinical case rare—but not acute—exacerbations in chronic that will occupy us later appears in a very inter- psychoses. In contrast, parakinetic and akinetic esting light, after this discussion. It is not uncom- states are not rare in chronic psychoses, and then, mon that healing of acute mental illnesses is their more coherent occurrence (limited to cer- delayed through an intermediate stage, which, tain muscle groups) corresponds to slow summa- unfortunately, is often of very long duration, and tion of focal symptoms. Here we deal with the where—apart from the delusions, of which more subject provisionally, just insofar as it is essential later—no psychotic symptoms other than halluci- to understand related explanatory delusions. nations make their appearance. I call this condi- Independent development of akinetic and paraki- tion ‘residual hallucinosis’ and have presented netic mobility symptoms, separate from normal one or more examples of this every semester for mechanisms of association, is one of the most many years. You may guess how we should inter- instructive examples of the sejunction process. pret these fi ndings: The acute disease processes A key to the resulting explanatory delusions is are over, but highly localized sejunction is per- provided by the impact of autochthonous haps still not completely balanced, or pathologi- thoughts and hallucinations, namely their being cal habituation has so relieved retrograde perceived as subjective processes foreign to the movement that even normal stimulus intensities personality. I remember an elderly female psy- drain away into sensory projection fi elds. In such chiatric patient whose incessant activity was to patients all stronger Affects tend to induce hallu- arrange a circle a few feet in diameter, and then to cinations—as is entirely consistent with our rotate about its axis. The explanatory delusion understanding of the symptom. It seems to be just related to this was that she was the world, and had in such cases that a slightly feverish co-morbid to rotate. Such a fantastic delusion, not driven by illness can bring about speedy recovery. An any Affects, is of course encountered preferen- example of this is a gentleman with whom I am tially among long- term patients for whom there still in contact, who, after a severe acute hypo- are already various alterations of content s of con- chondriacal psychiatric illness, suffered lively sciousness. But is it any less adventurous when a hallucinations for some years, and he was consid- completely fresh patient claims that he must be in ered incurable. Following infl uenza, he became the immediate vicinity of a machine, admittedly quite healthy within a few days. hidden from him, that turns him continually After this digression into theory, let us return around in circles? Of course in such cases mag- to the purely practical topic of symptomatology, netic and electrical forces are commonly to blame by turning to a further large group of explanatory as the effective agents. More rarely, but more delusions: conclusively, parakinetic symptoms are described The particular type of explanatory delusions by patients, without their being connected to any which emerge from elementary disturbances of explanatory delusion. Thus, during one clinical 12 Lecture 12 75 presentation, a female patient began to sing, and idea of being transformed into an animal: you may still remember how clearly she spoke outbursts of inarticulate sounds giving rise to the about the fact that she did this against her will, latter idea, along with biting movements, facial and did not feel like doing it. This was the same distortions, and using limbs in an animal-like patient in whom I was able to demonstrate manner, for example, walking about on all fours. another interesting phenomenon: She typically Where such parakinetic states occur only briefl y showed a defective pattern of breathing, which I during chronic psychosis, explanatory delusions call ‘phrenic nerve insuffi ciency’ [Ed], that is, likewise tend to be short-lived; at most it may during inspiration her epigastrium was drawn happen that memory of such explanatory delu- upward and the normal enlargement of the lower sions resurfaces, a patient believing that he had chest circumference was prevented. When sing- earlier undergone some kind of animal ing however, she suddenly presented a normal metamorphosis. respiratory pattern. I believe that I have demon- It is not infrequent that a limited set of move- strated conclusively that the explanation of this ments, usually reactive in nature, become fi xed phenomenon is possible only based on the sejunc- and habitual for a patient, so that they persist for tion hypothesis. A similar case distinguished by the rest of his life. More or less clownish, strange the absence of any explanatory delusion is that of facial expressions and gestures of older mental a woman I am currently treating. From time to patients are often based on such acquired habits. time she must both laugh and cry, without the For instance, I know an elderly female patient corresponding Affects; she complained espe- who, at every interview, used the index fi gure of cially about her ‘silly laugh’ [W], which might her right hand to turn the upper eyelid on that side lead her to be regarded as feeble- minded. In this upwards, probably a parakinesia, originating in case we are dealing with waning of a subacute abnormal sensations—and therefore ‘psychosen- psychosis, distinguished by mutual separation of sory’ [Ed]—which then became habitual. successive psychotic symptoms, progressing Another male patient you saw recently in the even to retrospective associated delusions (see department tends, during conversation, to place later). These examples, though incidental to our his hand on the crown of his head, and another actual topic, may fi nd a place here, to show you you will recall has the habit when speaking of the symptom itself, in all its purity. Very often it putting his hand over his mouth. In all such cases is expressive gestures which occur in this man- the movement is now quite unconscious, or at ner, some simple, like angry facial expressions, least motiveless, and if the patient’s attention is threatening with the fi st, outbursts of moaning, drawn to it, he can give no reason for it. The wringing of hands, and the like, but often also ‘crazy’ [W] veneer of many old psychiatric complex attitudes and series of movements, such patients, so striking to lay people, is based on as a praying posture, different types of fencing such peculiarities. Various explanatory delusions positions, dance movements, and the like. Such can be related to these. complex series of movements, such as exercis- Akinetic and hyperkinetic states are similar ing, or describing circular motion (as above), fall with regard to the range of phenomena. States of more into the category of initiative movements. general immobility occur only very exceptionally As soon as such movements become permanently in chronic psychoses, seeming to be reserved for established, corresponding explanatory delusions acute and subacute ones. If they do occur, they seem to arise without fail. Sometimes the content seem to have psychosensory sources, as in well- of delusions depends more on the fact of the known examples from the literature, of the man movements themselves, and sometimes more on who avoided any movement, because he believed their form. A physical persecution complex can an infernal machine dwelt within his body that draw on such parakinetic states—in brief, on a could explode if he moved, and similarly, the belief in supernatural powers, be they good or woman who claimed to be made of glass, and evil, of an obsession, and not infrequently of the feared that any movements would shatter her. But 76 12 Lecture 12 perhaps in such famous cases we are also dealing death of Christ. Patients therefore consider them- with residual, more acute motility psychoses. On selves to be the returning Messiah. If this idea the other hand, you often see motility becoming does not occur, a relationship with the prophets impaired only partially during chronic psycho- easily arises, and they are tasked with redeeming ses. Such partial akinesias, such as the inability to the world on the basis of alleged supernatural swallow, are also predominantly psychosensory experiences similar to the passion of Christ. In in origin, and could lead to the symptom of food other cases fantastic interpretation of akinetic refusal, which can then proceed entirely chroni- states is still strongly coloured by memory of cally. The accompanying sensation is usually visions and dreamlike hallucinations that took described as closure of the throat, and indepen- place during the acute episodes, and then have a dent explanatory delusions, somatopsychic in preference for ecstatic, religious content. There is nature, may be connected with this. Next to food no need to emphasize that the state of conscious- abstention, dumbness or mutism is the most fre- ness during times of the akinetic states cannot be quent form of circumscribed akinesia, and here observed directly, but must be inferred only later too, in some cases, it is psychosensory in origin. from the statements or behaviour of patients; yet One learns from such patients, sometimes in so far, we can be certain that these are very differ- writing, that their tongues seem to be totally ent circumstances, under which akinetic symp- missing and are swollen, paralyzed, curled up, or toms can have a completely separate status. completely stiff; however, the sensation probably In other cases you hear of patients who, once extends beyond the tongue, for in such cases they have awoken from a motionless state, have accompanying lip movements are often also experienced a variety of morbid sensations: pain absent. At other times the symptom is of a proof unbearable intensity, the feeling of cardiac nounced psychomotor type, since such sensa- arrest, failing breath, stasis of blood in every tions as those just described are expressly denied. vein, etc. These, then, would be cases of Mutism and food refusal are often combined. psychosensory- based akinesia. Sometimes These very localized akinesias with psychomotor patients portray their feelings as continuing death links often present themselves as forbidding throes. Hypochondriacal feelings are often ‘voices’ [W]; the fact that such hallucinations accompanied by corresponding skin sensations have no meaning other than that of verbalized and visual hallucinations, such as the feeling of intentions becomes clear from instructive exam- dying from blood loss, and the visual hallucina- ples in which the direct physical cause of the tion of pools of blood in their beds. Such com- movements in question is attributed to the voices. bined hallucinations are, as we see later, not Accompanying explanatory delusions that only uncommon in all situations of reduced sensation. certain people—whose voice is recognized—can It can be seen what an abundant source for ‘take away’ [Ed] speech, or prevent food intake, explanatory delusions is provided at times of thus are easily understandable. such suffering. Here too, there are comparisons Although general states of immobility, as with the suffering of Christ, or any similar mar- already indicated, do not really belong here as a tyr; most often this is linked to the grand delusion source of manifold explanatory delusions, they of redemption or the ‘calling’ of prophets. still deserve early consideration, because they Gentlemen! It is not always actual psychotic occur preferentially during acute episodes in symptoms that give rise to explanatory delusions; chronic psychoses. Patients’ subsequent interpre- it may also be normal processes of the organism, tation of such states commonly employs the or some kind of functional disturbance, which of belief that they have already died and returned to themselves would be of little importance. But life. Recovery of mobility is usually seen to be an here the relationship is shifted, so that explana- act of resurrection, specially connected with all tory delusions have no independent signifi cance, those explanatory delusions of a religious nature occurring only in relation to other pre-existing suggested by comparison with the suffering and delusions, and serving to expand these. Of such Reference 77 quite normal processes, sleep is the fi rst to be bances, discomforts of menstruation and preg- mentioned. Deep sleep occurring at the moment nancy deserve mention; and next there is ongoing of newly emerging changes of content is often heart-burn and digestive disorders, also found in perceived by patients as their having been hypochondriacal mental illnesses, often as actual ‘stunned’ [Ed.] to play a part in some manipula- pre-existing constipation. You see, gentlemen, tion. The feeling of pregnancy seen as ‘valida- that a pre-existing tendency to delusional inter- tion’ [Ed.] can be interpreted in this way; and the pretation is also fed by abundant normal or near- opposite idea, that sexual intercourse had never normal material for processing and evaluation, taken place at all, can thus be eliminated. Yet allo- and that here too, occurrence of explanatory psychic alterations in the content of conscious- delusional ideas provides a means to satisfy con- ness can also lead to delusional interpretations of sciousness with a number of ideas. sleep: Patients have been stunned, and, while in this state, have been brought into a strange environment. The situation is similar when dream Reference experiences, albeit recognized as such, are held up as divine enlightenment. Of existing—but 1. Kahlbaum KL. Klinische Abhandlungen über psy- delusionally interpreted—functional distur- chische Krankheiten. Vol. 1: Die Katatonie. Berlin: A. Hirschwald; 1874. Lecture 13 13

• Sensory deception of speech sounds or one thing already: The sejunction hypothesis is phonemes probably valid for the vast majority of hallucina- • Delusions of relatedness and reference: of tions, especially those of paranoid states, which autopsychic, allopsychic, and somatopsychic are our main concern here. origin Certain basic features of hallucinations emerge directly from our hypothesis. These include, fi rst, the ‘incorrigibility’ [Ed] of hallucinations: The reality of a sensory deception is Lecture maintained against the testimony of all other senses, and most fantastic attempts are made to Gentlemen! explain it, leaving no room for doubt, or the pos- Given the major role—which we can hardly sibility of their sense being deceptive. As you exaggerate—that sensory deceptions play in the already know, comparison with the other senses symptomatology of mental illnesses, seen also to is the only possible means of correction; but once some extent when they have run their course, we attention has been captured by morbid activation, should start by using part of the theory of sensory which rides the ‘crest of the wave’ [Ed] of psy- deception, which is indispensable for understanding chophysical motion, then constraints imposed on these symptoms, and for their clinical assessment. consciousness make instantaneous correction Let us stay with the sejunction hypothesis, which impossible. Formation of associations with any I developed earlier, without arguing whether this normal ideas, which such an image excites, is the only possible way in which sensory decep- thereby raising to prominence contradictory tions can arise. Indeed, we will later come across images, is made diffi cult or quite impossible by sensory deceptions that probably originate in the sejunction. stimulation process in projection fi elds of sen- Exactly the same arguments explain the famil- sory centres; and it must then be clear that their iar incontestable nature of those hallucinations causa effi ciens [W] and the target of the stimulus that either command or prohibit behaviour. must be sought in projection fi elds themselves, Again, countervailing signals become inaccessi- regardless of whether these fi elds are directly ble by the very fact of sejunction, so that the affected by an aberrant stimulus, or are affected nerve current, confi ned to a narrow pre-formed only indirectly as a result of a sejunction process channel, discharges with its elemental force upon and the hypothetical backfl ow of nervous current motor projection fi elds. However I have to add from complex associative structures. We can say that the compelling nature of such hallucinations

© Springer International Publishing Switzerland 2015 79 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_13 80 13 Lecture 13 is usually overestimated, and you often fi nd projection fi elds: Then we will realize that during patients who can resist unreasonable demands, central excitation of the concept resulting from the and who even complain about them. Thus, for ‘damming up’ [Ed] of nervous energy, excitation example, a patient may have a hallucinatory urge spreads to the sensory speech fi eld, multiplied to hit his doctor, which may not reach fruition, fi vefold, and in this way will achieve the abnormal when faced with that same patient’s attachment level of activation needed to generate a hallucina- to the doctor; but even this fact may be explained, tion. Equally favourable conditions are not to be by the different degrees of the sejunction process, found in any other sensory projection fi eld. as is readily apparent. When introducing psychophysiology I com- A second striking fact is the predominance of mented that you should assume that there are indi- auditory verbal hallucinations, usually identifi ed vidual variations in this relationship: Sometimes a by patients themselves, as a ‘voice’ [W], which, by more conceptual side prevails, sometimes more virtue of their special clinical status, deserve a spe- ‘thinking in words’ [Ed], that is, in speech sounds. cial name—a ‘phoneme’ [W]. Occurrence of other Before I made that suggestion, I had felt it neces- auditory hallucinations is no more frequent than in sary to warn you that in some quarters it is claimed other sensory domains. However, the fact that hal- that thinking takes place only through speech lucinations of many patients are exclusively sounds. However, if we accept that individual speech sounds, and that, for all hallucinations— variation in thought mechanisms does exist, then with few exceptions—hallucinated speech sounds we have found a key to understand an important predominate, must be taken as one of the most fun- clinical fact, which is probably quite universal: For damental characteristics of sensory deceptions, to a single form of illness (such as an acute ‘anxiety be traced back in the fi nal analysis entirely to the psychosis’ [Ed]), which entails an essential mental manner of their formation [1 ]. Let us remember content, one individual might portray the content that we developed our concept of secondary iden- itself, while another produces phonemes repre- tifi cation using the specifi c example of the sensory senting the same content. In this example, in one projection fi eld of language. The sound of a word case only ideas full of anxiety or ‘anxiety ideas’ is not suffi cient for us to understand it, without, [W] as I call them, in the other, frightening and fi rst of all, memory images, which make up the threatening phonemes, that is the same ideas, but corresponding concept being activated, so that put into words. We can assess such experiences secondary identifi cation can take place, and the not only among acutely ill psychotic patients, but sense of the spoken word can be grasped. Although in exactly the same way amongst those psychoses we can generalize this, we cannot fail to recognize arising slowly, and progressing chronically. To that it is just the sensory speech centre which has some extent, pent-up nervous energy amongst such close links with the simplest patterns of asso- individuals predisposed to hearing ‘voices’ [W] ciation: These are the terms for solid objects, if (and who, by the way, are in the overwhelming you do go as far as to equate a sound image with majority) [Ed] can fi nd greater excitability of the its concept. For a mechanical conception of pro- sensory speech fi eld and its converging incident cesses taking place during a hallucination, you pathways. must now realize that in no other sensory area does In some chronic mental patients you can a more intimate connection of a concrete concept observe a particular form of hallucinated speech exist than in the sensory speech centre. sounds, in that they believe that they hear quite Experiments show that the name of a specifi c complex dialogues. Patients often tend to show a object—which, we can assume has fi ve different preference for such hallucinations; they obvi- sensory qualities—can immediately be found ously fi nd them to be the best entertainment and when just one of them is activated, excluding all the most preoccupying. Probably these are always the others. Let us assume that similarly deep- the individuals whose mental activity has habitu- rooted associations exist between s , the auditory ally taken place mainly through resonating speech centre, and each of the fi ve sensory images of words. 13 Lecture 13 81

Gentlemen! I have repeatedly pointed out that case lies in the periphery, while for hallucinations the content of hallucinations is usually not ran- it lies in central, transcortical, sites, although the dom but depends on other more or less familiar target location is the same in both situations. We conditions. This is especially true, you might already saw in an introductory lecture, that all expect, for phonemes. Indeed, I have already stronger sensory stimuli arriving from the periph- mentioned anxiety ideas, commands, and prohi- ery are provided simultaneously with ‘feeling bitions, which often take on the guise of ‘voices’ tone’ [Ed], to be regarded almost as a sign of [W]; later we will encounter the grandiose ideas ‘corporeal Affect’ [Ed] (p. 27). We have recog- of manic patients and the self-accusatory ideas of nized defensive movements following sensory melancholia, each taking the form of isolated stimulation linked with strong feeling tone as a voices. The situation is similar for explanatory protective mechanism of the body, indicating in delusions of paranoid states. These often occur as part a remote ancestry. Here, it is of great interest voices and lead us to understand that voice con- that something quite similar occurs also in tent is predominantly threatening and abusive, chronic psychoses, except that the emphasis of corresponding to ideas of persecution, ideas that the feeling tone is due not to the strength of a often make up the content of the delusions. sensory stimulus—which is in fact the most ordi- Equally we encounter phonemes in the content of nary and, in content, most familiar of sensory grandiosity when the urge to explain leads to pro- perceptions. Rather, because of the mental ill- gressive elaboration of the grandiosity. Here we ness, that emphasis becomes an element of nor- encounter a phenomenon similar to that we came mal sensory perception in itself. The feeling tone to recognize earlier, as a source of explanatory given to commonplace sensations per se [W] delusions, but with quite a different signifi cance, leads to falsifi cation of secondary identifi cation, in that it brings together a verbal delusional in that, amongst all possible interpretations, the explanation, and the supporting impact of ‘sen- one relating just to the single person is pre- sory perception’ [Ed]. A delusional view of the ferred—Neisser’s morbid self-reference—and in outside world thus fi nds new avenues to exert its this way leads to development of ‘delusions of infl uence. When, as often happens, the same ele- reference’ [Ed]. The so-called delusion of refer- mentary system of phonemes is not recognized as ence [W], like paranoia, is only a collective name something alien, it is even more disastrous, the for a wide variety of delusions, which, however, explanation then being taken as a provocation, are somehow linked to the act of perception and referred to not as ‘voices’ [W] but projected onto occur along with it; it consists of falsifi cation of the people in the vicinity. This more severe level perceptions themselves. Examples may serve to of phonemic symptoms is a particular way in illustrate this symptom. Anyone walking down which ‘delusions of relatedness’ [Ed] are made the street will fi nd the bustle of other people manifest, to which I come very soon. unremarkable and mainly quite random. Although this is not the place to address the However, a mentally-ill person, suffering from a theory of hallucinations in an exhaustive manner, delusion of reference, may make the observation I must point out in advance that we must consider that, because of his presence, people stand still, the overarching processes of stimulation whereby step to one side, or make some kind of gesture. elements of sensory projection fi elds, which we When they spit, they are spitting in front of him; previously identifi ed as perception cells (p. 30), when they speak, they are talking about him; contribute to awareness of our own physicality. when they wait, they are waiting for him. Despite only cells representing a defi nite location Oncoming people want to confront him; those on the sensory surface of the body being stimu- behind are following him; random looks and lated, we can still explain the main characteristics facial expressions of other people are directed at of hallucinations, which we will study later. The him. Sensory perception is undoubtedly accurate, difference from actual sensory perception is then the illness process being only in their being limited, in that the origin of the stimulus in one referred to himself, this being inseparably linked 82 13 Lecture 13 to perception itself, in other words only to the reference is masterfully drawn by Fyodor fact of sensory stimuli being provided with strong Dostoevsky, when his hero Raskolnikov, con- emphases of feeling tone. scious of having committed murder, fi nds noth- With regard to elucidation of this symptom, ing but indifferent expressions and meetings, but we follow the path that led us to understand hal- will eventually betray himself, just in relation to lucinations. The symptom has an apparent inter- this fact. Should anyone experience a feeling of nal relationship with hallucinations, one perhaps deliberate rudeness when a greeting is omitted, to be described such that delusions of reference etc., then this also is an echo of a referential arise from abnormal accrual of stimuli operating delusion. at the same site as hallucinations, yet not reach- Examples just mentioned of ‘physiological’ ing levels needed to trigger hallucinations. [Ed] delusions of reference—or if you want to Therefore, the symptom is valid only in connec- avoid the word ‘delusion’ [Ed] in this context, tion with real sensory perceptions. We can easily ‘referential ideas’ [Ed]—present themselves to accept the heightened activation, derived once us as primary causes: a self-perceived change in more from the sejunctive process, occurring at personality; and we can distinguish this as an the same site, but lower in intensity than in the ‘autopsychic’ [Ed] origin for the delusion of ref- case of hallucinations. Experiences in the clinic erence. It is an Affective state based on an auto- provide the most telling evidence for such a view: psychic sense of ‘disarray’ [Ed], seemingly quite In very chronic psychoses of increasing intensity, intrinsic to the context—a perception of some- the initial stage commonly consists of such a thing foreign, not-belonging, not-yet-assimilated, ‘delusion of reference’ [Ed] to be followed by a or ‘digested’ [Ed] (forgive the word)—in a word, hallucinatory stage, mostly again of phonemes; the new experience encounters diffi culty form- and it is quite characteristic that the content of the ing associations. In a brutal habitual criminal, phonemes consists overwhelmingly of delusions the state of mind of a Raskolnikov would be of reference. However, delusions of reference impossible. As in these examples taken from tend not to stop immediately, once phonemes of normal situations, so too do autopsychic delu- the same content become established; they usu- sion of reference of mentally ill people assert ally continue at the same strength. Therefore, it themselves as very specifi c ideas or domains of follows from this that, as abnormal excesses of thought. There is, therefore, a ‘circumscribed activation continue, phonemes, which tend to referential delusion’ [W] developing autopsychi- appear only intermittently in such cases, require a cally. In some quite common cases of chronic special amplifi cation of activation before they mental illness, such circumscribed delusion of come to a standstill. Similar conclusions apply to reference—apart from certain ‘overvalued ideas’ residual hallucinosis (p. 74), which goes hand in [Ed] (see later!)—two single psychotic symp- hand with delusions of reference. Here too con- toms become manifest, relevant to emergence of tent of auditory hallucinations is derived mainly mental illness, which may be followed later by a from delusions of reference, and, in the aftermath lengthy chain of explanatory and analogous sec- of phonemes, the delusions of reference can still ondary symptoms. I return to these later. We remain on their own, for a time. encounter a more common autopsychic delusion Circumstances leading to referential delusions of reference when patients believe that events are by no means limited to mental illnesses. they encounter in the environment, or spoken Indeed, quite typical examples of this can be sounds they hear, are connected to their own found in healthy mental life. A high-school grad- thoughts. Instead of real sensations, visual hallu- uate appearing for the fi rst time in tails and white cinations or phonemes may underlie this delu- gloves may easily feel all eyes fi xed on him; and, sion; and so patients prefer these experiences to likewise, the young man entering the ballroom be followed by explanatory delusions, namely for the fi rst time accordingly acts in a very that their thoughts are heard out loud without awkward manner. A picture of such a delusion of their having been enunciated. Patients reach this References 83 view with particular ease when the phonemes drove him into the most powerful sexual arousal. represent answers to thoughts that pose questions Also while he was engaged in farm- labouring out or which refer just to a patient’s imaginary in the fi eld, his father would appear every now and responses. According to information provided by again, and arouse him sexually. The very sight of good observers of mentally ill people, there is no his father was apparently associated with a mor- doubt that this is often the origin of the phenom- bid feeling tone that in this case was linked to enon of ‘thoughts out loud’ [W] (p. 80). morbid physical sensations about which he was By analogy with autopsychic delusions of ref- uncomfortable. Such examples would probably erence, we can speak here of an allopsychic delu- have been called refl ex hallucinations by sion of relatedness [W] (perhaps an expression of Kahlbaum [2 ]; the best known examples are when allopsychic ‘disarray’? [Ed]) when there is a clear soup is being ladelled out and distributed, and a change in a patient’s awareness of the outside mentally ill person alleges that he too would be world. We will need to return often to such cases ladelled out; or when a fi re was being lit that he amongst the acute psychoses. At other times fal- too might be burnt, etc. However, to me, the name sifi cation of allopsychic consciousness cannot be does not appear appropriate, because morbid shown directly; however, the symptom is so dis- physical sensations, although having some anal- tinct that there is no doubt as to its allopsychic ogy to sensory hallucinations, should be differen- origin. Examples mentioned above (p. 82) fall tiated from them in practice. (The same can be into this class. argued for Cramer’s so-called hallucinations of Finally, we can conveniently distinguish a muscle sense.) Somatopsychic delusions of relat- ‘somatopsychic delusion of relatedness’ [W] even edness are indeed particularly common amongst when, in itself, commonplace sensations become acute psychoses, but they also play a major role linked to subjectively perceived morbid sensa- amongst chronic psychoses. Sometimes this state tions or other changes in a patient’s own body. merges gradually into chronic somatic psychosis; Corresponding examples can be subsumed partly sometimes it appears late in the course of chronic under the heading of somatopsychic delusions of progressive psychosis to which somatopsychic relatedness [W], but differ to some extent from symptoms are added; and sometimes, within an these when special emphasis put on common- otherwise stable state, patients may even experi- place perceptions appears necessary to understand ence acute exacerbation in which morbid physical the conclusions which are reached. A typical sensations occur concurrently. So-called hypo- example came to my attention when I was asked chondriacal persecutory delusions [W], which for a second opinion about a diagnosis. I will may soon be joined by grandiosity, come from describe this here briefl y to illustrate such a symp- such somatopsychic delusions of relatedness. In tom for you. A young man in his formative years every mental hospital there is a series of such came before the court because he had carried out patients who, through occasional outbursts of a murderous attack on his father while the latter angry exchanges, demonstrably motivated by lay sleeping in bed. He readily admitted that he delusions of reference, disturb the peace. was extremely embittered against his father, and had the intention of ‘setting him straight’ [Ed], without murdering him. The source of his embit- References terment lay in observations he described as fol- 1. Cramer A. Die Halluzinationen im Muskelsinn bei lows. It was not uncommon, while they were Geisteskranken und ihre klinische Bedeutung, ein sitting at the table, for a quarrel to break out Beitrag zur Kenntnis der Paranoia. Freiburg: Mohr; between them, in which other family members 1889. would take part, sometimes on his behalf and 2. Kahlbaum KL. Die Sinnesdelirien: Ein Beitrag zur klinischen Erweiterung der psychiatrischen sometimes on the side of his father. It often hap- Symptomatologie und zur physiologischen pened that the father pounded the table, which Psychologie. Allg Z Psychiat. 1866;23:1–86. Lecture 14 14

• Retrospective delusional explanation brings about substantive changes of conscious- • Falsehoods of memory ness: It is sejunction, or the uncoupling of associations. We can now defi ne as mental illness, the occasions when, due to disease of nervous tissue, such dislocations of association take place. In Lecture such a way breakdown of nervous structure—a change occurring at a defi nite location—leads to Gentlemen! signs of defi cit, with no possibility of recovery by The sejunction hypothesis clearly shows us regeneration (as indeed is common in the periph- how to reach a mechanistic understanding of psy- eral nervous system), or its replacement by estab- chotic symptoms. As with brain diseases, it turns lishing new associations. However, we should out that when we penetrate the nature of mental also consider curable acute mental illnesses, as illness more deeply, then functional defi cits [Ed] examples of just such regeneration or replace- give us a valuable clue to aid our understanding. ment. It seems that dissolution of associations in However, more complex circumstances underlie some circumstances is equivalent to destruction aberrant processes of activation [Ed], and in of certain psychological units. Later we will be some way must be seen to depend on symptoms able to assess a loss of concepts, that is, a reduc- of defi cit. In this regard we can never ignore les- tion of the number in use, as a defi cit state occur- sons from brain pathology. In the light of our ring in the wake of mental illnesses. hypothesis, the patient with whom I started our First however, we have more to learn about the fi rst clinical demonstration becomes more com- sejunction hypothesis and how to use it to under- prehensible to us, and appears to be more con- stand other clinical phenomena that we observe sistent with this abnormal process in the organ every day among so-called old cases. This pri- of consciousness, made up solely of neural marily involves correction of the contents of elements. consciousness in the aftermath of mental distur- We set out initially to study alterations in the bance—or retrospective explanatory delusions content of consciousness. We identifi ed acute and [Ed]. We see this process taking place, always in chronic mental illnesses according to the pro- the same manner, during recovery, or at the cesses by which they arose, and acknowledged beginning of a chronic mental illness, or fi nally in their mutual relationship in terms of our knowl- acute mental illnesses that have reached a chronic edge of brain pathology. We may think that, by stage. The modifi ed contents of consciousness now, we know what is the main process that must be reconciled, according to our prevailing

© Springer International Publishing Switzerland 2015 85 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_14 86 14 Lecture 14 notions of causality, with old, as-yet unchanged character they might have in the judgment of domains. The more that discernment can be those same persons when they are in good health. regained or has been retained during chronic psy- Often, previous knowledge might have stood in choses, the more mental activity takes place the way of resolving a problem, for instance according to strict standards of logic, and the when belief in the principle of conservation of more imperative it is to restore some semblance energy constrains acceptance of ‘perpetual of order in structures brought into disarray by ill- motion’ [Ed]. Here, however, such knowledge is ness. Normally, in a complex brain mechanism, modifi ed in such a way that the obstacle no lon- there should not exist the remotest corner that is ger applies, and can then explain many of the cra- in discord with all other parts, and which does not ziest inventions and discoveries. function under their infl uence. An example will In particular, specifi c earlier experiences may best illustrate this process. You will remember the form the subject of such reinterpretations. Guided patient, a Doctor of Philosophy, whose explana- by newly acquired and supposedly better insight, tory delusion was built on teachings about sug- demonstrations of love appear as hypocrisy or gestion and hypnotism. This patient had already cunning calculation; hostile actions as good survived an episode of mental illness 8 years ear- deeds; insignifi cant incidents as highly signifi - lier, but had recovered from it to the extent that, cant events; and a random event as a deliberate for many years, he had full insight into the symp- action by some patron or adversary. toms of his acute illness. When I met him recently The process of subsequent correction achieves during a new episode, to my great surprise I special importance as soon as it extends beyond found a remarkable development that his insight knowledge, judgment, and more complex end into his illness was lost, so the patient now processes, to include memory of earlier percep- asserted that the basic symptoms of his fi rst ill- tions, and in this way leads to subsequent falsifi - ness, namely phonemes, had not been the result cation of secondary identifi cation. We want to of an illness, but of the effects of hypnosis designate such retrospective correction of earlier induced by some adversary. However, he had memories as retrospective delusions of related- accurate recall of the fact that for many years he ness [W]. They involve events analogous to those had regarded his auditory hallucinations as signs in normal mental life. Every one of you will of an illness; but now he noted quite correctly know of times when, only retrospectively did you that such a conceivable insight into his illness remember having encountered an acquaintance could be explained as effects of suggestion. You to whom, because you were preoccupied at the will see from this example the ease with which time, you had paid no attention. This late recol- judgments, which, for many years, he regarded as lection can just as well be accurate as inaccurate having ‘made his own’ [Ed], as hard-won prod- in its content, and normally a person takes this ucts of complex thought processes, could be into account. Amongst mentally ill people there overturned by a supposedly new insight, itself are also often those, perhaps identifi ed subse- aberrant. Nevertheless, if, as I do not doubt, we quently, except that their most superfi cial fea- should regard this process not as aberrant in itself tures usually suffi ce to identify them. In such but only as a reaction of a normally functioning patients with established grandiose delusions, brain mechanism when challenged by a material such reinterpretations are often based on memo- change, you will not be surprised that often, a ries of their youth. The patient remembers for patient’s limited knowledge of the physical basis example that once, as a boy, he had been spoken of most mental illnesses is overwhelmed by the to by an offi cer, who, as he subsequently recalls, testimony of their senses as they experience hal- was Kaiser Wilhelm, or Kaiser Frederick, or lucinations, such that assumptions about super- some other highly-ranked, popular personage. In natural effects, subterranean tunnels, hollow school at the same time he was asked by his walls, and the like, used to explain alien, subjec- teacher who were his father and grandfather. This tive perceptions, lose the outlandish and grotesque question was about that same high-ranking 14 Lecture 14 87

personage, and should indicate where he had to the symptoms belong with three groups of disor- look for his father or grandfather. Should the ders, whose components are seldom absent and objection be raised that this could also have been all feature memory defi cits starting in a timely an inconsequential question, such patients rebut fashion: hebephrenia, presbyophrenia, and pro- this by pointing to a meaningful glance or a tell- gressive paralysis. ing gesture by the teacher in his statement—clear No less remarkable is the negative [W] form proof that the perception itself has been falsifi ed of falsifi cation of memory, in which circum- in memory. Amongst such patients, you can lis- scribed gaps in otherwise well-preserved mem- ten for hours to stories of childhood memories ory might occur, with no sign that any clouding described mainly just as they had been experi- of the sensorium or loss of retentiveness could enced. Overall however, their perceptions show have intervened at the time of the experience in every nuance of referential delusions, which an question. For correct understanding and descrip- outstanding psychiatrist has described succinctly tion of this symptom, high value must be placed with the words ‘tua res agitur ’ [W]. on the latter precondition. No one would be sur- Retrospective delusions of reference can eas- prised if a patient with initial symptoms of ily lead to completely false notions among uned- abdominal typhus or meningitis has totally lost ucated and uncritical people, not used to memory for hours and days, for example the dis- separating their subjective impressions from tance travelled under these conditions on a jour- objectively perceived material; and it is often dif- ney from Rome to Berlin. Nor should we wonder fi cult under these circumstances to single out the about the total loss of memory during epileptic facts as they had actually happened. Nonetheless, twilight states, alleged experiences of Delirium clinically, it is necessary to make a clear distinc- tremens, or any other delirium from severe intox- tion between retrospective delusions of related- ication, hysteria, or, lastly, during normal dream- ness and another elementary symptom, which is ing. So, for any such experiences occurring inclined to be preferred in similar patients: so- during a mental illness in which simultaneous called falsifi cations of memory [W] [1 ]. This memory loss can be shown, complete amnesia symptom involves either of two equally signifi - seems quite understandable. The behaviour is cant changes, one positive, and the other nega- quite different for the symptom of negative falsi- tive. The positive [Ed] form of falsifi cation of fi cation of memory. In that case, individual memory [1 ], also called confabulation [Ed], con- actions and events that occur when mental clarity sists of appearance of memories and experiences seems to be perfectly normal are wiped from that are certainly not real. The content of such memory, while events occurring nearby in time confabulation is usually so coloured as to signify are still recalled exactly. However, two circum- prevailing mania. Thus, for example, in previ- stances, never lacking as features of this symp- ously mentioned cases of established grandiose tom, should serve to suggest its explanation: The delusions (p. 87) the content provides much of incident in question, and the action taken, always the evidence for the patient’s claim to his having seem to fall at times of particularly high Affect. high- status parentage, or a relationship to such; In addition, they are related to a specifi c ‘over- in cases of systematized persecutory delusions valued idea’ [Ed], such that either they both (often directed at a person) confabulation may appear as an emanation of the latter and are thus contain most fantastic, alleged persecution. In motivated by it, or have their signifi cance in its other cases the symptom again refl ects incoher- rebuttal and refutation. I have found the most ence in content of consciousness (decay of indi- typical examples of this to have occurred in so- viduality, see above) as in the case of Rother, and called querulous delusions and related conditions very often also in the fantastic and audacious sto- of chronic partial psychoses. To put the previous ries of the paralytic. An internal link to memory points by way of an example, I cite the case of a disturbances, which one may already suspect a master craftsman, living here—incapacitated but priori [W], can also be detected clinically, since still busy—who, in public and on a public street, 88 14 Lecture 14 insulted a policeman with that insulting phrase place slowly, as real, conscious thought processes familiar from Götz von Berlichingen and the leading to a conclusion after long brooding, when accompanying gesture, and afterwards denied the patient has clarifi ed various things that previ- under oath that he did this. This man was under ously seemed incomprehensible. The patient the infl uence of an overvalued idea that, for some Böhm who you will remember was just begin- time, had compelled all his actions; he regarded ning such a process of clarifi cation, and said that offi cials as his personal enemies and watchdogs; he could not, at the time, decide which of the shortly before, he had suffered mortifi cation con- various assumptions was the correct one. nected with this idea, and no doubt at the time of However, it stands to reason that the very the offence was acting under the infl uence of slowness and thoroughness of such retrospec- strong Affect. However, given both the precise tive correction must lead to irreparable falsifi ca- knowledge of the person and the whole state of tion of intellectual acquisitions. Even the affairs, it was inconceivable that this decent- waning of elementary symptoms, such as pho- minded, religiously-inclined man could con- nemes arising from explanatory delusions, leads sciously commit perjury, although he had actually to falsifi cation of mental ownership, which, given false testimony under oath. With respect to once acquired, cannot be amended. Explanatory aetiology, only a strong family predisposition to delusions and subsequent corrections are the mental illness was established in this middle- two foundations of any so-called systematiza- aged man. tion; it is therefore no surprise that you fi nd the Gentlemen! While the process of correction theorem still applied everywhere, and that could itself be regarded as normal, those last systematization signifi es ‘incurability’ [Ed]. three symptoms, linked to subsequent corrections However, as a generality, the theorem is incor- of the content of consciousness, are an abnormal rect, and certainly does not hold true for most excess of such corrective action. All three phe- systematizations in acute mental illnesses based nomena clearly belong together, and their mutual on explanatory delusions in the sense just relationship can be expressed by subsuming the described. On the contrary, as we see later, there fi rst as a ‘qualitative falsifi cation of memory’ is one mental illness—one of the most curable— [Ed], and the other two as ‘quantitative falsifi ca- where systematization almost always occurs: tions of memory’ [Ed]. Instead of the terms ‘pos- acute hallucinosis, or strictly ‘acute hallucina- itive’ [Ed] and ‘negative’ [Ed], it might be more tory allopsychosis’ [Ed] (p. 103). appropriate to call them ‘additive’ [Ed] and ‘sub- In contrast, the theorem should apply with no tractive’ [Ed] so that we would now have a uni- restrictions to chronic psychoses. Yet even here, form nomenclature to differentiate three forms of how much more favourable are the conditions for falsifi cation of memory: one qualitative, one retrospective correction, albeit in an aberrant additive, and one subtractive. sense! In the acute illnesses we dealt with, there If we now want to attempt an interpretation, it are weeks or months during which abnormal would be best to treat all four phenomena in con- components increase, usually to such an extent text. Turning fi rst to the subsequent correction, that one displaces the others, all fl owing into con- you will soon notice how closely the phenome- sciousness. Afterwards, elementary symptoms non is related to explanatory delusions, which go quiet, and what remains of them is no longer you have known for a long time. However, the strong enough to overwhelm earlier acquisitions, subsequent correction possibly corresponds to a but is subject to the combined power of restored more refi ned psychological need, while explana- normal functioning of the identifi cation process tory delusions are driven by a coarser motive. and of earlier acquired ideas. In chronic cases on Explanatory delusions take advantage of con- the other hand, new acquisitions carry too much sciousness, usually quickly, through unconscious of the stamp of normality for the old repository to processes, and thus with much elemental power; be treated in any way different from normal new subsequent corrections, on the other hand, take acquisitions. 14 Lecture 14 89

Gentlemen! As we have just seen, the excit- detail of the vividly described events that were atory processes, which are the root of elementary never experienced. Assumptions which come to symptoms of chronic psychoses, can all be inter- mind and seem to any knowledgeable person to preted as consequences of sejunction; we must exhaust all other possibilities are that they repre- therefore also consider the associated explana- sent arbitrary productions, deliberate misrepre- tory delusions and retrospective correction in sentations, or lies in the usual sense of the word. paranoid states as inevitable, if indirect, conse- These confabulations are defi nitely not lies, quences of the sejunctive process. The phenom- because mentally-ill persons are totally con- enon of retrospective delusions of relatedness, on vinced of their truth. Since the content of this the other hand, allows us to recognize a direct confabulation often also has a fantastic character connection with sejunction. We saw that we must similar to dream experiences I think it is quite trace delusions of relatedness back even as far as possible that they are actual memories of dreams. an excitatory process asserting itself in secondary One might argue for this possibility as fol- identifi cation. Once we accept this view, nothing lows: Even a mentally-healthy person may have stands in the way of the further assumption that the experience that, on awakening from a dream, the same level of activation generated in the act for a short time he believes in the reality of the of perception by external excitation of a projec- dream events. However, this happens only when tion fi eld also increases excitability for memory the content of the dream does not contradict prec- images in association pathways, and can thereby edents from reality too severely, and also if it can misrepresent the relationship of that image to the be related easily to experiences from the recent person himself or herself. However, the required past. The latter condition would be fulfi lled, for increase in level of activation can, as we have example, if memory of an experience from the seen, arise from nervous energy accumulated as a previous night were lost, or could be recalled result of the sejunction. only imprecisely due to mild intoxication. The positive or additive form of memory falsi- A mentally ill person can completely lack these fi cation requires a preceding break-up of associa- two constraints: Temporal continuity of memory tions. This needs no extensive discussion. The becomes a weaker chain, so that insertion of alien strength and reliability of our memories are due intervening links is more easily permitted, nor mainly to strict correlation in timing between are precedents from reality as unassailable to him them; and, as an image that you may envisage, as they are to a sane person. Obviously, it is again along the time axis, memories are strung so close the fact of sejunction that removes normal barri- together that alien elements fi nd no place between ers to the storage of dream experiences in the them. This temporal association must therefore memory banks; but perhaps something else may be broken if the pseudo-experiences of confabu- still be needed to bring about confabulation, such lation are to be taken as true. Of course only the as abnormal vividness of dream experiences. possibility [Ed] of occurrence of a symptom is However it would lead us too far off course, if we explained by this; therefore, the actual [Ed] were to address in more detail the associated mechanism of formation remains obscure. But it conditions, which in themselves are not is precisely the manner of occurrence of the inaccessible. symptom and its origin that requires discussion. For the negative or subtractive form of mem- The most obvious assumption, that we are ory falsifi cation a familiar analogue is seen dealing with memories of pseudo-experiences of amongst post-hypnotic phenomena. Familiar acute mental illness, obviously does not apply to commands can be given to a hypnotized person, all those confabulations occurring without any which he or she later carries out while awake, previous acute stage of illness, which is what we while failing to remember the command. For our envisaged, while virtually excluding other situa- purposes, execution of the command is irrelevant, tions from our concept of confabulation. being no more than a check on whether con- Somewhere those situations must defi ne every sciousness had been affected at all at the moment 90 14 Lecture 14 of the command. What is signifi cant for us is the fact that the associative link is not entirely miss- complete amnesia for the palpable reality of the ing, but is heavily biased towards and limited to command, and also that the action is certainly not the overvalued idea, without which insight the to be regarded as a real act of will. We must trace apparently conscious act could not be explained. back any suggested effect to the fact that alien So this probably represents a narrowing of con- components have been implanted in the organ of sciousness, as is known otherwise only in states consciousness without their recruiting associa- of high Affect. Since actions occurring during tive links with remaining contents of conscious- periods of memory lapse often appear to be due ness. This is a circumstance, incidentally, that just to Affects, we can also see here an opportune brings the compelling infl uence of such trans- moment for future forgetfulness. However we planted components of an alien consciousness to cannot exploit this moment, because it remains be grasped in a gross, mechanical way in terms of unexplained why only certain types of mental movement. In any case, we must also refer to the patient show this symptom. absence of associative links to account for gaps in memory, the symptom we are concerned with, to explain the fact that the previous history of events Reference cannot actually be recalled. However the close relationship between the content of these mem- 1. Kraepelin E. Über Erinnerungsfälschungen. Arch ory lapses and the overvalued idea points to the Psychiatr Nervenkr. 1886;17:830–43. Lecture 15 15

• Retrospect of earlier account of elementary ideas and obsessions [ 1], and then of hallucina- symptoms tions and delusions of relatedness and reference. • Overvalued ideas Explanatory delusions, which took up much of our discussion, could then be likened to normal expressions of conscious activity, in contrast to the aforementioned primary psychotic symp- Lecture toms. We then came to recognize subsequent corrections of the content of consciousness as Gentlemen! conditions essential for the so-called systemati- An overview of elementary symptoms occur- zation, itself related closely to explanatory delu- ring during paranoid states allows us to make the sions. We also found amongst these corrections a following distinctions: First, we found several process, which we viewed as normal conscious changes in content of consciousness, namely activity reacting against ‘false intruders’ [Ed]; delusions and delusional judgments, expressed and we also saw psychotic symptoms in various within an unbroken train of conscious activity, in types of memory falsifi cation, seemingly quite so far as they were in a logical form, preserving aberrant in themselves, yet appearing to stand in attentiveness and memory, and in their moment- regular relationship with existing disturbances of by- moment adaptability to any given situation. the content of consciousness, such that their However, the intactness of these faculties in no occurrence depended on the extent of changed way prevents the remaining content of con- content. Amongst such psychotic symptoms we sciousness appearing to have disintegrated, to a distinguished at least three different points of degree, into fragments a fact to which we gave origin, all emerging in part as a reaction of intact the name ‘sejunction’ [Ed], in other words, the conscious activity to alterations of content of detachment of individual components one from consciousness. These included explanatory delu- another. Such components initially form tight- sions and subsequent corrections, either of which knit structures, as complete experiences, but occurred as a direct consequence of sejunction; their sejunction is shown by the fact that memo- the latter included contradictory contents of con- ries that fl atly contradict each other can coexist. sciousness in many old cases, and additive and The sejunction hypothesis then led us to a closer subtractive ways in which memory can be falsi- understanding of certain symptoms of activa- fi ed. Lastly, there were excitatory processes aris- tion, fi rst, of manifestations of disturbed con- ing out of the sejunctive processes: these scious activity itself, then of autochthonous included hallucinations, delusion of relatedness,

© Springer International Publishing Switzerland 2015 91 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_15 92 15 Lecture 15 and retrospective delusion of relatedness, and cherished event can lead to emergence of an fi nally autochthonous ideas. overvalued idea; that it does not depend at all on The last mentioned group included overval- the type of emotion; and that there must be over- ued ideas [W] already mentioned repeatedly; valued ideas that are in themselves completely these have an obvious relationship to obsessions normal; yet the way that an individual is treated and autochthonous thoughts, the questions then can determine whether they acquire an aberrant being how they differ from such symptoms, and character. People who commit suicide after loss whether any sharp boundaries can be found. of a fortune, after being sentenced to dishonour- Overvalued ideas are sharply distinguished from able punishment, or after death of a loved person, the autochthonous ideas in that they are evaluated are certainly acting under the infl uence of an within a patient’s consciousness, and thus, by no overvalued idea; and we should regard their con- means are to be viewed as alien intruders: Indeed duct as abnormal, even though not due to mental patients see in them expressions of their very illness. Therefore, in every single case, we should being, and quite rightly take a leading role in establish whether an aberrant, overvalued idea is their elaboration—a struggle for their very own present, or whether it falls within the bounds of personality. Nevertheless they are often perceived normality. Your decision on this will probably as painful, and patients may complain that they depend on whether the motive triggered by the cannot think of anything else. However, they still relevant memory, and which leads to its acquir- remain quite distinct from obsessions because ing a dominant role, is suffi cient grounds, or not. they are seen to be normal, to be accounted for However, this criterion is sometimes left com- fully by their mode of origin, while obsessions pletely undecided, as in examples of malcon- are recognized as untrustworthy, and often as tents: Some such patients have [Ed] actually manifestly nonsensical. been unjustly judged in the fi rst place, and have Clinically, one can easily distinguish this every reason to feel indignant about this. A reli- symptom from the two other closely related ones; able criterion is that in cases of aberrant over- yet the mechanism of their formation remains valuation of ideas, the symptom does not remain unexplained. In this regard, note that, in general, in isolation: A number of other psychotic symp- we can defi ne overvalued ideas as any kind of toms soon appear, especially delusions of refer- memory, but especially of Affective experiences, ence characteristic of such cases, yet quite or a whole series of related experiences of this circumscribed (p. 82). kind. So, for example, the following incidents led The following is a typical example of an aber- to the emergence of overvalued ideas: the discov- rant overvalued idea: A 61-year-old person of ery, by a man who had taken over the administra- independent means, who was recently presented tion of an inheritance and, as an heir, was then to you, gives, as reason for his being admitted, the involved in its distribution, and that he had sig- ‘hounding’ to which he had been exposed outside nifi cantly disadvantaged himself; news of the the institution. Inside the institution he is com- suicide of a personal friend; the death of a hus- pletely free of such annoyances, and feels so well band; an older girl’s delusion that a gentleman that he is already in his fourth year here, and had paid her attention; a wife’s remark that her intends to stay. Several attempts to discharge him husband, despite her objections, sniffed a lot; the have failed because, repeatedly, the same harass- sight of cleansing of a person infected with lice; ments have led to police intervention and intern- and, fi nally, one of the most common cases, judi- ment. Originally it was a certain gentleman, cial condemnation, or judgment by superior known to him only by name, who lived in his authorities perceived as an injustice. The Affects neighbourhood and who he therefore often revealed can be very diverse in character, and can encountered on the street. He came to believe that soon manifest themselves as anger or insult, this gentleman stopped and waited for him, stand- sadness or disgust, or as sexual arousal. In any ing as though counting windows of a house. He case we can infer from this list that almost any therefore crossed to the other side of the street but 15 Lecture 15 93 noticed next time how the same gentleman, at the observed even a hint of a delusion or any other same spot, was talking to an acquaintance, no sign of mental illness in this patient. doubt about him [Ed], of which fact he was con- We see here, in a typical case of circumscribed vinced, without being able to hear what was said. autopsychosis [W], how the overvalued idea He therefore went close to the two men and said, linked initially to a very circumscribed delusion ‘Do you perhaps want something from me?’ He of reference, expanded subsequently, yet never then went home and observed that the men fol- comes to light within the institution, where the lowed him and remained standing in front of his patient meets only with strangers. The basis of house. Having reached his home he then went to the overvaluation of the idea is therefore the same the window and waved his stick, calling out to as for delusions of reference: namely the inner them ‘Come right up! I’ll give you what for!’ confl ict between the not entirely honourable A similar encounter on another occasion led to the course of action, which he described, and the oth- two men actually following him to his home, who erwise righteous character of the patient. We can then found out his name, and laid complaints with probably assume that, at the time of the fi rst men- the police. That event led to the patient’s initial tioned incident, the patient was busy internaliz- admission. I took him into the clinic soon after, ing his previous experience, which felt like his and established that the patient’s delusion of ref- own failing. A passing glance, the expectant atti- erence was directed solely against one of these tude of the man who might know his affairs, led two, a master carpenter; and I then asked him: to an abiding association with the currently dom- ‘How did this gentleman come to harass you?’ inant distortion—albeit not in content but in the The answer was quite typical. He could think only falsifi ed evaluation of thought content, a falsifi ed as follows: The gentleman in question was the secondary identifi cation very similar to that brother of a close friend, who 6 years ago had based on the delusion of the young murderer, been, like himself, a regular guest of a particular mentioned earlier (see p. 83). As you will remem- wine merchant. The patient himself had been ber, it happens in just the same way even for interested in this businessman’s daughter for physiological delusions of reference, as described years, and had even proposed to her, but had then so well for Raskolnikov. It is probably no coinci- broken off the engagement, because he had been dence that Dostoevsky’s central character (from told that her father was in fi nancial diffi culties. As Crime and Punishment) has already been the master carpenter had spoken to the other gen- described as a man of almost unhealthy nervous- tleman about him, he had probably said, ‘There ness, and softest, most compassionate heart: goes the scoundrel who left the girl in the lurch’. Under such circumstances alone, memory of the Detailed investigation and observation of the murder he had committed must have remained, patient failed to fi nd any kind of psychotic symp- so to speak, as utterly unique in his conscious- toms, other than his continuing to insist on the ness. As in all cases of autopsychic delusions of accuracy of these allegations. Therefore he was reference we meet the diffi culty of assimilating discharged, at his own request, after a few weeks, these to pre-existing contents of consciousness, but was soon readmitted; and this was repeated a that is, by associative processes, this being the second time. Since then he no longer tries any basis for his overvaluing the idea. more. The harassment that the patient was exposed Judging by features of the present case, we to when outside the institution occurred far more might propose that such experiences would frequently on the two further occasions than favour emergence of an overvalued idea, which, before; also, other people were involved, as well in its content, would be particularly diffi cult to as the police. However everything always came bring into congruence with existing content. back to the one master carpenter who, meanwhile, Since such experiences are no stranger in the had served up the old story to other people, and mental lives of even the most healthy of us, some notifi ed the police of his observation s of mental special conditions must prevail before such over- illness. Nowhere in the institution has anyone emphasis takes on an aberrant character. 94 15 Lecture 15

Normally there is contradictory evidence, which paternal guidance: These are powerful and gradually corrects any overvaluation. For aber- salutary corrective experiences. Healing itself rant overvaluation however, these counterargu- always happens very gradually, the principle ments, demonstrably, are no longer available, being that, by avoiding occasions when Affect is and, at the same time, clinical signs of delusions renewed, the Affect itself disappears, and neces- of reference also appear, all in accord with the sary correctives gradually gain acceptance and activation hypothesis, which I connected earlier prove to be effective. to the sejunction process. It would take too long, were I to introduce all If we want to pursue these clinical features individual cases of overvalued ideas here; even further, it turns out that the ‘damage’ [Ed] pro- then, I might not exhaust the topic, since there ceeding from the present symptom is well known, must naturally be almost limitless variations, to be sought in the high levels of Affect accompa- topic by topic, on this otherwise well- nying particular experiences. Since this frequent characterized theme of chronic autopsychosis. antecedent cannot be discovered for other psy- For practical reasons I allow myself just the sug- chotic symptoms, this one serves also to charac- gestion that, when anyone has the possibility of terize aberrant overvaluation of ideas. acquiring an accident-related annual payment, it As in the case just described, a fairly stable can easily lead to overvaluation of ideas. Finally, and enduring disease picture can be seen in a I do not want to shy away from the idea that series of similar cases, and, on account of its almost every other psychotic symptom, as well as strong inclination, bears the traditional name of being an overvalued idea, can be the initial stage obsession [W]; yet in most cases, delusional of an acute or subacute psychosis which pro- explanatory statements are added on, and these gresses, including progressive paralysis, and this can continue to grow in strength. Subsequent cor- it is seldom absent as a feature of melancholia. rections to the content of consciousness and the To conclude this discussion, I want to describe various ways in which memories can be falsifi ed an instructive case, as far as systemization goes. thereby join in, giving rise to a close-knit delu- A single woman in her 40s, a science teacher at a sional structure, whose complex content does not secondary school for girls, who is very keen and match its relatively simple, and often minor, capable, possibly a little too intense in her profes- point of origin, and serves to conceal or disguise sion, believed that she noticed that one of her the latter. In old cases of this kind, one can easily male unmarried colleagues, with whom she had determine such a delusional structure, but often enjoyed friendly relations over many years, had one cannot go beyond assumptions [Ed] about serious intentions towards her. The idea came to the underlying overvalued idea, and the experi- her that during lessons in his class he often stood ence to which it is linked. For all such cases we at the window, from which it was possible to can understand why patients can no longer reach glance into her classroom; that in his free time he a full recovery, as is the case for all other cases often stood on a landing which she had to pass with more extensive systematization. However, with her pupils on their way to her classroom; when the extent of the disease is limited just to and that he greeted her very sincerely. She soon the fi rst psychotic elements, it is possible for found this perception to be confi rmed by all sorts health to be restored through the gradual appear- of random encounters, which aroused strong ance of more powerful countervailing arguments. Affect; she spent days and nights in inner turmoil Two cases of this type, where recovery has taken about how she should respond to this, and espe- place, are related to the typical scenario of a socially how she should behave as inconspicuously called malcontent’s delusion. The clinical pre- as possible, so that pupils and colleagues would sentation of such cases has proved useful to me never notice. When she believed that she could several times, as is the process of ‘internalisation’ no longer stay in control of her actions, she tried [Ed] itself, that is, a conscious ability to recog- to avoid such encounters, and even went so far as nize mental illness, and to constantly accept to deliberately refrain from replying to his 15 Lecture 15 95

greetings. Around this time she also noticed that children. Since she did not strike me as odd, her students seemed to be aware of what was either in her behaviour or her expressions, the going on; remarks were dropped that referred to news that she had been declared terminally insane it; perhaps there were isolated phonemes, for she by the director of an institution of course aston- heard, ‘How distressed he looks’. Female col- ished me; she was therefore persuaded to accept leagues who had previously kept apart from her my counsel. I found her an educated, sensitive now visited her more frequently, and spoke quite lady, who was quite clear that she should have often about the young man; good female friends, had the right to arrange her relationships with on the other hand, withdrew from her and that young man as she saw fi t; however her sense appeared to disapprove of her ‘relationship’ [W]. of duty to the school left her with no choice, ‘She Even the Director intervened, by speaking with had the right to sacrifi ce herself to her duty’. She the male teacher in the breaks, and keeping him was in no doubt that the young man would have in a completely different location, further from intended to propose to her. Yet she had to admit her than he would otherwise have done. After that not a single word had ever come from him some time the male teacher in question left the which, similarly, could not be interpreted in an school to continue training overseas. At a fare- indifferent sense either. That he never did declare well visit he was utterly confused, with altered himself, which she had thought was a little unfair complexion, and, in particular, a long glance told on his part, was due mainly to the intrigues and her that he knew very well what was going on indelicate interference of the director and the inside her, and also returned her affection. After entire teaching staff. She gave no credence to my he had left, she noticed that, in exchanges with assurance that all her perceptions of events could her female colleagues, they were sometimes deri- be explained by an abnormal preconceived opin- sive and gleeful, and at other times also sympa- ion which was deceiving her; yet she had allowed thetic and considerate; in any case her relationship herself voluntarily to be admitted to a hospital, was generally known, and any mention of the where she remained I should say for a few weeks teacher in question contained allusions to it. The only. Now, 2 years later, I learned that the patient Director must have mentioned the subject at a has resumed her teaching activities at a private staff meeting; she could tell this from the expres- school, has proved herself perfectly effi cient sions of all those present, when once she attended there, but has now completely broken with all her a staff meeting. All these events took place over 2 former friends, and holds them partly to blame years. No direct messages came to her from the for the fact that she has been cheated out of her teacher, and she began to doubt whether he was a happiness. Explanatory delusions and falsifi ca- man of honour. Although she had to acknowl- tions of memory will have become building edge that her behaviour would have repelled him, blocks of a now-completed system. she believed that, as a righteous man, he should Gentlemen! I cannot help but add a brief com- have explained himself. Quite satisfi ed by having ment here. Had it been a rather more ruthless per- sacrifi ced her own interests through her behav- sonality, instead of a tender-minded and educated iour, in favour of school discipline, she even lady, she would certainly have asserted her claim made a violent scene with the Director, whose on the teacher more vigorously, and become a indelicate interference she had not forgotten, and typical example of the ‘persecuted pursuers’ she was put on leave, with advice to go to a men- [Ed], so often mentioned in recent times [2 ]. I am tal hospital for 6 months. The head of the institu- convinced that the majority of such cases can be tion she visited diagnosed grandiose delusions traced back to some aberrant overvalued idea, and delusions of persecution, and declared her save that the very base of the system often incurably insane. When I saw the patient for the remains hidden in the self-conscious prejudices fi rst time about 3 years after the onset of her ill- of observers [ 3]. Even the head of the institute ness, she was a guest of a friend’s family, and whose above-quoted dictum aroused the not made herself useful by giving lessons to the entirely unjustifi ed indignation of the lady has 96 15 Lecture 15 focused just on the surface of the matter, appar- References ently with no idea of the true nature of the illness. 1. Friedmann M. Über den Wahn, eine klinisch- In this lady there was no psychopathic basis physiologische Unterstellung, nebst einer Darstellung der normalen Intelligenzvorgänge. Wiesbaden: JF from which the overvalued idea would have Bergmann; 1894. grown. However, you will not go far wrong if you 2. Magnan V. Psychiatrische Vorlesungen. Vol. 1. Ueber take note of the ‘critical’ [W] age she had reached, das ‘Delire chronique à evolution systematique’ combined with an excess of mental energy, and (Paranoia chronica mit systematischer Entwickelung oder Paranoia completa). Leipzig: Georg Thieme; 1891. resulting in improper lifestyle, as suffi cient rea- 3. Hitzig E. Über den Querulantenwahnsinn, seine nosol- son for occurrence of a sexually-coloured, over- ogische Stellung und seine forensische Bedeutung. valued idea. Leipzig: FCW Vogel; 1895. Lecture 16 16

• When has a mental illness run its course? This question is of paramount importance because of the overwhelming signifi cance of symptoms, especially explanatory delusions, in almost all paranoid states. In fact, this often Lecture shows up as an endless succession, in that one symptom can always emerge out of another; and Gentlemen! so the process of delusion formation takes place The question—if and when a psychosis that has over and over again. By contrast, in other cases not reverted to full health is to be regarded as hav- the same substantive changes persist, to be joined ing run its course—is, from everything we cur- by delusional explanations only in outline. An rently know, one of the most diffi cult we can pose; obvious difference here is certainly defi ned by and yet it is at once of both theoretical and practi- the different ways in which patients react; the cal signifi cance. From a theoretical point of view, question then is only whether this has a basis in its importance is clear from the idea that in autop- actual pathology. I have already mentioned that a sies of deceased cases we can see only remnants vigorous reaction to change in content of con- [Ed] of the disease process in the organ of associa- sciousness, once that has happened, is to be seen tion [1 ], but no longer the changes themselves, in as normal [Ed] mental activity; accordingly, the organ. In practical terms, cases where active explanatory delusions which subsequently cor- illness is fully extinguished implicitly intermingle rect the content of consciousness cannot be based their healed defi cits with ones that remain in other on pathological processes. After all, such subse- areas of pathology. Nothing would stand in the quent correction is conditional upon substantive way of a patient being discharged from a mental change of consciousness remaining to command hospital as soon as the change in content of con- each patient’s interest. sciousness, taken by itself, becomes harmless, as The simplest example on offer here is that of is often the case for an alleged inventor and founder a delusional idea of a psychiatric patient lacking of new world views. Evidence by which we can insight about his illness, who at the time of that answer this question must of course be found illness had been illegally detained and robbed of exclusively in the area of symptomatology. Our his freedom. We can assume that such a patient, task then is to examine psychotic symptoms we on resuming a regular job and returning to a nor- have met so far, with a view to determining mal way of life, would fi nd so many other nor- whether, and to what extent, they are expressions mal interests that, only if his main interest of a more active disease process. remained focused on the alleged injustice, would

© Springer International Publishing Switzerland 2015 97 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_16 98 16 Lecture 16 he reveal any particularly unfortunate traits. But fact, such non-recovered mental patients are let us assume instead that a lawyer, full of legal unpredictable in their actions. concepts, suffered the same fate; then his main We now want to examine conditions under interest would focus on the injustice he had suf- which, despite the fact that he survived a mental fered; and accretion of new delusional explana- illness, such a disastrous outcome could have tions would probably become obvious. He might arisen. The fact that special individual factors fi le a complaint claiming compensation. Since play a major part was already pointed out. I have ‘what befalls one befalls another’ [W]—there already emphasized the importance of suitable would be no more closely linked notion than that employment, as this may draw out the patient’s others too might have suffered the same injus- interest—usually in a quite normal way. Of tice. If his complaints are then rejected, he might greater importance however is the social milieu come to believe that not only he himself but also in which the patient fi nds himself, and his accep- his fellow sufferers are deemed guilty; and so he tance there. If he has to deal with foolish people continues to pursue his rights. Constant rejection who offer support for his misconceptions about shakes his faith in Justice; he comes to suspect the past, and reinforce his beliefs, he will delve that judges were bribed, possibly by the same just as injudiciously into newspaper reports about faction that had seen fi t to put him away in the his fellow victims; he will again be excited by mental hospital; or that the law was bent, to these and can hardly escape from delusions, cover up the institution’s alleged crimes. Even which continue every day and week that passes his earlier personal experience becomes general- after his discharge, unless he puts his allegations ized. He now considers every lawsuit from the to the test, thinking this to be in his best interests, same point of view, and therefore constantly thus helping the inherently false focus of his arrives at new false judgments. Let us make the attention to fade away. Thus an Affect-laden quite plausible assumption that his wife had frame of mind must be seen as the most common arranged his admission to hospital. Even in the precondition for explanatory delusions. institution, he has harboured the suspicion that Gradually, and in favourable cases, patients she has taken up with another man; yet he has themselves notice that return of awareness of fought—and temporarily overcome—this belief. their illness period is unhelpful; and I could show Now however, when outside the institution, the you several such patients who are ‘right back suspicion re- emerges: He begins to observe all into’ [W] their life, and who are independent of his wife’s comings and goings from this point enough to earn their own bread; yet they are very of view; he pays attention to things he had never reluctant to talk about their periods of illness, noticed before; he highlights remarks of an even setting up major barriers to clinical probing. incriminating nature, and so on. If, following In practice, it follows from this that one cannot be from normal expression of Affects, abnormal too careful when planning discharge of mental jealousy were to arise, delusional jealousy with patients who are only ‘improved’ [Ed]; yet the all its confl icts may end up in the patient’s being issue cannot be side-stepped, as it is a means of readmitted. In all these trials and tribulations the strengthening each patient’s normal interests as patient now assesses his relationship to other they make their way forwards independently, people and to legal institutions incorrectly, thereby granting them further possibilities of according to his biased viewpoint, focusing on subsequent rehabilitation. Unfortunately, how- whether they support him or his opponents. ever, it is often inevitable that patients return to a Thus, we see a whole chain of false judgments life with no structure of regular activity, nor any being formed; expanding delusions, with each ordered social engagement, conditions that are subsequent link as the logical consequence of harmful both through the lack of normal inter- the preceding one; and, for malcontents, each ests and also even by pre-disposing them to station along the entire pathway as a possible emergence of depressed Affects. Their main starting point for their insults and violence. In interest may then remain focused on experiences 16 Lecture 16 99 of injustice; an Affect-laden state of mind sets in, acute psychosis, so that just the aforementioned and further delusion formation is inevitable. Thus elementary symptoms emerge in their purest we see that individual circumstances can decide form. The assumption was made above that the outcome—another argument supporting our habituation of excitation occurs through back- view that the formation of explanatory delusions fl ow of ‘nerve current’ [Ed]; and thus aforemen- cannot be based on an ongoing disease process. tioned symptoms could become habitual, while Further evidence for this lies in the fact that cer- the pathological process itself had reached a tain acute illnesses are characterized by clear standstill. This assumption would seem to apply absence [Ed] of explanatory delusions, this going only to cases in which phonemes and delusions hand in hand with pronounced defi cit symptoms, of relatedness had already existed for a long that is, an apparent dearth of mental activity. period, especially during acute phases of the ill- Delusion formation cannot occur in such cases, ness; and for such cases one must concede the precisely because normal processes for contex- possibility that these symptoms persist to some tual change by the association mechanism are extent as a purely functional disorder. Apart lacking. from that, it will always be justifi ed to take the The situation for most other symptoms that above-mentioned symptoms as signatures of a you already know is quite different from such still active disease process, even if it is in decline. explanatory delusions. The fi rst things that come A second exception is the occurrence of a to mind here, as the principal means of systemati- circumscribed delusion of reference, as we zation, are symptoms of additive and subtractive came to recognize it on p. 92. Amongst very falsifi cation of memory, and retrospective delu- stable fi ndings seen in these patients in every sions of reference. As shown above, their read- other respect, and with emergence of delusions justments seem to occur only when the solid of reference always limited to very specifi c situ- structure of associations has been loosened by ations or the sight of certain people, here too we sejunction processes. However, since those same can see delusions of reference as relatively symptoms may be absent in the presence of this fi xed, now quite habitual, and thus to be viewed condition, without this being explained by any as the outcome [Ed] of a functional change. At actual defi cit state, we must assume that these the same time this urges us to consider that symptoms, so essential for development of a these delusions are nothing new as regards their delusional system, must have another basis. The content, and therefore represent no further most obvious assumption is that it is not sejunc- development of the delusion. tion which has already happened that is essential, If we apply the same criterion to the now- but that which is still in progress, as an ongoing habitual phonemes and the delusions of related- disease process. At least, this assumption is most ness in each previously mentioned case, we might likely for the three other symptoms: autochtho- expect, by their characteristic content, that they nous ideas, hallucinations, and delusions of relat- too can be seen as expressions [Ed] of current edness, albeit with some restrictions. delusional ideas, without their leading to any fur- I remind you that in the case of residual hal- ther development, or incorporation of new delu- lucinosis we came to know a stage of illness, sions. In fact, there are related cases of illness in which along with the accompanying delusions which, despite persisting hallucinations and delu- had been viewed mainly as a sequel to the sions of relatedness, actual systematization never sejunction process, after the latter had died occurs. down. This formulation may be conveniently In general, from a patient’s displays of Affect, modifi ed, so that it corresponds to the stage of one has an indication of whether the hallucina- ‘dying away’ [Ed] of ‘subsidence’ [Ed] of the tions and delusions of relatedness move just sejunctive processes; a stage therefore in which along familiar paths, or contain new items. the most acute sejunction processes have already Fading Affect is therefore often a sign of faded, along with all other severe symptoms of favourable outcome, in that it indicates fading of 100 16 Lecture 16 hallucinations and delusions of relatedness, and ments and adversities, continue to fi ght to the their gradual cessation. Apart from that, internal utmost for their rights. links between Affects and occurrence of those Gentlemen! As a main criterion for the dis- symptoms of active psychosis cannot be underes- ease process being really over, we must con- timated, since those Affects, given their origin, sider a critical test: whether the return to civilian must be considered normal, but clearly are often life meets with success. This test should there- occasional precursors of sporadic occurrence of fore be carried out, if at all possible; and the task phonemes and delusions of relatedness in other- of the institution, to create conditions of an wise stable states. We have already met an exam- active and free life in an artifi cial way, should be ple of this in a rare case where isolated phonemes reserved only for those invalids who cannot occurred among malcontents. This is also the rea- exist otherwise. A second criterion is just as son why patients in whom the sejunctive pro- important, but sometimes fails in individual cesses were only moderately pervasive must cases. It consists of the ‘general condition’ [Ed] often continue, even after their relative restora- of a patient. The crudest measure of this is for a tion of health, to rely on life in the institution. patient to have a constant, relatively high body Any attempt to return to the hard struggles of life weight. Disturbed sleep and appetite are already outside leads to relapse, with acute psychotic excluding factors. We face as a fact, which for symptoms; and only a well-equipped institution laymen is quite surprising, that the brain has a offers such patients constant thoughtfulness and large infl uence on diet. This confronts us par- benevolent treatment, as well as the freedom ticularly in acute psychoses. However, this is from material wants, which for them is a precon- also revealed in chronic psychoses, and particu- dition for permanent mental equilibrium. larly in paranoid states where each more severe Gentlemen! As a generalization, one could exacerbation and every state of intense Affect state that a fi ne measure of how secure the consti- are associated with a decrease in body weight, tution of a person’s brain might be is to be found often in striking contrast to apparently unaltered in the brain’s ability to withstand Affects of espe- balance between intake and output, to be cially distressing kind. Therefore you sometimes explained only by specifi c trophic infl uences. see apparently strong men, who have never expe- This offers a rewarding task for metabolic rienced mental illness, steering clear—with anx- experiment that, doubtless, will lead to an inter- ious dread—of those occasions when powerful esting and instructive result. Affects are unavoidable in their mental processing of annoying events. In contrast, I know of nothing more conclusive for the partial nature of Reference the disorder and healthy performance of the brain (in contrast to the alleged ‘degeneracy’ [W]) than 1. Weigert C. Beiträge zur Kenntnis der menschlichen the elation and joy with which many malcontents Neuroglia. Frankfurt: Moritz Sierterweg; 1895. Aus d. Abhandl. d. Senkenberg. naturforsch. Ges. 1895; join their fi ght, and who, despite all disappoint- 63–209. Lecture 17 17

• Course of chronic psychoses psychotic symptoms, is no better than everyday • Aetiological classifi cation parlance and must elicit the deepest suspicion, • Griesinger’s primordial deliria when used as the basis of diagnosis of a paranoid state. It deserves to be rejected most strongly when, in such cases, the claim is made that we are dealing with a well-known and relatively simple Lecture disease state, given the accurate name of paranoia chronica simplex. Then, it is easy to arouse Gentlemen! the impression of intentional deception, for both With the summary knowledge of paranoid judges and lay people, thereby harming the repu- states that you have acquired so far, I realize that tation of the entire alienist profession. If you so far you have become acquainted only with cer- want to avoid such mistakes, please note that the tain dominating symptoms; but many others that most obvious self-aggrandizement is far from occur concurrently can also be found only as any grandiose delusion; mistrust and hatred of a acute psychoses. However, you will now be able few—or many—people is not a persecutory delu- to discover the main features of the vast majority sion; and paranoid states are mental disorders of paranoid states—and so satisfy the require- which are always relatively easy to grasp, ment which must be fulfi lled, with examples, in detected by very specifi c psychotic symptoms. each psychiatric report, namely that psychotic In some of our most widely read textbooks symptoms which constitute the mental disorder you will see sub-classifi cation of paranoia into in each specifi c case must be recorded in precise paranoia chronica simplex and hallucinatoria . detail—a requirement that sadly is seldom met in You can infer from my comments how much or reports of even so-called authorities. I cannot rather how little such distinctions are justifi ed. emphasize strongly enough that you have the There is no merit at all in independent terminol- right to declare a person mentally ill only when ogy for hallucinations, at least for phonemes, you can produce evidence of this by establishing which almost always predominate. defi nite psychotic symptoms; only then will you Perhaps it requires a certain apology, when, be spared the embarrassment of your opinion with motives such as I have just outlined, I being exposed to justifi ed attacks by lay people. choose the term ‘paranoid states’ [W] to cover The ‘general impression’ [W] sometimes relied all chronic mental disorders in which material on even by better known representatives of our alterations of consciousness are dominant. One profession, when they fail to elicit defi nite might object by demanding that I at least make

© Springer International Publishing Switzerland 2015 101 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_17 102 17 Lecture 17 an attempt to delineate clearly the supposedly hallucinations themselves: the so-called physical well-known paranoia chronica simplex [W]. I persecution complex [Ed], with hallucinations deliberately avoid such an attempt because, in related in turn to the agent behind the persecu- my opinion, there is no well-known illness of tion, and his motives. Grandiosity preferentially this type, unless you want the name to monopo- links up with a series of explanatory delusions, lise that very small number of individual cases because of the logical necessity of explaining that happen to match one another. I come back to how such a large following—an array of so many those cases shortly (p. 102). people—should develop. If discernment and for- With regard to the broader range of paranoid mal thought processes are well preserved, this states, our lack of our knowledge is particularly fi nally leads to formation of technical terms of a noticeable when we try to subdivide them accord- more or less adventurous nature, often appearing ing to their respective course and later develop- at fi rst as phonemes, providing patients with ment. In this regard, we are familiar with only newly formed words. Such patients express some limiting cases. I shall briefl y recapitulate themselves in a changed manner, which is very these here, according to data that I have often characteristic. By means of their intact sense of touched on. Among residual mental disorders are logic, their entire world view is gradually trans- some we have come to recognize as stable states, formed and, depending on the sick person’s state usually characterized by low incidence of symp- of mind, philosophical systems may be advo- toms, and integrity of other functions. Then, there cated with quite outlandish structures. Formally are other cases, about which we know little, correct logic and unmistakable intellectual pro- which are characterized by very gradual, creep- ductivity remain right to the end. In the philo- ing development, and an equally slow, steadily sophical literature of the last decade, you may progressing course, never amounting to actual have been struck by a multi-volume work written acute attacks or severe exacerbations. For both by an apparently mentally ill scholar, which types of illness, as for all major changes, we can would have left you shaking your head. The fi nal construct a disease curve corresponding to the outcome of the full disease process is a material expansion of the disease state. In the fi rst situa- change in all three domains of awareness, because tion the corresponding curve remains parallel the patient sooner or later becomes aware of with the x -axis; in the second—it rises uniformly physical changes in his body. Thus, if you want to and slowly away from the x -axis. choose a name for such cases, then in the later A few remarks are directed to those latter stages you are dealing with ‘chronic total psy- cases with an extremely chronic course. They chosis’ [Ed]. The initial symptoms are likewise correspond to the rather more common type, of beyond any question, the entire fi rst period of the slowly emerging persecutory delusions, which, illness manifest predominantly in the allopsychic after some time, may evolve into grandiose ones. area. Delusions of relatedness are detectable by The period of slow, imperceptible development themselves for a long time, entirely of an allopsy- in such cases, which often makes it diffi cult to chic character as just described. Hallucinations determine the precise starting date, is character- with explanatory delusions bring about gradual, ized by occurrence of delusions of relatedness, but inexorable, reinterpretation of the outside and, shortly afterward, by isolated phonemes world; and for initial years of illness, the designa- with the same content. An overvalued idea may tion of ‘chronic worsening allopsychosis’ [Ed]— take hold as the fi rst and foremost symptom, and also ‘chronic hallucinosis’ [Ed]—is justifi ed. The determine the substance of delusions of refer- qualifi er ‘worsening’ [Ed] indicates that the psy- ence. Gradually the phonemes get out of hand, chosis gradually becomes total, since, from the and other sensory hallucinations and abnormal time of onset of grandiose delusions, it also sensations may even join in. Persecutory ideas encompasses the autopsychic domain. That it are then systematized in two ways. One is via never comes to more severe symptoms in the area delusions of explanation, which refer to the of motility also seems characteristic of such 17 Lecture 17 103 cases. While relatively common (pp. 63, 64), standing, I notice that the substantial confusion is only a small absolute number belong to the class by no means due exclusively to this course of of ‘purely chronically progressing’ [Ed] cases. events, but occurs with any extensive falsifi cation These correspond most closely to the commonly of consciousness. Patients ultimately function alleged paranoia chronica [W]. The two female using a series of idiosyncratic terms, making patients, Schmidt and Reising, are examples of them unintelligible to other individuals, and they this—the latter, right from the outset, in conjunc- may even be understood falsely by others. Such tion with an overvalued idea. confusion is then only apparent confusion, not A third trajectory for paranoid states has noticed at all by another individual with just the become known to me over the course of time same falsifi cations of consciousness. through several cases. It develops in a special Undoubtedly, in years to come, there will be manner, representing continuation of a bout of success in determining a well-characterized set acute psychosis, after surviving several such of trajectories amongst paranoid states, apart bouts in previous years with total recovery. Up to from the four just presented here; but for the time the present, I have seen such a disease process being I content myself with these hints, and con- after acute hallucinosis, or acute hallucinatory fi ne myself to indicating the task that awaits us allopsychosis (see later), usually in alcoholics. here. It will consist of establishing the regularity Progression of the chronic condition, which with which individual psychotic symptoms and always takes the form of a physical delusion of signifi cant changes follow one another, for it can- persecution, here seems to be more rapid and del- not be accidental how the symptoms are grouped eterious than for the aforementioned chronic together, any more than it is mere coincidence forms. that in the entire domain of other nervous dis- I can mention a fourth form of paranoid state eases it often comes down to particular, well- only in anticipation here. Amongst acute psycho- characterized groups of symptoms. In the latter ses, about which we will learn later, is the state of case, the reason for this is no secret: It lies in the depressive melancholia, an acute general illness particular arrangement of the nerve pathways in characterized by intermingling of Affect and gen- certain parts of the brain. If I remind you that we eral akinesia of intrapsychic origin. Such a mel- could likewise regard those major changes in ancholic state can, for a long time, imply consciousness as, in a certain sense, focal points, existence of pure melancholia, until clues are then we can apply the same principle here too, provided from a patient’s altered behaviour that enabling us also to think of particular groups of intrapsychic dysfunction is subsiding, but at the symptoms as the expressions of defi nite anatomi- same time, delusions of relatedness and corre- cal arrangements in association pathways. For sponding phonemes appear. Usually it is any out- the time being, as I have said, we are right at the break of indignation that prompts a patient to beginning of our knowledge of such groupings, speak out, and with one stroke, to reveal an and I would caution you to interpret the manners entirely different picture. The paranoid state, of progression outlined above only as groupings which is now revealed, is usually made up of per- of the most common cases. In reality, they are secutory and grandiose delusions in equal mea- only a fraction of the many variants of unknown sure. Outbursts of wild ranting and a tendency to type included amongst the many paranoid states. violence accompany it in nearly characteristic Gentlemen! It may perhaps seem surprising to ways, leading quite soon to falsifi cation of the you that I neglect classifi cation by the principle entire contents of consciousness, to the point of of aetiology when trying to organize the many material confusion. Patients seem to be able to forms of paranoid states. If I were actually to remain in this stage of major confusion for a long carry that out, I would certainly be taking a false time, although with decreasing energy in their path. However, in what I specifi cally described, actions, but without actual dementia. I am not yet for a psychosis that begins in bursts and then pro- clear of the fi nal outcome. To avoid misunder- gresses towards physical persecution mania, you 104 17 Lecture 17 will fi nd an aetiology of alcoholism. The swirl of public opinion. You could easily gain the question of aetiology is the second task that impression that a new, opportune expression had needs to be addressed, one of equal importance. been found for several universally known clinical Thus, just as it would be wrong to deal with palsy facts, and that there were actually only two major due to lead poisoning before you are familiar disease groups to be distinguished amongst with its most common form, namely bilateral chronic mental disorders: mental disorders of radial nerve paresis, so it would also be incorrect degeneration on the one hand, and mental illness methodology if you wanted to start classifying which is probably well defi ned clinically, but not psychoses on the sole basis of aetiology. I can by aetiology, and which the French author calls easily show how one-sided is this approach by Délire chronique à évolution systématique [W] the fact that acute hallucinosis of a drinker also but which the German translator calls paranoia occurs in non-drinkers. Let us assert that the psy- completa [W]. As you can see, basically I have to choses are brain diseases, and that we can assume reject such a classifi cation because of what it that one and the same site always produces the leads to: a supposedly clinical, well-known form same symptoms. Here then is an area accessible of chronic mental illness—the supposedly well- to research. For some causes however, we cannot defi ned chronic paranoia—separate from all other expect that the effects will always point to the mental illnesses, and the so-called degeneration, same sites, just as if a brain haemorrhage always acknowledging the latter to have only one aetiol- has to be in the same site in the brain. The aetio- ogy. You encounter here, in my opinion, just the logical factor must therefore be only secondary in same exaggeration, which has so far led to failure this area of research. I know full well that under of all attempts at classifi cation of the psychoses. some circumstances the site that is attacked is The class of ‘complete chronic paranoia’ [Ed] is, also determined by the aetiology, particularly the in my opinion, far too broad, containing a wide paresis already mentioned; but disease of the pos- diversity of different chronic psychoses, which terior columns, produced by alcoholism and are yet to be differentiated. Only in this way could syphilis, and, fi nally, the best known type of pro- that author get to the contrasting idea of ‘degen- gressive paralysis are also examples of this. Later eration’ [W] accounting for the entire fi eld of psy- too, in acute hallucinosis of alcoholism, and in choses. As for these latter cases, I do not doubt presbyophrenia we will learn about psychoses that even this aetiological point of view, as well as where the same is true. In general however, I can- many others, will prove fruitful; in Magnan’s not emphasize strongly enough that the forth- work however, it is grossly overestimated; and I coming principle of classifi cation must be that of believe that I should point out to you, as a core of anatomical arrangement, giving a natural group- the notion, just one fact: In ‘degeneration’ [W], ing and sequence of material changes. psychotic symptoms appear preferentially, either Gentlemen! I must content myself for the time in isolation like overvalued ideas or just at such being, with explaining my point of view on these low intensity that it remains in doubt whether the important issues, reserving the right to come back individual in question is to be regarded as already later, with more detail, since acute psychoses nec- mentally ill. Evidence for the fact that such bor- essarily require a defi nite opinion on these issues. derline cases are particularly common among the However, I cannot side-step mention of a specifi c ‘degenerates’ [W] can hardly be found anywhere point here: Chronic psychoses are, to a large except in Magnan’s studies. There again it is extent, no more than outcomes of acute psycho- based on exaggeration, where the author appears ses. Given that, it seemed to me advisable, con- to regard cases of illness—that I described as cir- cerning certain phenomena mentioned in the cumscribed autopsychoses or overvalued ideas— literature, not simply to remain silent on these as occurring only among degenerates. This is not undercurrents. Works of an eminent French psy- the case at all, unless you want to acknowledge chiatrist, Magnan, have drawn us, even here in occurrence of psychosis itself as evidence of Germany, in his direction, in the back-and-forth existing degeneration. 17 Lecture 17 105

Gentlemen! Allow me to end this discussion shared by well-known older authors, in that he with a remark intended to prevent possible mis- denies that primary material changes can occur understandings. I am well aware that I have ful- without preceding melancholy mood; and only in fi lled the task that I originally set myself—that of 1867 [1 ] did his view shift to a more accurate one constructing for you a lifelike portrayal of para- with his proposal of a ‘primordial delirium’ [W], noid states—in only a very inadequate way. You this coming after a preceding lecture by Snell [2 ] will fi nd later that I have not even touched on entitled ‘Monomania as the primary form of several important symptoms, and, on the other mental disturbance’ [W]. Given the dominant hand, have already mentioned some things that status going along with Griesinger’s strong per- actually belong in the fi eld of acute [Ed] mental sonality, you can imagine that the teaching of pri- illnesses. But the diffi culty here lies in the subject mordial deliria now proclaimed by him shifted matter. It is actually impossible to give a vivid everybody’s perceptions, and was welcomed as a portrayal of even a single area, such as I have great step forward for our science. I know this selected here, without expanding to the entire myself, from the beginning of my career in psy- area to put it into perspective. This impossibility chiatry in 1871; and I still clearly remember that has, however, come to my attention even more in this point was always a focal point of discussions, acute mental illnesses, so that after many years of whenever psychiatric topics arose. However, one work I had to decide to reverse my strategy, and to of the unintended effects of the book, and of start working from the ground upwards, placing Griesinger’s teaching, was that primordial deliria acute mental illnesses, which are still the main rarely happened, and the interest of all young source of paranoid conditions, as the precursor of psychiatrists was focused mainly on diseases of the latter. It is just the same with individual symp- nerves and brain. In this regard it will seem toms: Each newly-emerging symptom of mental strange to you that amongst psychotic symptoms, disorder may have an acute character. Most which are regarded as the foundations of para- chronic mental illnesses can even be character- noid states, I have not yet mentioned ‘primordial ized by their acute episodes, with new symptoms, deliria’ [W]. Let me now explain this; but fi rst, which may occur at any period along their course. please let me pass on a remark about Snell’s posi- I have intentionally avoided describing these tion, in that he indisputably had priority over states wherever possible, because they belong Griesinger. Why then was the famous concept of with the acute psychoses; but this was not wholly primordial deliria linked not to Snell’s name but successful for separating such episodes from to Griesinger’s? The answer is simply that, newly-emerging individual symptoms, because although the same phenomenon was recognized even there, just as everywhere else in nature, by both researchers, the versatile, thoroughly- imperceptible transitions take place. trained clinician, complete master of the clinical Gentlemen! The history of psychiatry is prob- method, felt the need to trace it back to certain ably an area that is extremely interesting to elementary psychotic symptoms which he had experts, but for you, who still require instruction just named ‘primordial deliria’ [Ed]. Both authors in the rudiments, it must take a back seat com- started from the same clinical experience, that in pared to the greater needs of the moment. a certain type of mental illness, which Griesinger Nevertheless, I should not omit one topic here, called ‘primary craziness’ [W], and Snell called whose place in the history of our science we can- ‘monomania’ [W] without prior melancholy (in not deny. This concerns what Griesinger called the sense of older authors); primary ideas of per- primordial delirium. In in-patient clinics you will secution apparently arise at a time of elevated, have heard so much about this great clinician that self-confi dent mood. But while Snell was satis- you will not be surprised that his textbook of psy- fi ed with sketching the general course taken by chiatry is still one of the most widely read books, these cases, with intelligence remaining intact, and produced downright amazement in its day. yet with frequent additions of subsequent grandi- Yet in this book Griesinger takes a position not ose ideas, Griesinger sought to penetrate more 106 17 Lecture 17 deeply into relevant pathways, to fi nd, in neurasthenic patients; the overwhelming inci- primordial misconceptions, and specifi cally, in dence of ‘animal delirium’ [Ed] in delirium false judgments, the source of those ideas of potatorum [W]; and fi nally the subjective sensa- persecution, and possibly also of grandiose tion of a particular colour, red, in certain patho- ideas. To clarify what I mean, I give detail of logical brain states (e.g. epilepsy). Here a such judgments: The idea emerged in one connection with legitimate false judgments of patient, by way of example (a case of anxiety mentally ill people is produced only by taking psychosis) that his parents, his wife, and his obsessions into account. So, the great mystery children were dead, and he was readily con- remains for Griesinger: how such regularity of vinced of this. To another came the thought that content can arise—the occurrence of ideas of he should be executed, and to a third that he was grandiosity and persecution, in which ‘perhaps a millionaire, or of princely descent. Thus, there among ten patients, only fi ve throughout the are ‘emerging ideas’ [W] that are held to be true, whole duration of the disease, form the main a phenomenon that may remind you of obses- content of the delirium’ [W]. Now we have sions and autochthonous ideas. known since Meynert that it is the properties of So I fi nd that I can understand only Griesinger, the primary Ego of the child, and of primitive and thereby catch a glimpse of his real stature. people, that are refl ected in this regularity, and Let us see how he himself spoke, in his lecture at I need only refer you to his essay Über den the opening of the psychiatric clinic on 4 May Wahn [W] [3 ] to allow you to get your orienta- 1867 [1 ]: ‘In ganglion cells of cortical grey mat- tion on this. In the natural state, people interpret ter, according to our current assumptions, pro- as actions any events that touch their well-being cesses that trigger [Ed] the imagination come or might harm them; and on this basis, ideas of fi rst’ [W]. Abnormal transmission is then the persecution or grandiosity develop as two basic result of tabes dorsalis [Ed], a disease of dorsal ways in which an individual might react, as does columns; and ‘then abnormal action of those cor- anybody, to impressions from the outside world. tical cells immediately triggers images, words We now must ask: Is there really such a pri- and ideas of all kinds, which no longer corre- mary mode of origin for delusions of persecution spond with reality’ [W]. Here we see Griesinger and grandiosity, in Griesinger’s sense? I can give putting forward a proposition that is close to our an affi rmative answer only in a very limited own. However, it is not lost on him that such nonsense: To my knowledge, the supposed primary sensical judgments should be constructed from delusion of persecution of chronic psychoses pre-existing material within the thought pro- generally develops from either delusions of relat- cesses. To explain why, he indicates two sets of edness, as described above, or explanatory delu- phenomena. First [Ed]: Disturbance of ganglion sions; and, in my opinion, other modes of origin cells can be purely functional, they being excited for paranoid states can be excluded, if you do not from other distant sites. He calls this phenome- want to include paranoia of feeble-mindedness as non ‘associated signs’ [Ed], in which the fi rst well. The same goes for grandiose delusions [4 ]; activation may, for example, be produced by sen- but I submit that besides the consecutive grandi- sation in the bowels. We can simply accept this ose delusion, which develops in a logical succes- view, and you will remember that I repeatedly sion from persecutory delusion, and furthermore indicated such a development of specifi c mani- besides the grandiose delusion of the feeble festations using the term ‘anxiety phenomena’ minded about which we shall speak later, there [W]. In acute psychoses their location can be are two other sources of the so-called grandiose traced back to this in a comprehensive manner. delusions, which can easily be overlooked, and The second [Ed] set of clinical phenomena, can then mimic the appearance of a grandiose in which he contrived an analogy with primary delusion in its primary sense. One is the occurrence of certain erroneous judgments in substantive somatopsychic change mentioned the insane, is the occurrence of obsessions in once or twice earlier, a hypochondriacal feeling References 107 of happiness, with a feeling of anxiety located in tioned, actual psychotic elements is detectable, on the chest region, and probably varying along with account of their long-term feeble- mindedness this. Usually this is correlated with the process of identifying them as hebephrenia. respiration, and is described as very light, easy Gentlemen! I cannot end this historical digres- breathing. Such was the case for example in an sion without mentioning a signifi cant literary earlier mentioned patient (p. 73), Schulz, who event, in which somebody spoke eloquently believed himself to be fi lled with the Holy Spirit, about Griesinger’s primordial deliria, but unfor- preached inspired sermons to people, and trav- tunately found defenders shooting wide of the elled to a nearby region to have himself conse- mark. Friedmann, in his book Über den Wahn [ 6 ] crated by the court chaplain. Grandiosity in this [W], investigated the essential nature of delu- case is merely a case of what I call ‘ideas of hap- sions—let us say the substantive falsifi cations of piness’ [W] and forms the complement of occa- consciousness—in paranoid states as such, sionally mentioned ‘ideas of anxiety’ [W]. The according to the false judgments, corresponding second source is again delusions of reference, to the type of primordial deliria. Closely related often connected to certain overvalued ideas, or at obsessions are regarded by him as a fundamental other times to the hypochondriacal happiness symptom of ‘paranoia’ [W] which he also described above. Autochthonous ideas emerge in accepted, but understood in a very broad sense. such cases, with falsifi cations of memory, and We shall see later that his assumption about acute retrospective delusions of reference, which dress mental illnesses is true in many cases, but we themselves up as facts, to fulfi ll a scheme, and are must reject his attempted generalization. In made manifest in the elevated mood and enhanced chronic cases it is contradicted by experience, clinical facts. and we are not mistaken if we attribute the one- I would like expressly to state only one excep- sidedness of this astute researcher to his lack of a tion, so as not to distort the clinical facts. There large sample. seems to occur, although very seldom, in young people developing a chronic mental illness what Sander [5 ] calls ‘original craziness’ [W], in which References the primordial deliria, in Griesinger’s sense, form the original source of grandiose ideas. Yet pure 1. Griesinger W. Vortragsur Eröffnung der psychia- cases of this kind are seen only quite exception- trischen Klinik zu Berlin am 2 Mai 1867. Arch ally. Closer examination of these cases almost Psychiatr Nervenkr. 1868;7:143–58. 2. Snell L. Über Monomanie als primäre Form der always allows grandiosity to be traced back to one Seelenstörung. Allg Z Psychiat. 1865;22:368–81. of the other previously named elementary psy- 3. Meynert Th. Ueber den Wahn. In: Sammlung von chotic symptoms. Apart from this, the majority of popular-wissenschaftlichen Vorträgen über den Bau such cases of so-called original craziness [Ed] und die Leistungen des Gehirns. Vienna: Wilhelm Braumüller; 1892. p. 83. belong to borderline feeble- mindedness, which 4. Snell L. Die Ueberschätzungsideen der Paranoia. Allg may remain undetected for a long time, since the Z Psychiat. 1890;46:447–60. so-called original craziness usually occurs as a 5. Sander W. Übereinespezielle Form der primären hebephrenic psychosis; and only in some Verrücktheit. Arch Psychiatr. 1868;1:387–419. 6. Friedmann M. Über den Wahn, eine klinisch- extreme—yet undoubted—cases, can it be distin- physiologische Unterstellung, nebst einer Darstellung guished from them. In my experience, in the der normalen Intelligenzvorgänge. JF Bergmann: majority of such cases, not one of the above-men- Wiesbaden; 1894. Part III Acute Psychoses and Defect States Lecture 18 18

• D e fi nition of acute, as opposed to chronic, However, were we to focus solely on the time psychoses course to determine whether a psychosis was • Presentation of an almost recovered case of acute or chronic, it would have little bearing on acute psychosis the complexities of real situations and the terms • Features and special coloration of ideas of used to describe them. Instead, it is the character- explanatory delusions istics of the clinical presentation, its ‘acute • A few new sources of delusional elaboration: nature’ [W], which immediately denotes it as – By analogy being the result of rapid development. Even with – By failure of attention a long duration of illness, or where the onset is – And by aberrant restructuring of associations not rapid, these characteristics are suffi cient that they provide independent criteria for recognizing an acute psychosis. This shows the special position that must always be given to diseases of the Lecture nervous system: Long-standing sciatica or other neuralgia, or an old Tabes [W] can go hand in Gentlemen! hand with severely racking pain; and the over- Acute psychoses are characterized primarily whelmingly chronic suffering due to brain by their manner of creation: We should consider tumours brings with it regular periods of the most as acute [Ed], using the word ‘acute’ [Ed] as it is acute neurological symptoms, such as combina- used in other organic diseases, all of those mental tions of headaches, dizziness, vomiting, and gen- disorders which develop within hours, days, or eral convulsions. Thus, acute reactions of the over several weeks to produce a signifi cant level nervous system reveal themselves quite generally of symptoms. Further development of the illness as depending on the timing of stimuli, which has is then subject to whether and for how long the little apparent connection to the basic progres- patient remains in the acute stage, whether there sion of a disease process, namely change in ana- is recovery, or whether the disorder progresses to tomical tissue. In our efforts to characterize acute a chronic condition. In the latter situation, acute psychoses in more detail, we must consequently psychosis merges into an acute initial stage of a rely, essentially, on other more detailed criteria. chronic psychosis. With the same logic, acute May I remind you, gentlemen, of remarks (p. 54, stages of chronic psychoses presenting at times Lecture 9) I made on the mutual interactions other than the initial period must be regarded as between content of consciousness and conscious acute psychoses. activity and, in consequence, on the resulting

© Springer International Publishing Switzerland 2015 111 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_18 112 18 Lecture 18 effects that abnormal alterations in content [Ed] duration than those in chronic illnesses. of consciousness produce on the main object of Nevertheless, the clinical signifi cance of substan- our study, as we dealt with chronic psychoses. tive disturbances of consciousness during acute We must now add, in so far as this is familiar to mental illnesses is so signifi cant and crucial for us, permanent or irreversible changes in content establishing the characteristics of illness that any of consciousness. However, we will have no teaching on illness which neglected this point of problems with the further conclusion that abnor- view in a one-sided manner would turn out to be mal changes of conscious activity [Ed] help insuffi cient to encompass the clinical facts. While defi ne the form for acute psychoses. in chronic psychoses or paranoid states we could Gentlemen! If you now recall the schema limit ourselves mainly to changes in content [Ed] (p. 13) I gave you at that time, for deriving psy- of consciousness, you should understand how chotic symptoms, you will soon fi nd that it also much more complicated are our tasks in describ- represents a schema of the abnormal changes in ing acute psychoses, where changes in activity of conscious activity, changes which we identifi ed consciousness are just as important as the changes wholly as disorders of secondary identifi cation. in its content. To show how symptoms of mental illness are In addition, secondary processes, which we derived from this schema, and to put their occur- saw added to various elementary symptoms in rence and importance in various mental illnesses the chronic psychoses are, to a great extent, also in their proper perspective, would be a separate present in acute psychoses. They may even be and independent teaching exercise; yet any such enhanced—for instance the principle of explana- attempt might take us too far from our real task, tory delusions; and, just as explanatory delusions which is to become familiar with specifi c cases of do not in themselves represent abnormal activity, illness. I shall therefore restrict myself just to the so in acute mental illnesses we will get to know most important problems of identifi cation from a new sources of delusion formation [W], which theoretical point of view: I shall discuss these likewise are aspects of normal mental life. separately, in some detail, as ones which are quite Experiences that we will gain in this respect, essential for understanding the general pathology forming, in one sense, an addition to the theory of of mental illnesses. These are mainly symptoms paranoid states, are also quite appropriately falling in the domain of hallucinations, or which included here. A patient who is now due for dis- have internal links with such symptoms. charge, and who has been free from psychotic Otherwise, I must restrict myself whenever I symptoms for 3 months, offers us a good opportu- present an illness to shedding light on the mean- nity. He is a 27-year-old, academically-qualifi ed ing of the new symptoms you will encounter, in mechanical engineer K. who is considered to relation to our schema. have recovered from this, his second episode of a Gentlemen! Simple refl ections will show you severe mental illness, complicated by his lack of that, for symptoms derived from our schema, the insight into a few symptoms of his illness persist- symptomatology of acute mental illnesses is a ing from the time of its acute onset. He has a fi eld with no boundaries. Earlier we had come to complete memory for the entire period, approxi- realize that the activity of consciousness gener- mately 1½ years of illness, and his intelligence ates the content of consciousness, so that altered and training in scientifi c observation make him activity of consciousness must also result in quite rare, as a reporter about certain symptoms. changes in the content of consciousness; and we I skip over the fact that this patient can give us could thus defi ne acute mental illnesses as the a detailed account of the voices and autochtho- changes in content of consciousness taking place nous ideas at the time of his illness. We learn within a certain time frame (p. 54). However, from this only that these familiar elementary now we can assume a priori [W] that such symptoms of paranoid states often also occur in changes in content of consciousness during acute acute mental illnesses. Much more important for mental illnesses will be less fi xed or shorter in our purposes are the explanatory delusions which 18 Lecture 18 113 the patient connects to these experiences. He tioned—of having lived twice previously, at dif- was, in fact, always fully aware that the voices, ferent epochs—had been formed in this way. If which he could see as having no objective basis, such emergent thoughts are to be recognized as could not be explained by any physical means, alien, a minimum level of judgment must never- and so there remained for him only the evidence theless still remain. We should therefore not be of his senses, and—much as he struggled against surprised if acutely ill mental patients who lack it initially—the assumption of supernatural such discernment fi nd themselves in a state of effects of ‘spirits’ [W]. He then attributed the more or less total bewilderment, and then strange thoughts as coming from these spirits; express rather outlandish ideas without offering and the fact that they never led to a physical delu- any critical opinion, or attempt an explanation. sion of persecution but rather to the assumption In this sense I recognize the occurrence of what of supernatural effects can, to some extent, be Griesinger called primordial delirium in people ascribed to this person’s scientifi c training. We who are acutely mentally ill, as mentioned ear- see also from this example that delusions of lier (p. 107), referring to Friedmann’s book on explanation in acute mental illnesses [W] play no delusions. Although, in his more recent work on lesser role than they do in chronic states. Of origin of delusions, this author has persistently course, as a prerequisite, there must be, to a cer- maintained his point of view—an excessively tain degree, a retained ability to think—that is, far- reaching one in my opinion [1 ], based on there must be requirements of logic and the logi- comparative ethnology—it nevertheless contra- cal ability to provide explanations for these dicts clinical experience, exactly in relation to strange phenomena. In general, this condition the exception just presented. Incidentally, you corresponds, to some extent, to his discernment, can immediately see that development of obses- as was mostly present in our patient. In addition, sions or rather the correct judgment which pro- the content of explanatory delusions depends on tects patients from developing those ideas individual characteristics of each patient. How which might result from aberrant stimulation is much this is the case, you will see from a second generally conditional on a patient having a cer- case. Among thoughts that had been instilled in tain level of discernment and judgment. In him, our patient announced that he had already future, we should remember that gradations of been in the world several times, as Wotan, and as this sort can be obscured by new thoughts, Ahlbrecht the bear. He therefore believed in which emerge suddenly among the acutely transmigration of souls. When I asked him how mentally ill, to be replaced by primordial delir- he had imagined it, and if it was an act of resur- ium in Griesinger’s sense. This is no cause for rection, the patient expressed his view that the surprise, because the stormy Affects that inter- personality of every person should be viewed as a fere with orderly thinking often occur naturally specifi c arrangement of material components, in acute mental illnesses. and he thought it possible that precisely the same This patient also describes to us a form of order of molecules could be repeated at various delusion that we have not met before, and which times, and could produce the same person. Much he refers to as a ‘vision’ [Ed]. He believed that as the patient himself now laughs at this assump- during his illness he experienced whole scenes tion, you must admit that only a scientifi cally- and situations that sometimes played out in other minded person could formulate such an explana- historical periods. He described to us, for exam- tory delusion. ple, that he had seen his father in a French When the conclusions a patient reaches Marshal’s uniform, standing by the scaffold, the amount to more complex explanatory delusions, threatening crowd below, and the hangman next a degree of discernment may be an indispens- to him; he heard the howling of the crowd and the able prerequisite, as is likewise the case in his hangman calling out, ‘You have to go up’ [W]. assessment of autochthonous thoughts. Assume When I questioned him, he stated that he believed that a false judgment, such as that just men- that he had been transported to the time of the 114 18 Lecture 18

French Revolution, and had no doubt about the time. Now the patient gives us the explanation reality of the events, which he now regards as a that he made errors of observation due to lapses vision. We will study this type of hallucination in in attention. He was often so preoccupied with greater detail later, under the heading of ‘dream- auditory and visual hallucinations that he paid like hallucinations’ [Ed]. Here we are interested insuffi cient attention to events around him. in the conclusions that the patient drew from this. Mostly he even had his eyes shut, a statement I He believed, in fact, that he had been transported can verify. Here, in a most instructive way, we are to other lands and time periods, and explained confronted by a new source of delusion forma- this by wizardry. However, when I objected that tion [W], following a familiar principle of he should not have believed the experience to be attempted explanation—the diversion of atten- real, because his father had not even lived during tion by internal events [W]—and we see how, in the time of the French Revolution, he weakened this manner, very minor and ordinary events take in a quite remarkable manner. He stated that he on an obscure and eerie appearance to patients, had believed at the time that his father, and other but with delusional explanations differing accord- people as well, such as the head warder, had pre- ing to individual characteristics, in this case lead- viously lived during different time periods. ing to an assumption about magic. We can guess Apparently we have encountered here a conclu- just how uncanny and disorientating such experi- sion made by analogy, as the source of the delu- ences will prove to be in all cases, whether or not sion, and the patient himself confi rms that he explanatory delusions are added, according to reached this conclusion, because he was fi rmly each patient’s powers of reasoning. convinced of his own former existence. You will If we continue examining our patient, we soon recall the patient (Rother, p. 56) who claimed to come upon a new source of delusions, again an have a Doppelgänger [W], and who generalized unfamiliar one for us. At one point during his ill- this by saying that everyone has a double. You ness the patient had addressed the ward physician see, gentlemen, how the mentally ill apply in familiar terms, and later made the remarkable Goethe’s line—‘What befalls one, befalls the statement that he regarded him, to some extent, other’ [W]—in practice, a rich source for form- as his son, also indicating that one of his fi ngers ing of delusions, with incalculable scope. signifi ed the physician in person. We learned However, a prerequisite for such delusions by later that each of his fi ngers represented a partic- analogy [W] is a facility for relatively well- ular person: one as his father, one his mother, one ordered thinking. as Napoleon, while it remained in doubt who is Gentlemen! We shall see later that hallucina- represented by one fi nger. The patient spoke tions that combine several sensory modalities, of occasionally of the lawful role of pater familias which you have just seen an example, are linked [W] in Roman law, evidently in accord with the preferentially to dreamlike states. Also, in the sense of this delusion. He could shed light on this present case, careful observation revealed that the for us as follows: The idea that one of his fi ngers patient often seemed quite absent minded, and represented the person of the physician arose unaware of events in his surroundings. He is now because every time the physician came into view, able to explain to us in a satisfactory and very even in dream images, and when he heard his instructive way some strange utterances he made voice, a peculiar sensation arose in this fi nger. at that time. On one occasion he expressed his The other fi ngers behaved similarly. The patient astonishment that the head warder had disap- was unable to describe the sensation in more peared through one door of the hospital and detail, although he indicated that it had not been simultaneously entered through another door. On painful. We see here a new kind of concept for- another, food suddenly stood before him without mation fulfi lling itself, the result of an abnormal any delay, a process that reminded him of the process, namely the occurrence of certain fairy tale ‘the wishing table’ [W]. Both events localized morbid sensations, simultaneously seemed supernatural and magical to him at the with—be they real, or aberrant—perceptions 18 Lecture 18 115 with a certain content. We shall designate this my questions. All of a sudden he turned towards process as aberrant new formation of associa- me, addressed me by name, showed himself well tions [W], and will encounter it very often in orientated about the situation he was in, and at acute mental patients, even if it is rare to get such my request correctly named Pythagoras’ theo- clear evidence for it. Incidentally, when I asked rem. He refused to prove it, when I asked this— the pointed question on whether his fi nger was to saying it was too hard for him. Suddenly, and be identifi ed with the doctor, the patient fi rmly quite abruptly, he interrupted in a lively tone: denied this: He had meant no more than that the ‘You don’t know Saxony and England’ [W]. But latter stood in a certain legitimate relationship then he became lost in contemplation once more. towards him. He indicated that he was very preoccupied with Gentlemen! The example from which we have alleged mishandling by the warders, who were just learned will certainly call to mind things you also present, and talked about this extensively, already know. You may recall the young man always returning to the subject. Here in Breslau (p. 83) who at each sight of his father became there was something odd. External voices had sexually aroused. I presented this to you as an already appointed him as Mayor of Breslau. The example of a somatopsychic delusion of related- voices came out of the air, and from many sides. ness; however we cannot doubt that here too it They were heavenly voices; but he concluded was based on a process of aberrant elaboration of that he could not see anything. In addition, new associations. In our patient still other exam- thoughts were piercing him: He was both a ples showed up in this connection, with somato- Christian and a Jew, and had had a previous exis- psychic delusions of relatedness forming via tence; and he refuted my doubt by pointing to the processes of aberrant association. Thus, on one third article of Faith that relates to the resurrec- occasion during his illness he requested that tion from the dead. Suddenly, and quite abruptly, nobody should touch his bed lest blood be pulled he again said animatedly: ‘The run of life’ [W]. out of his heart; he had a phase when he would You can see that he understood my questions not let himself be touched, because it would and willingly engaged with them, and yet it is cause him discomfort; he once declared that his striking that he sometimes looked distracted, and head would burst if one of the warders uttered a initially answered my questions with the counter- certain word. We can also perceive all these as question: ‘How?’ [W]. Clearly, to sustain his examples of somatopsychic delusions of related- attention to external stimulation required on- ness. It is also readily apparent that such aberrant going effort, and otherwise he seemed to sink associations can exert a decisive infl uence on the into a type of dreamworld, with vivid hallucina- behaviour patients show towards certain people, tions. Nevertheless, in between such times, he and on their actions in general. Some whimsical, was fully attentive and showed himself able to strange actions that are quite incomprehensible reproduce a four-digit number correctly after a during healthy thinking, but are also dangerous at delay of 10 min. He promptly gave the date of his times, and certainly unpredictable, can be the fi rst most acute illness, 5 years previously; he result of such aberrant elaboration of new was also aware of a later relapse; and he consid- associations. ered it quite possible that he was now sick again. Gentlemen! A favourable coincidence pro- On inquiry we learned that he was not suffering vides us with the opportunity to show a case of headaches but experienced very unpleasant sen- distraction through internalized processes, just as sations in his head, which he described as dull patient K. described it, as a fi rst-hand account. and dragging—they were a result of mistreat- This is a very similar, complicated case, just as ment by the warders. He added this information patient K., and, by chance, also a young person as we delved more deeply, along with more about with some technical expertise. Initially we could mistreatment by relatives, who had been not get a word out of him. He looked quite absent committed at the same time. Suddenly, with minded in the auditorium, and seemed to ignore another glance at the warder, who by chance had 116 18 Lecture 18 risen from his seat: ‘I am not guilty’ [W]. He will report on magical occurrences during the claimed that he had observed that the latter had time of his illness, and will even be in a position spoken to him. As I bade him farewell, I tried to to explain them quite accurately as diversion of explain the purpose of the clinical presentation. his attention, as did patient K. He left us with the reply: ‘But you also judge Delusion formation through analogy; by those who infl ict something on me. Every offi cer diversion of attention from proceedings in the has his honour; I am no common man’ [W]. outside world; and by abnormal newly formed We see in this patient changes between very associations—are often also encountered in different states of consciousness: sometimes dis- chronic psychoses. In contrast to other changes tracted by internal processes, making him almost with which we are already familiar, whose sub- inaccessible, and most reminiscent of the physi- stantive changes are much easier to comprehend, ological state of the so-called bewilderment; at these appear to be of secondary importance. other times well attuned to the demands of the However it is different in acute cases where, in moment, and, despite repeated changes of his consequence of multiple alternate disruptions of mental states, with a well-preserved memory. content, fi rst one and then the other dominate, The state of distraction is reminiscent of delir- and, through their infl uence on the patient’s ium, and appears to be associated with a dream- actions, gain attention. In this regard the report of like clouding of consciousness. We can conceive our patient is instructive, and should not be of no sharper contrast than the attentive, razor- neglected. Yet, understanding of acute mental ill- sharp consciousness, which follows immediately nesses demonstrates itself to be far more diffi cult afterwards. We can discern amongst the internal than comprehension of chronic cases. stimuli mixed together in the centre of his radiant mind abnormal sensations, autochthonous ideas, and simple, disorientating phonemes. Reference Disorientation occurs predominantly in the autopsychic area, followed by the allopsychic area. It 1. Friedmann M. Weiteres zur Entstehung der Wahnideen is quite possible that later, this patient, suppos- und über die Grundlage des Urteils. Monatsschr ing that he recovers from this, his second relapse, Psychiatr Neurol. 1897;2(1):10–22. 120–33, 353–76. Lecture 19 19

• The science of hallucinations We must consider how far primary identifi ca- • Hallucinations in various senses tion is involved, when we come to discuss the • Combined and dreamlike hallucinations theory of sensory perceptions. • Historical section The main experiences of hallucinations are to • Theory of hallucinations be found in the sense of hearing; so let us start with these, especially since they can claim, by far, the greatest clinical signifi cance. Here again I limit myself to essential points in clinical Lecture experience. Auditory hallucinations take two different Gentlemen! forms, namely voices (or phonemes [W]) (p. 80), Learning about hallucinations, which we and auditory perceptions of a different kind. The merely touched on in previous discussions, is latter, also called acousmata [W], can show up in probably the most important topic in the general the widest variety of ways, so that, for example, pathology of mental illness; and we therefore sick people hear slamming, banging, clattering, have to know about their basic features before we knocking, thunder, drums, shooting or chirping, can proceed to studying examples of the various hissing, boiling, howling, barking, neighing, or clinical pictures seen in acute psychoses. Since roaring. Such noises are seen particularly in very the time of Esquirol [1 ], sensory perceptions have acute disease states, often accompanied by been differentiated into two major groups: hallu- severe morbid changes in the general condition cinations and illusions. Hallucinations are sen- of a patient. If there is a dry tongue and oral cav- sory perceptions that occur without excitation of ity, the mucous membrane of the Eustachian the relevant sense by any external object or exter- tube and inner ear may also be affected, so one nal stimulus; illusions are false perceptions— cannot exclude the possibility that hallucinations misconceptions in perception of objects that are classed subjectively as tinnitus are of peripheral actually present. For the purposes of our schema, origin; and this is particularly true for simple, hallucinations belong to the group of psychosen- elementary sounds. You would have heard of the sory hyperaesthesias (p. 13); that is, they repre- group of hallucinations arising from peripheral sent a pseudo-identifi cation produced by aberrant irritation of the inner ear, singled out by stimuli; illusions are attributable to psychosen- Kahlbaum [ 2], the Phenazismen [W], to be sory paraesthesias; that is, they represent a falsi- classed as disorders of primary identifi cation. fi cation at the level of secondary identifi cation. This type of acousma is apparently very close to

© Springer International Publishing Switzerland 2015 117 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_19 118 19 Lecture 19 an illusion, since the fact that it originates ear. It also happens quite often that the voices peripherally does not prevent its being inter- seem to change their location independently of preted and used by a patient in a fantastic way. each other. The patient thereby acquires some This manner of origin draws on occasional expe- form of personifi cation of a voice: He complains riences of every healthy person of a subjective that the voices fl y or buzz around him; he looks tinnitus, and also on inner ear peripheral irrita- for them under his pillow and hunts for them as if tion. It is also known that pure tones can arise in they were an annoying insect. Our engineer K. this way. Acousmata such as distinct melodies, heard them, among other places, in his food an orchestral piece, or other auditory impres- bowl. At other times, it is not so much the abnor- sions of more complex nature, such as groaning, mally fi ne localization, but the vivid perception moaning, whimpering, or screaming children— that the voices are accompanying the patient, for these cannot be explained in such a way, and example when he changes his location, or on a must have some other origin. walk, and this leads him to conclude that the The ‘voices’ [Ed]—or phonemes—also occur voices can also change location. in two different forms, namely when they are In the case of unilateral hallucinations, which expressly identifi ed as ‘voices’ [Ed], which a occur quite often, the direction from which the patient himself perceives as something special voices come changes with the patient’s own posi- and different from ordinary experience, or when tion, a manifestation that under favourable cir- they are attributed to another person who is actu- cumstances can lead to our investigating the ally present, or to a person nearby. The fi rst case subjective nature of the symptom. In such cases is a clear instance where a patient himself creates we usually succeed in detecting either a high his own form of expression to describe it as a level of deafness or reduced acuity in one ear. symptom. If you ask such patients to say whether Hallucination in these cases may be encountered they hear voices, they usually affi rm it without sometimes on the side of the healthy ear, and hesitation, conveying also that they fully under- sometimes on that of the damaged ear. Perhaps stand the question. Other patients also will come there is some regularity in this respect, which is out with the description of ‘voices’ [Ed], without apparent if we pay attention in a medical exami- any external prompting with this term. This nation to the localization of ear impairment. Our clearly indicates that auditory hallucinations patient K., who is hard of hearing in his right ear made up of words seem to be inseparably linked as a result of old middle-ear catarrh, reported a to a very specifi c vocal quality. Patients can usu- voice that had been so loud and so close to the ear ally specify with certainty whether the voices that the ear began to bleed and in fact he once come from known or unknown persons; in the found a small bleed in the external auditory former case they can name them, and distinguish meatus. men’s, women’s, and children’s voices. The Those voices that are interpreted as originat- terms ‘angelic voice’ [Ed] and ‘voice of God’ ing from persons present, and which are pro- [Ed] occasionally issue from an unusual, alien jected onto these persons may perhaps owe this tone of voice. The voices seem sometimes far property to the aforementioned abnormally pre- away, and sometimes nearby; often they come cise localization of phonemes. This type of voice, from close-up, so that it seems to the patient as if through which patients reach a misconception someone were whispering, speaking, or scream- about surrounding people, therefore deserves to ing into their ear. Usually the direction from be called disorientating phonemes [W]. Such which voices appear to come can be precisely experiences are of particular importance for their specifi ed; and patients often develop, in this practical consequences, since they often lead regard, quite striking ability to localize, found patients to direct their anger, wrath, and hatred only in cases of illness. The source of the voices towards certain people, and may provoke them to is indicated not only by the direction, but even by dangerous actions. Patient K. explained his attack the very precise location and distance from the on the head warder in this way. Thus, disorientating 19 Lecture 19 119 phonemes represent the worst manifestation of often throughout the whole duration of the attack. voices; and in fact it is often noted that the fi rst- Unceasing, overwhelming hallucinations, occur- described form of voices develops into the sec- ring without any break, are observed only in the ond, while at the same time the patient’s whole most severe cases of mental illness, with simulta- condition worsens. The same observation can be neous disorientation. Apart from that, you usu- made in reverse order. ally fi nd it possible, with some medical Hallucinations can force themselves upon a encouragement, to distract a patient during the patient’s attention, even if erroneous sensory per- act of examination, and the hallucinations may ception is not understood. So, by way of exam- even subside or cease altogether during this time. ple, indefi nite noises precede distinct phonemes; In general, solitude, silence, and especially seclu- and quite often the phonemes fade out in such a sion from busy sensations have a favourable way that patients no longer speak clearly but hear effect on occurrence of hallucinations; yet every only a whisper. In both cases, patients give a clear now and then, cases are seen in which the very indication that they need to listen to the sound, same conditions can bring about the disappear- even though they do not understand its meaning. ance of hallucinations while, on the contrary, Even with the new patient K. it was the same. stimulating them (functional hallucinations , Like many others, he felt a compulsion to listen, Kahlbaum) [W]. as a physical torment, to an intrusive act of abuse. Under refl ex hallucinations [W] Kahlbaum A second feature of hallucinations is their includes those produced either by actual percep- incorrigibility. It has been known for a long time tion or by another hallucination, whether these that, even using the strongest reasons, and the are brought about by the same or a different sen- witness of all other senses, one can never prevail sory modality. For example, one of Kahlbaum’s in convincing mentally-sick people of the subjec- patients heard, every time, on fi rst catching sight tivity of their hallucinations. The main support- of strangers, the nickname ‘Uncle August’ [W]. ing argument that patients use is heard quite A patient under my observation, in early stages of often, when they say ‘I have seen it with my own delirium tremens [W], heard with great fear, from eyes or heard it with my own ears’ [W]. They the ticking of a clock, and from the swirling necessarily trust the testimony of their own sound of a water outfl ow, the words ‘Mangy dog’ senses when the focus is on actual sensations; but [W] and ‘Go hang yourself’ [W]. When a patient this is always also the case for hallucinations, and who had behaved very badly for a long time we hear it from our own patients. The fact that became highly motivated, because I usually made consciousness can be narrowed—which you will an insulting comment at the end of a conversation recall from my eighth lecture—gets in the way of with him, this also probably indicates a refl ex every corrective strategy at the moment of hallu- hallucination. Some patients, at the sight of the cination; only after disappearance of the halluci- meal set before them, hear every time quite con- nation can correction become effective, always tradictory instructions—‘eat’ [Ed] and ‘don’t eat’ when it is already too late. Even the most intelli- [Ed]—and this is probably also based on refl ex gent patients faced with a choice whether or not hallucinations. In their inner disarray only a reso- to trust the testimony of their senses would rather lute command by a physician can tip the balance resort to outlandish attempts at explanation than and motivate them to eat. concede that their hallucinations are essentially Following auditory hallucinations [W], we subjective. Phonemes are not generated continu- should next consider those of smell and taste ously, but mainly leave breaks in between, during [W], mainly because of their major clinical sig- which, with proper instruction, some doubts nifi cance. Most often these take the form of about the objectivity of the voices can gain patients believing that they are tasting and smell- ground. Sometimes voices occur only in spasms. ing poison, the word poison apparently being At the height of such bouts the accompanying used by patients to refer to the widest variety of symptom of anxiety occurs quite regularly, but strangely occurring substances. There is no lack 120 19 Lecture 19 of detailed descriptions of these substances: chlo- images seemingly lacking the depth dimension. roform, phosphorus, and sulphur are smelled; Very often patients themselves refer to them as nauseating things like dog or human fl esh mixed ‘images’ [Ed], and at other times as phenomena, with manure, mud, or urine might be tasted. shadows, or even as ghosts, a term implying some Olfactory hallucinations alone are often of very form of explanatory delusion. Common expres- long duration and continuous, especially that of sions such as ‘It shows me something’ [W] sug- putrefaction, or some other disgusting odour, gest that hallucinations in the visual sense are interpreted as a disease process in the body. Taste distinct in their appearing to be deceptions of hallucinations usually tend to occur only at the reality. An exception to this most common expe- time of food intake. They are, by nature, often rience may occur when the sensorium is clouded; inseparable from tactile hallucinations of the when drowsiness, or stupor, or an ecstatic condi- tongue, which also usually relate to alien admix- tion is present; or when half-asleep. So it is quite tures to the food. The above examples show the common for these same patients who see only content of hallucinations usually to be unpleas- ‘images’ [W] during the day to report visions of ant, and threatening. Accordingly, the importance a physically tangible type during the night. of this symptom is that patients partly or totally Likewise, states of extreme Affect make physi- refuse food as a result of their perceptions. Taste cally tangible visions more likely. A hazy state of and olfactory hallucinations are among the most consciousness can be the basis for visions of an important and most common precipitants of food alcoholic delirium, which sometimes even have refusal. In general hallucinations of taste and the hallmark of reality, just as other acute intoxi- smell tend to indicate a particularly bad progno- cations provide fruitful soil for this. We will sis. However, in acute and especially the most examine the content of such visions later. Just as acute forms of mental illness, smell and taste hal- for phonemes, we will fi nd that it depends to lucinations do not allow a specifi c conclusion on some degree on a patient’s Affective state. the prognosis. Intelligent and discerning patients who can A familiar exception to the general principle talk about their visions describe them as captur- that content of hallucinations is mainly unpleas- ing their full attention. For example, a female ant is to be found in later states of general paraly- patient sees a man appearing at a certain place in sis. Such patients tend to indulge in scents, and the room, at night. She must look at him, she can- you often see them spending hours or days chew- not take her eyes off him, and her gaze follows ing, tasting, and making tongue-clicking mouth him as he slowly approaches the bed and bends movements with all the signs of satisfaction, and over her; all this is accompanied by feelings of often without any previous intake of food. anxiety, gradually rising to unbearable intensity. Likewise, in certain ecstatic states of hysterical Likewise, amongst delirious visions, such feel- mental patients, and in the wake of some acute ings of anxiety not uncommonly surround the intoxications, such reveling in pleasant hallucina- entire delirium with an aura of fear. The content tions can occur. of the visions matches this: the devil comes to In all cases of acute mental illness, as a conse- fetch her; hell opens up; an abyss opens at her quence of powerful Affects and associated rest- feet; walls move; the ceiling threatens to col- lessness, dryness of the mouth and nose may set lapse; and the like. In situations of melancholia in, which must provide fertile soil for the devel- we encounter occasional hallucinations that are a opment of illusions. Such sensory illusions true refl ection of the prevailing feeling of misfor- appear to be even less easily separated and distin- tune: deceased relatives, corpses, a coffi n, and an guished from actual hallucinations in the realm entire funeral. of taste and smell than for other senses. In so far as we hear clear descriptions of these Hallucinations of the sense of vision [W] have visions, they are projected to precise parts of a a general peculiarity that they do not bear the room. You will remember the patient with numer- stamp of tangible reality, but appear as solid ous and varied visions who described accurately 19 Lecture 19 121 to us that an image was about 1½ feet in front of attributable to hallucinations of cutaneous sensa- him, the whole thing being no bigger than the tion, while bites, blows, thumps, and other palm of a hand; nevertheless, he saw an entire infl icted pains represent hallucinations of com- landscape—the bank of a river—and recognized mon sensation. quite clearly the form of a former friend who was Hallucinations often are not limited to a single swimming. When patients speak of shadows, this sensory modality, but embrace several modali- sometimes provides us with the detail that their ties. The most common combination, already visions are transparent; in this way, a male patient mentioned, is a combined hallucination of smell described among others the vision of a deceased and taste. The result of such a combination is, of loved one. course, that abnormal sensory perception in one Visual hallucinations are far less common domain is taken as confi rmation of hallucinations than phonemes; and their clinical importance is in others. The prerequisite for this is a degree of in no way comparable with the latter. Since they ‘kinship’ [Ed] of hallucinations so that combin- do not usually bear the full stamp of reality by ing sensations belonging to two different sensory themselves, they are far less effective in produc- domains occurs in the same way as happens in ing feelings of disorientation or disarray than are reality, in perceiving specifi c objects. It is pre- phonemes. Nevertheless, they are a common cisely this process that appears to be the rule for source of explanatory delusions, coloured in dif- combined hallucinations [W]. Simple combina- ferent ways, according to each individual’s per- tions—such as that of taste and smell just men- sonality. As you will recall, our Engineer K. tioned—occur most often in those sensory fl uctuated between assumptions of magic and modalities characterized by lively organ sensa- that the spirits which he also heard wanted to tions, such as—besides those mentioned—those conduct various procedures on him on purpose, of touch and the so-called hallucinations of com- for the spectators, even the dream images that he mon sensation [Ed], which we will deal with in described. more detail later. More striking manifestations Hallucinations of touch [W] or, perhaps more are those combining so-called higher senses, and accurately, of cutaneous sensation are best known which are therefore characterized by predomi- in Delirium tremens [W]. Patients experience the nance of sensory content. Thus by congruent sensation of creatures crawling on their bodies, interaction of hallucinations in the senses of taste, whether they be vermin, reptiles such as snakes, sight, and touch, the most complete deceptions of lizards, toads, and so on; and they show them- reality are created. A patient believes that he has selves incessantly trying to sweep them off by been transposed into a certain situation and envi- appropriate movements. Possibly, such cutane- ronment, for example to his home in the bosom ous hallucinations can occur in other acute men- of his family, or into a churchyard in the middle tal illnesses as well. More often, however, they of a burial service. He sees the people in action, take another distinct form, in which patients feel hears them speaking, and hears all kinds of asso- that they have been sprinkled or sprayed with ciated noises such as the rattle of carriages, powdered substances or fl uid in droplet form, funeral music, and the like; in short, an entire naturally of a harmful nature. This hallucination event is reproduced, rather like in the theatre, the is also extremely common amongst chronic patient even being able to interact. Once the hal- patients, usually those classed as hypochondria- lucination is over, the patient sometimes explains cal paranoia. An abnormal fl ushing of the skin that ‘it had come to him’ [Ed], or that it had been may underlie this, so that delirious, raving as if he found himself in that particular environ- patients feel that they have to strip off their ment—statements that allow a patient insight clothes. The tingling sensation described pre- into the abnormality of the event. Combined sen- cisely by many mental patients, interpreted as if sory hallucinations of a delirious patient are quite they have been electrifi ed, and also morbid sen- similar: He might see himself as a coachman sit- sations of heat and cold are likewise probably ting on the box, with the horses and road before 122 19 Lecture 19 him, and required to take evasive action when he theoretical considerations, by way of some com- hears the horses neighing and people screaming, ments on history. The oldest theory of hallucina- while in reality he is in a hospital room lying in tions, which prevailed for a long time, developed bed. Such combined hallucinations are rarely under the infl uence of the great physiologist seen among mentally ill people, except in delir- Johannes Müller [3 ], and is derived in the sim- ium tremens [W]; they are however peculiar to plest way from physiological processes of sen- fevers in severe physical illnesses such as typhus, sory perception. It started from the fact that we in the specifi c brain disease of meningitis, and in can normally make a clear distinction between certain acute states of recovery, and characterize memory images (fantasy images) and real sen- them all. In all such cases, a precondition seems sory perception. For physiological investigations to be a mild to moderate degree of drowsiness however, the difference is based on the fact that, along with diminution of the sensorium. Since with sensory perception, there is always excita- they also appear to have greatest similarity to tion of a sense organ or of sensory nerves. So, to sensory delusions of dreams, we can appropri- explain the same perceptions—which cannot be ately refer to them as dreamlike hallucinations avoided, bearing in mind the nature of hallucina- [W]. Epileptics and hystero-epilectics can expe- tions—and with excitation of memory images rience such dreamlike hallucinations for hours or (fantasy images) as an exception, then such perfor days; in pathological intoxication, they occa- ceptions can only become a hallucination if aber- sionally present as though under the infl uence of rant excitation takes place simultaneously in the ether, chloroform, belladonna, or similar poisons. periphery, that is, in sensory nerves; and then In people severely predisposed to nervous dis- such excitation forms the most essential prereq- eases, they can occur sporadically, without our uisite for a hallucination. Following from this ever being able to infer a mental illness. viewpoint, people have developed a theory along Kahlbaum already pointed out that such the line that hallucinations are diseases of sense dreamlike hallucinations commonly escape med- organs or sensory nerves which lead to such exci- ical detection, and can be revealed only retro- tation; yet only very rarely have such changes spectively from conversation with patients. We been detected in sense organs or nerves, and are not then entitled to conclude the genuine some apparently confi rmatory fi ndings have presence of hallucinations, except in cases out- aroused valid concern about the correctness of lined above; our focus should rather be on the the theory. Thus in visual hallucinations the optic already familiar stages of progressive falsifi ca- nerves were found to be completely degenerated, tion of memory. Another combination of halluci- and transformed into a mass of connective tissue, nations not belonging to dreamlike states deserves even in cases where long existence of this change mention here because of its frequency. It consists had been proven before the onset of hallucina- of hallucinations in other sensory domains, or in tions. The same happens in other cases of blind- the domain of hearing being interpreted and con- ness due to destruction of both eyeballs. In such fi rmed along with the ‘voices’ [W], and eventu- cases, it seemed to be a very forced conclusion ally put into words. For example, nothing is more that after years of inactivity of the optic nerves, common than for patients with taste and smell the assumption should be made that they became hallucinations occasionally to hallucinate the operational once more with the onset of a mental words ‘poison’ [W], ‘human fl esh’ [W], and the illness, or that from the very sites of disease from like, or that patients with abnormal physical sen- which nothing at all had been previously noticed, sations use particular names for them, which they you might expect activation to arise. The out- use all the time, made manifest as further audi- come of this diffi culty was that the required stim- tory hallucinations. ulation process was moved from sensory nerves Gentlemen! Our understanding of hallucina- themselves at their central end and indeed accord- tions as symptoms of acute psychoses is of ing to one source (Schroeder van der Kolk) [ 4 ] to such importance that I cannot omit introducing the so-called nucleus [Ed], and according to 19 Lecture 19 123 another to the thalamus. It was considered ana- Gentlemen! If I am forced here to argue tomically proven (by Luys) [ 5 ] that the thalamus against one of Meynert’s hypotheses, then I represented a central station for all sensory should guard myself against possible misunder- nerves. This assumption, fi rst established by standing: I am far from making the mistake that Hagen [6 ], now has the most followers. Its latest the hypothesis of this deep-thinking master fi nds and most effective proponent, in slightly modi- support merely in his very special view of the fi ed form, is Meynert [7 ]. His views can be sum- intervention of the vascular system in the cere- marized roughly as follows: If a mentally ill bral mechanism, and that I have singled out only person has a hallucination and, despite normal one member from a chain of hypotheses whose functioning of other senses still available to him, force lies in its solid structure. But merely from has no insight into the abnormality and subjec- the descriptions emerging in our clinical studies tive quality of this deception, then this shows a we are forced to renounce the hypotheses as not certain weakness of intelligence or hemisphere strictly necessary for our understanding. performance. However, the hemispheres are not Moreover in fairness I should mention two of only supporters of intelligence, but have a second Meynert’s predecessors, following his train of major function consisting of inhibition and sup- thought. In his work, already mentioned, pression of automatic and refl ex effects of stimuli Kahlbaum (on the basis of anatomical views of within the subcortical ganglia. A reduction of Schroeder van der Kolk) suspected that the site of hemispheric performance means abolition of this the stimulation process in some types of halluci- inhibition, and therefore has an effect on subcor- nations was in subcortical centres and indeed in tical ganglia, such that stimulation processes tak- the nuclei of origin of the nerves. Finally we must ing place there are amplifi ed to the level of mention a purely psychological viewpoint, of stimuli otherwise transmitted from the outside H. Neumann. Neumann explains hallucinations world. Thus hallucinations are explained by a as being due to the elimination of those normal state of ‘irritable weakness’ [Ed], whereby the activities of the brain, which he called a ‘critic’ stimulus and the weakness have their locations in [Ed]. He treats hallucinations as diseases of this two different regions. This hypothesis has the critic. That this consideration, which dispenses fl aw that it is based on several other hypotheses: with any experiments on localized function, coin- such as the assumption that abnormal stimulation cides perfectly with Meynert’s assumption that occurs in subcortical ganglia, which must surely hemisphere activity (which would do just as well be present if it is to be amplifi ed to an aberrant as the ‘critic’ [Ed]) is reduced is readily apparent. level, and further that hemispheric performance Neumann’s approach, at least, is noteworthy for is reduced in hallucinating patients. We will see its great impartiality. later that this assumption is quite superfl uous. These brief remarks on the history of halluci- However, if you want to accept it, it would still nations may suffi ce to show how, in pursuance of all lie within Meynert’s train of thought fi rst to Johannes Müller’s original assumption, previous think about the fact of mutual inhibition of hemi- authors have been forced to wander further cen- sphere performance, and to seek a location of trally, and to relocate the aberrant stimulus from both these opposing states within the hemi- the sense organ and sensory nerves, fi rst to sen- spheres themselves, so that we might envisage sory nerve nuclei, and then to the next higher sta- some degree of functional weakness as being dis- tion—the subcortical ganglia. Involvement of the tributed in remaining parts of the hemisphere, central projection fi elds therefore remains indis- while the amplifi cation of function, on the other pensable, since supposed stimuli from subcorti- hand, is distributed in central projection fi elds of cal ganglia could not possibly engage in the sensory modality in question. In this case, associative activity presupposed to account for nothing forces us to make the further assumption the ordered character of the real perception. of a change in stimulation in the subcortical Our position on this question is given simply ganglia. by considerations that I developed for you in my 124 19 Lecture 19 introductory lectures (pp. 15–50, particularly of the retina. Such preformed adjusting move- pp. 27 and 30). The difference between a mem- ments can also be seen in relation to the organ of ory image and a visual image becomes blurred in hearing in all animals with moveable ears; and hallucinations, by an abnormal process. We the vestiges of aural mobility, which humans still found this difference earlier, when the fi rst termi- possess, are proof that humans could also once nation of the projection system in the central make such adjustment movements. It has indeed fi elds of the cortex, which we named ‘perception been reported by primitive peoples that their cells’ [W], was co-stimulated in the act of per- greater acuity in the sense of hearing enables ception. We became acquainted with these cells them to locate the source of sounds or noises in a as carriers of the organ sensation and components surprisingly accurate manner. Civilized humans of consciousness of our own physicality. We can have lost this ability. However we see it reappear therefore also identify the essence of a hallucina- in cases of illness and, as seems quite understand- tion by saying that the aberrant stimulus extends able to us, linked to abnormally strong organ sen- via the memory image to these carriers of the sations that, in part, are directly felt as painful, organ sensation; and a memory image becomes a capturing attention to such an extent that the visual image, and next becomes a hallucination, patient is forced to listen to a hallucinatory hiss as soon as it makes contact with the associated even though he cannot understand a word of it. organ sensation—by excitation of those percep- As we shall see later, such abnormal localization tion cells. Thus it is a disorder of consciousness seen for phonemes also occurs internally in the of corporeality, which constitutes the main fea- body, in a leg or ‘a boot’ [Ed], as one patient ture of hallucinations. The essential features of expressed it. From time to time we will also fi nd hallucinations analyzed above thus become the Affect of fear located in this strange way. In explicable to us. Above all, as an example, we this, we will see examples of abnormal associa- can explain the compulsive demands on attention in the domain of consciousness of corporeal- tion. Each intense organ sensation exerts such ity, and we will no longer fi nd them so strange. compulsion, as I already demonstrated to you in various examples (p. 27), and you will also recall that this compulsion is, at the same time, a pro- References tective measure for the very essence of corporeality—Meynert’s ‘primary ego’ [Ed]. We can also 1. Esquirol E. Des maladies mentales considérées sous now understand that the Affect of fear itself les rapports médical, hygiéniqueet médico-légal, vol. shows such an intimate connection, often depend- 1 and 2. Paris: Chez J-B Baillière; 1838. ing directly on hallucinations. Such an Affect, 2. Kahlbaum KL. Die Gruppirung der psychischen Krankheiten und die Eintheilung der Seelenstörungen. you will recall, always occurs when corporeality, Danzig: AW Kafemann; 1863. the ‘primary Ego’ [W], is threatened. 3. Müller J. Ueber die phantastischen Thus we also gain an understanding of the Gesichtserscheinungen. Eine physiologische remarkable observations of abnormally precise Untersuchung. Coblenz: Jacob Hölscher; 1826. 4. Schröder van der Kolk JLC. Bau und Functionen der localization of hallucinations. Organ sensation as medulla spinalis und oblongata und nächste Ursache a constituent of overall consciousness of corpore- und rationelle Behandlung der Epilepsie. ality always refers to a specifi c location on the Braunschweig: F Vieweg und Sohn; 1859. p. 105. cutaneous sensory layer, or of the retina, or of the 5. Luys JB. Recherches sur le système cérébro-spinal, sa structure, ses fonctions et ses maladies. Paris: epithelial layer lining other sense organs. Thus, Baillière; 1865. in the retina, the entire specifi c projection is 6. Hagen FW. Die Sinnestäuschungen in Bezug auf mapped upon space, a property which, as we saw, Psychologie. Heilk Rechtspfl ege. Leipzig: Otto is entirely fi tting for vision. It has been pointed Wigand; 1837. 7. Meynert Th. Ueber Fortschritte im Verständniss der out previously that adjustment movements of the krankhaften psychischen Gehirnzustände. Wiener med eyes must be derived from the organ sensations Blätter 9. 1878. Lecture 20 20

• The science of hallucinations, continued central projection fi eld, with no relationship at all • Cohesiveness of preformed associative to those functional units for remembered images organizations and the corresponding concrete concepts [Ed]? • Involvement of the projection fi elds in We encounter this diffi culty more sharply, in the hallucinations case of unique hallucinations in a single modal- • Special localization of memory images ity, or in the case of dreamlike—or indeed any • Paraphasic speech compulsion of paralyzed type of—combined hallucinations. However, we patients should take notice of the peculiarity in such • Compulsive repetition of phonemes dreamlike hallucinations that the excitatory pro- • Different intensity of memory images cess causing the hallucination takes place in a • Hypermetamorphosis similar manner in the different projection fi elds, • Hyperaesthesia that is, with just such an organization of stimuli • Modifi cation of the schemata for disturbance as refl ects an accurate picture of reality. In fact, to of identifi cation explain this strange coincidence we cannot dispense with a hypothesis that I proposed earlier (p. 66) that clinical experiences force us to transfer the theory of specifi c energy of sensory ele- Lecture ments to the entire organ of association, and to assume that resonance of the same combination Gentlemen! of associative elements always leads to the same The view just developed raises a problem mental process taking place. We previously deserving our attention. How is it possible, we applied this only insofar as we needed it to might ask, that a pathological epigenetic activa- explain the emergence of certain thoughts, as just tion, whose localization is in one sense subject to such a resonance of a very specifi c combination chance, replicates the very activation pattern of a of associative elements. We now have to go a step particular visual memory image, or an artifi cial further to consider the emergence of dreamlike grouping of unique impressions such as the hallucinations as resonance of such functional acoustic memory image of a word or a melody? units by any [Ed] type of activation. In other Should we not rather expect that a process, whose words, in whatever way excitation of elements aberrant action depends on its affecting a chance making up functional units and pathways location, would likewise result in totally-random occurs—and however, by repeated function, they stimulation of perception cells in the relevant always act—the effect is invariably the production

© Springer International Publishing Switzerland 2015 125 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_20 126 20 Lecture 20 of a defi nite content, specifi c to them. So the con- Clearly, this view can only be seen as supporting gruence of the parts of combined hallucinations an assumption that memory images are trans- gives us an exact example of the fi rmness with ferred to spatially separate sites in the cortex, which those functional connections [1 ] are estab- rather than to the site of perception itself. The lat- lished, which represent the outside world. In par- ter assumption has already gained signifi cant ticular, the hypothesis just proposed should apply support from a study by H. Sachs [ 4 ] in my clinic. to propagation and spread of activation from any As you will recall, in my Introduction, I por- [Ed] site, onto the intact central projection fi elds, trayed the form [Ed] of the stimulus—a recipro- although diseases of the projection fi elds are cal relationship of stimulated perception cells—as themselves capable rather of generating abnor- the essence of memory images; and Sachs has mally altered [Ed] hallucinations. In this way we proven, or at least made very likely, that memory can understand A. Pick’s [2 ] remarkable observa- of this relationship in the visual sense is to be tion in an individual who had earlier suffered sen- conceived not as distributed amongst specifi c ele- sory aphasia. Here auditory hallucinations had a ments of what he called the ‘light fi eld’ [W]—the pronounced paraphasic character, consisting of cortical endings of tractus opticus —but in the distorted words, sentences with malapropisms, oculomotor projection fi eld [Ed]. We must think and the like. The same author [3 ] reported on a of vision as coming about in such a way that cer- patient with a hemianopic defi cit of homonymous tain memories of oculomotor images are immedi- quadrants of both visual fi elds. The visual hallu- ately aroused as a result of the sejunction process, cinations of this patient had the peculiarity that and only from there are associated perceptual they were concerned with gaps corresponding to elements of the so-called light fi eld [Ed] aroused. the quadrant in question, so that, for example, a This second action is known to be beyond our head appeared with the corresponding, sector- voluntary control, so we must conclude that only shaped cut-out. In progressive paralysis in par- activation of abnormal strength can overcome ticular, which always leads to a localized those resistances preventing the enforced rever- pathology in projection fi elds, distorted or com- sal in the direction of conduction. We conclude pletely meaningless words are often hallucinated, that such resistances are very important, from the but elementary sounds can also occur, which are fact that most visions are manifest as shadowy likely to owe their origin to the random activation and less bright, while the other fact, that they in situ [W], in a projection fi eld which is itself appear only as two dimensional, and as ‘images’ disturbed. In the visual area, most diverse visual [Ed], indicates that propagation of activation phenomena—visions of lightning, and fi reballs— from one oculomotor fi eld to the corresponding may be experienced. The vast majority of halluci- one in the opposite hemisphere usually does not nations, however, are certainly attributable to occur—possibly because no preformed pathway spreading effects of stimulation, since we learn for this exists. We cannot expect activation from neuropathology that the majority of symp- caused by aberrant processes to be symmetrical toms of activation are based on a propagated acti- at identical sites in both hemispheres; or we vation, often from quite distant parts of the brain. regard this possibility to be exceptional, found Gentlemen! From views just developed, we only under special conditions. For perception of cannot construe hallucinations as localized pro- depth, insofar as it is mediated through the eyes, cesses, assuming their location to be confi ned to interaction of the oculomotor projection fi elds of projection fi elds of corresponding modality. both hemispheres appears always to be neces- Indeed we are forced to overlook any initial stim- sary. You see, gentlemen, that by assuming a ulus in the location corresponding to memory more or less arbitrarily localized pathological images, and thereby to assume further activation point of activation, the simplest explanation is of associated sensing elements—‘perception provided for certain fundamental characteristics cells’ [W] as we named them earlier—arranged of visual hallucinations. Of course we cannot according to the norms of that projection system. exclude the other possibility that pathological 20 Lecture 20 127 activation achieves exceptional salience in the In contrast to such a defi cit is a speech compul- ‘light fi eld’ [Ed] itself; thus we do encounter so- sion, commonly quite isolated, seen in paralytics, called elementary [Ed] hallucinations, the most with no admixture of paraphasias. This is actually diverse kind of light experiences, whose form is a symptom of mania, where compulsive speech, irrelevant. If someone sees lightning fl ashes, a by its content, reveals mainly motor characteris- fi ery cloud, a fl aming sword, or a sea of fi re before tics, based undoubtedly on activation whose start- him, or if he rejects milk because he regards it as ing point is the diseased left temporal lobe. We blood, or sees a pool of blood in his bed: These conclude from this that any activation in the left will be forms of primary activation of the light temporal lobe can develop along quite different fi eld—due of course to the sejunction process. lines, which are to some extent the opposite of The fact that similar considerations apply to those of the acoustic perception fi eld, the activa- mental images of sounds, and especially speech tion then making use of the preformed pathway to sounds, has been developed in ingenious ways by Broca’s convolution [ 6 ]. H. Sachs in the above-mentioned work. Here too, With similar focus on localizing points of the relationship of tones and sounds infl uences activation, another fact deserves mention here: I each other within memory images, and it is there- mean the common cases of compulsive repetition fore likely that the reach of such relationships is of phonemes. This equally specifi c motor symp- linked to an acoustic motor projection fi eld—cor- tom, which under special circumstances can also responding to the oculomotor projection fi eld. be linked with paraphasias, indicates activation Only propagation of the aberrant activation from which strikes, one after the other, the two familiar this supposed fi eld to the acoustic perception fi eld pathways for spread. It has the peculiarity that the gives rise to the hallucination, and (since speech actual phonemes are often a memorized series of sounds are defi ned by a vast number of related associations, otherwise lacking Affect, for exam- variables) to the subjective quality of the speech ple, the list of a series of numbers. Although this sounds. In exceptional cases, where the acoustic fact speaks for localization of activation closer to perception fi eld is primarily affected by such acti- the temporal lobe itself, these cases in no way vation, there arise subjective sounds and tonal belong among paralyses, but among motility psy- combinations of a random nature, which we earlier choses, the same being true of the compulsive called acousmata. Because, unlike visual halluci- speech, especially without prior hallucinatory nations, auditory hallucinations—especially pho- speech sounds. nemes—bear the full stamp of reality, we might Gentlemen! You can see that just by getting to expect the ‘centre’ [Ed] for word sound patterns to know all these internally-associated symptoms be unilateral, so that in phonemes, we are pre- we see in the right light the signifi cance of the sented with an exquisite focal symptom of the left fi rst left temporal convolution as the site of ‘pho- temporal lobe although the symptoms have lim- nemes’ [Ed], the most common—and you could ited value for localizing the symptoms. As is almost say, the most important—of all the psy- known, this value increases signifi cantly as soon chotic symptoms. Nevertheless, we cannot doubt as defi cit symptoms are mixed in with those of that, except for certain very special cases hinted activation; and here we should recollect what I at here, the left temporal lobe is not the actual earlier called ‘manic aphasia’ [Ed] [ 5]. We will see seat of the disease process, the effects of whose later that this name may no longer apply, since it is activation are revealed to us. Phonemes are more more of a simultaneous hyper- and parakinetic commonly indirect effects, or side effects, and, in symptom. This symptom itself, not uncommon any case, are phenomena based on spreading, to among paralytics, is an impulse to paraphasic be interpreted as disease processes—sejunction speech, specifi cally a symptom of motor [Ed] acti- processes—whose localized origin is elsewhere. vation within which the defi cit, a disturbance aris- This is already proven by the admittedly funda- ing in the fi rst left temporal convolution, manifests mental fact that exactly the same types of disease itself as paraphasically altered speech output. can occur sometimes with, and sometimes 128 20 Lecture 20

without, phonemes. Phonemes then show up as A second, equally-sharp question, mainly of replaced by corresponding thought content, interest in psychiatry, is whether thinking takes although not assembled precisely in words. place in—or mainly in—words, or in concepts. As Furthermore, the phoneme content follows a set you may recall, I have previously expressed my pattern, depending on the disease type, just as do view that thinking is not tied exclusively to exis- the thought contents. We should look into this tence of concepts as words, or even just word point immediately. sound patterns, but rather that we recognize con- Gentlemen! You have found that any attempt ceptual thinking as independent. However I did to reach a deeper understanding of psychoses concede earlier that individual differences may leads necessarily to some burning questions exist in this respect, as ‘brain habits’ [Ed], so to about brain pathology, such as the one just dealt speak, according to which, one person thinks pre- with: the specifi c localization of memory images. dominantly in words, and another predominantly In my opinion such a question, the so-called in concepts. I imagine also that predominantly asymbolia , has now been closely studied—not conceptual thinking is a superior form, more only from the well-known theoretical side by closely matching reality and to some extent the H. Sachs, but also from the admittedly few obser- more scientifi c. However, I cannot conceal the vations into such cases, where more accurate fact that outstanding brain experts like H. Sachs post-mortem fi ndings have been compiled. Three hold a different view and locate the entirety of such cases from my clinic, including two with logical thought in the site for sound patterns, that autopsy results, have recently been described by is, in the left temporal lobe. As I commented ear- Heilbronner [7 ] in treatises on psychiatry pub- lier, in my opinion, this is going too far, and is lished by myself; and according to these, asym- refuted by clinical experience of disorders of the bolia presents as a combined disorder, insofar as left temporal lobe. However I must admit that, there are losses in identifying sensory impres- apart from any individual differences, various sions—which is in part secondary, and in part words may be connected mainly with the left tem- primary identifi cation. The former can be poral lobe as the site of word memory images; and explained by autopsy fi ndings, namely bilateral that is because, in contrast to other words—nota- damage to deep white matter of the cortical con- bly all concrete concepts—the corresponding vexity between occipital-temporal lobe and the image of a word sound becomes the sole focal rest of the brain. Disturbance of primary identifi - point of all its associative links, all of which links cation, however, fi nds suffi cient explanation in are acquired via language. Here, I do not mean the partial destruction of occipital and temporal expressions for states of inner experience that I lobes themselves. Thus the clinical syndrome of mentioned earlier, but rather artifi cially learned asymbolia, with the integrity of the actual act of concepts, acquired through instruction, and not perceiving, is thereby also confi rmed by autopsy only abstract concepts. Here belong, for example, fi ndings—in that Sach’s so-called light fi eld of series of numbers and their manipulations; con- the occipital lobe and large parts of the temporal cepts of historical data and personalities; and lobe are preserved and remain along with the pro- many abstractions attached to certain names. We jection fi bres. To state my view on this unambi- can then envisage a thought which is independent guity, I should explain that I take it that functional of the left temporal lobe only when restricted to propagation from centres for perception to those examples which are mainly concrete, with a for memory serves primary identifi cation; and I somewhat simplifi ed thought content. While clin- understand that the transcortical conduction of ical psychiatry takes motor behaviour under vari- the stimulus via the latter is needed only for sec- ous external conditions as the focus of observation, ondary identifi cation. Moreover, autopsy fi nd- it makes no extensive claims about this matter; ings of a case of psychic blindness, accurately the less so, the more colourful is the clinical pic- observed in the clinic by Lissauer [8 ] and ana- ture, so that we really should take account of the tomically studied by Hahn [9 ], support this view. proposed variation between individuals. 20 Lecture 20 129

In any case, I know for a fact that there is a to actual auditory sensations [Ed]. Given the whole series of mental illnesses that occur some- same strength of aberrant activation, the further times with and sometimes without hallucina- assumption then necessarily arises: Activation tions—always involving mainly phonemes—and extending back to the site of organ sensation, that there is no other explanation than that there are is, the acoustic perception fi eld, must have its ori- individual differences in habits of thinking, gin lying functionally closer to one of the tempo- which can easily clarify the increased excitability ral lobes, than to the other, which had already of word sound patterns, and thus the easier occur- exhausted itself at the site of where memory rence of hallucination, among those who think images are located. We thus come to conclude, as predominantly in words. I suggested earlier, that differences in location of Gentlemen! If there is any possible doubt the sejunction process are the basis for differ- about whether thinking occurs exclusively as ver- ences between hallucinations and autochthonous bal memory images, it is impossible to deny that ideas. it occurs mainly through memory images, and Gentlemen! I indicated earlier that primary that we do need a clear marker of the difference identifi cation can be affected in mentally ill peo- between a mental image and a visual image. ple. The two symptoms to be considered here However, the question is how might we judge involve the borderline between secondary and mental images of varying intensity—and whether, primary identifi cation, namely those actual sen- in this respect, a more detailed analysis of ele- sations which are closely linked to ‘perceptual mentary symptoms, as we envisaged them ear- cells’ [W]; and it is probably no coincidence that lier, such as autochthonous thoughts, obsessions, they are observed mainly in disease states, which, and overvalued ideas might be possible. Of these in their entire character, are close to the so-called three symptoms, obsessions appear to be best organic [W] brain—or neurological diseases. known and easiest to demarcate. However, they Under hypermetamorphosis [W] we recognize are of only minor signifi cance in acute psycho- an organically-produced compulsion to take note ses. Overvalued ideas, as we shall soon see, of sense impressions, and to fi xate attention on require a somewhat broader defi nition. It then them. This can usually be determined experimen- turns out that they can claim a signifi cance simi- tally, by bringing favourite sensory stimuli into lar to hallucinations in the clinical picture of the vicinity of the patient: for example, pulling acute psychoses. As for autochthonous ideas, we out a watch, a handkerchief, the stock market saw earlier that they are closely related to pho- report, or noting how objects are casually played nemes: they can precede them or be transformed with, to give a sense of sight; producing a sound, into them; and occasionally they are indistin- making the clock strike, or making a suppressed guishable from them, in that patients themselves comment to a third person, letting a tap run, and do not know whether or not thoughts that have humming a melody in front of him, to produce come into their heads are based on an actual auditory impressions; occasionally touching the vocal sound. It may also happen that autochtho- patient, to produce tactile sensations; and placing nous ideas appear to focus consistently on certain scented materials nearby to give a person sensa- words, and that, in their content, these have the tions of smell. Usually the whole deportment of same meaning, as shown most clearly when the the patient makes the symptom unambiguous, content corresponds to a command or a prohibi- and immediately recognizable, and hospital pro- tion, and has a decisive effect on actions of the cedures are especially likely to capture interest of patient. such patients. There is often a difference in sen- The aspects listed allow us to interpret autoch- sory areas affected, in that many patients are cap- thonous ideas, just like phonemes, as symptoms tivated more by mental impressions, and many of excitation of the temporal lobe; that is, they others by auditory sensations, especially com- appear as very vivid remembered images [Ed] of ments made by other patients. We fi nd one expla- word sounds, without the stimulation extending nation for the symptom if we assume an increased 130 20 Lecture 20 excitability of organ sensations, so that the intrin- when, because of apparent reduced activity of the sic tendency for attention to be captured even by sensorium and presence of stupor, it is very simi- weak, otherwise imperceptible sensory stimuli is lar to known symptoms of organic brain disease enhanced. It is self-evident that with such an (especially meningitis). The ‘jumpiness’ [Ed] of increase of organ sensations, even the most some of the most acute pictures of mental illness peaceful wards, with the most monotonous activ- that we will get to know later probably has the ity, offer patients suffi ciently extensive material same basis. Apart from this, hyperaesthesia of the for their sensory perceptions. The symptom has sense organs is observed particularly in the initial considerable practical implications, since it can stage of developing acute psychoses, and during evoke, maintain, and increase restlessness in such convalescence from these, where it makes the a patient, apart from the fact that other patients patients more or less insufferable, discontented, are usually affected, and disturbed; and so the or irritable, according to their personality, by the most suitable place for such patients to stay is in impressions made by their surroundings. an isolated room. The main consequence of Gentlemen! You can hardly have missed the hypermetamorphosis is absent-mindedness, that reminder that the last two symptoms gave you of is, the intractable nature of thought processes, earlier discussions, where we attempted to defi ne and inability to follow a closed train of thought. mental illnesses as distinct from brain diseases. If A patients’ answers, disclosures that they share, hypermetamorphosis is based on increased excit- and messages that they want to initiate can there- ability, as a sustained state of activation of the fore give the appearance of incoherence, because perceptual elements, namely perception cells as they can be interrupted at any moment by each we called them, then they do not belong to the new sense impression. Hypermetamorphosis is disturbances of secondary identifi cation but have therefore a key part of the complex of symptoms their site in the immediate destination after the that we will come to know in more detail under projection system itself. The same applies to the name ‘confusion’ [Ed]. In this symptom com- hyperaesthesia of sense organs even though the plex hypermetamorphosis can sometimes even be origin of such symptoms is to be sought more the decisive, dominant element, although it can- peripherally in the nervous system, a generaliza- not constitute a disease in itself, but seems always tion that might apply equally to all cases of to be just an accompaniment, though neverthe- hyperaesthesia manifest in just a single sensory less an important symptom. (The discoverer of area. That is also why hyperaesthesia has, from the symptom, H. Neumann, indeed proposed time immemorial, been treated amongst the such a disease, but with such an admixture of so diseases of the peripheral nervous system. many other elements that it can support my Hypermetamorphosis on the other hand has opinion.) always been credited with having a central origin. Most closely related to hypermetamorphosis Clinical observations confi rm our opinion insofar is the so-called hyperaesthesia of the sense as we meet this symptom mainly in severe dis- organs [W], a symptom well known in many ease conditions, other than its very common physical illnesses. Hyperaesthesia is by no means occurrence in agitated forms of paralytic psycho- the same as hypermetamorphosis and should not ses. Amongst non-paralytic psychoses there are be confused with it. Among mentally-ill persons in particular the two clinical pictures of confused it is of only minor signifi cance, hardly ever occur- mania and hyperkinetic motility psychosis, where ring independently, and mostly found amongst the symptom is almost never absent, and forms those chronically mentally-ill persons, where it an essential part of the clinical picture. has to be seen as a transition to a hysterical per- Gentlemen! You must not be surprised that sonality, and is thus found almost exclusively our sAZm schema also allows us to derive certain amongst hysterical women. Furthermore, it is the borderline cases, in which a disorder of second- possible cause of the symptom of startle responses ary identifi cation is the primary impairment, and in some semi-consciousness states in epileptics, a transition between primary and secondary 20 Lecture 20 131 disturbances of identifi cation seems to occur. We which, through a ‘short-circuit’ [Ed], seems to will encounter the same experience in the area of imply the shortest path between s and m, a path motility, where we confront states of muscle that still conveys full conscious awareness of cor- rigidity accompanied by severe loss of con- poreality, yet is relatively independent of other sciousness, which form a transition to epileptic activity in the organ of consciousness. We thereby seizures, and yet, to judge from their develop- gain understanding of the variety of ways in ment, can be considered only as a massive which movements can be expressed, which, increase of hyper- and parakinetic motility symp- according to their form, are familiar to us in toms in the course of severe motility psychoses. healthy mental life, as reactions to strong organ Moreover, we will often see actual contractures sensations, and are observed in mentally ill per- developing as a result of parakinetic disturbances sons, under conditions indicative of major reduc- of identifi cation, which have become habitual in tion in functions of the sensorium. the psychomotor area. This demonstrates how, in For example, wallowing or burrowing move- our schema, as everywhere else in Nature, nature ments in many deep twilight states of epileptics does not actually work schematically. We should and paralytics, reminiscent of jactation and often always remember, simply, that any schema, ours totally identical with it, sometimes continue included, has value merely of a means of teach- unabated for several weeks, always executed in ing and understanding, and becomes superfl uous the same monotonous style. Sometimes the as soon as a better, simpler, or more correct movements have a more defi nite confi guration, grouping of facts is found. Rest assured, gentle- such as writhing (in pain), or doubling-up, indi- men, nobody is more aware of this than I, and cating vivid organ sensations in abdominal vis- that respect for the facts when searching for a cera leaving no doubt about their central origin. way to represent mental illness as seen in the We can then presuppose the same mode of origin clinic is my primary consideration. when patients are indeed conscious, but are also You will now also understand that without capable, at the time, or subsequently, of giving risking the charge of inconsistency, we are enti- information about their organ sensations as the tled to amend our schema itself as needed. Here reason for their movements. Thus you will is probably the appropriate place to explore how observe a patient’s expressive movements of far such a need exists. screaming and roaring, often at the top of his I remind you once more of my introductory voice, due to the Affect of anxiety. Such move- remarks on organ sensations and consciousness of ments may be modifi ed when anxiety is expressed corporeality. Back then we became familiar with in specifi c locations, such as the throat, stomach, certain ways in which movement was expressed, bladder, or uterus, usually accompanied by severe which we interpreted as protective measures for physical sensations in these organs, and utterance the body, and which could be traced back to pre- of grunts, and more or less animal-like sounds, formed, probably hereditary mechanisms [1 ]. with touching of the body regions in question, or Some such movements, such as innate refl exes tugging at them, etc. Moreover, the feeling of like the locating movement of the eyes, and the indefi nite physical restlessness, combined with withdrawal of a limb from a painful stimulus, corresponding restless movement, often found were of a simple nature; others were more com- during full awareness, which the patient traces plex patterning of movements, such as our recoil back to indescribable uncomfortable sensations, in terror, sideways leaping, and the like. Such would fairly be attributed to murky organ sensa- movements have in common that they are reaction, analogous to the jactation seen in uncon- tions to vigorous organ sensations, and are indeed scious states. As you can see, in these expressions only half-conscious, or at any rate occur without of movement, induced purely in somatopsychic any more complex mental activity. Amendment of ways by short-circuit, consciousness need not be our schema, as required here, needs to consider no switched off; yet consciousness participates more than that we have a type of cortical refl ex, merely as a spectator to these processes, which 132 20 Lecture 20 play out partly at a deeper level, and sometimes in hand with the most severe malaise and usually even as an ‘active’ [Ed] spectator, when an Affect a complex of symptoms of melancholia. of disarray or certain explanatory delusions develop against this background. Gentlemen! When you consider that paralytic References weakness of hind limbs can be produced experimentally by crushing of internal organs such as 1. Hirth GCLO. Energetische Epigenesis und epigene- tische Energieformen, ins besondere Merksysteme the kidneys, you will also take into account the und plastische Spiegelungen. Eine Programmschrift possibility that, in the same way, direct infl uence für Naturforscher und Aerzte. München und Leipzig: of aberrant organ sensations on motility (by G Hirth; 1898. short-circuit) can also bring about conditions of 2. Pick A. Uber die Beziehung der senilen Hirnatrophie zur Aphasie. Prag Med Wochenschr. 1892;17:165–7. immobility, even of an akinetic type. Healthy 3. Pick A. Beiträge zur Pathologie und pathologischen mental life already provides analogies of this. Anatomie des Centralnervensystems. Mit When patients with renal or biliary colic cannot Bemerkungen zur Normalen. Berlin: Karger; 1898. move because of pain, we take it as quite natural. 4. Sachs H. Die Entstehung der Raumvorstellung aus Sinnesempfi ndungen. Breslau: Schlettersche Perhaps we should apply the same concept when Buchhandlung; 1897. a moderate state of general immobility is seen in 5. Wernicke C. Lehrbuch der Gehirnkrankheiten für a patient who complains of unbearable tickling Aerzte und Studirende, vol. 3. Berlin: Th Fischer; sensations in his intestines, or when a female 1883. p. 551. 6. Broca PP. Nouvelle observation d’aphémie produite patient after emerging from a state of severe gen- par une lésion de la moitié postérieure des deuxième et eral immobility of several months’ duration indi- troisième circonvolution frontales gauches. Bull Soc cates that the reason for it was that she sensed Anat. 1861;36:398–407. that she had a bird within her body, and so on. In 7. Heilbronner K. Über Asymbolie. Psych Abhandl. 1897;3/4:42. particular, we will then fi nd that we can under- 8. Lissauer H. Ein Fall von Seelenblindheit, nebst einem stand in this way the emergence of akinetic Beitrag zur Theorie derselben. Arch Psychiatr symptoms, when musculature itself is the site of Nervenkr. 1890;21(2):222–70. aberrant organ feelings. I have repeatedly 9. Hahn E. Pathologisch-anatomische Untersuchung des Lissauerschen Falles von Seelenblindheit. Arbeiten observed such cases, wherever more extensive aus der psychiatrischen Klinik in Breslau. Leipzig. passive movement is felt as pain, this going hand 1895;2:105. Lecture 21 21

• Disorientation: the fundamental symptom of included in our schema represent only the route every psychosis [Ed] by which nature brings about such disorien- • ‘Disarray’ [Ed] linked with conditions of acute tation; but every psychiatric patient is in some origin way disoriented. If he is not, then he is not men- • Various types of disorientation and disarray tally ill in a strict sense. The actual damage that • Treatments arising from this the still-largely-unknown disease process wreaks • Motor disorientation and disarray on mentally ill people is through such disorienta- • Transitivism tion. All abnormal alterations in content of consciousness that occur temporarily or permanently in mental patients are included under this concept of disorientation. From my earlier explanations Lecture about our schema, namely the relationship between activity of consciousness and its actual Gentlemen! content, these regular consequences of disorien- Before we go any further, it would be advanta- tation will appear just as natural aberrant modifi - geous for us to consider in greater detail the cations of the activity of consciousness. We are patient who is the most authentic example of all struck by the importance of this aspect all the acute mental illnesses to whom we have access at more, as I already stressed, by the fact that the present, our instructive case, the engineer K. The content of consciousness—and alterations to it— psychosis that Mr K. has experienced will not be provides us with the most tangible, most obvious, looked at in any greater detail later, because it and most easily assessed symptoms. Therefore represents a very complex and as-yet little known we will derive our classifi cation of acute psycho- form of illness. For this very reason the case is ses from the material changes brought about by useful for our present purpose, because the the illness, in exactly the same way as we did for patient not only has personal experience of most chronic psychoses; and we will fi nd that we of the elementary symptoms that can be derived obtain a basis for a natural system of classifi ca- from our schema for problems of identifi cation, tion, with room enough to accommodate all the but can also convey with eloquence the effects facts. Corresponding to our classifi cation of con- that they have produced in him. The best general sciousness into the three areas—of corporeality, term we have for this effect is disorientation [W]. the outside world, and personhood—we will In disorientation we come to see the real essence meet the clinical requirement of differentiating of any psychosis. Disorientation disorders corresponding types of disorientation; and here

© Springer International Publishing Switzerland 2015 133 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_21 134 21 Lecture 21 we use the terms ‘somatopsychically’ [Ed], ‘allo- which had developed years previously; who, 1½ psychically’ [Ed], and ‘autopsychically’ [Ed]. In years ago in the eighth month of pregnancy, and addition, we will distinguish the domain of motil- following frequent epileptic seizures, underwent ity disturbances, which falls partly under the term a brief period of psychosis lasting only 6 days, ‘somatopsychic’ [Ed] and partly under ‘autopsy- after which she has become imbecilic, and has chic’ [Ed], as a special type of disorientation. since survived repeated shorter and longer bouts When disorientation irrupts acutely, as in acute of severe, post-epileptic psychoses. Recently she psychoses, it is inherently connected with a vivid again had four epileptic seizures in 1 day, fell ill Affective response. For this Affective state, the with febrile angina the following day, but slept in German language offers us the pithy expression the evening and the greater part of the night. Ratlosigkeit [W], a term often used by mentally Towards morning she woke up suddenly, in a ill persons themselves. According to this, in what state I was able to observe during a ward round follows, we will also use precise expressions for 6 h later. She presented with a most Affect-laden various colorations of this Affect, with the words picture of despair: fi re, hell, and murder threat- somatopsychic, allopsychic, autopsychic, and ened her; she should be taken by the devil, torn to motor disarray [Ed]. pieces, tortured, killed, broken on the wheel, Thus Mr K. spoke spontaneously of the disar- burned, and thrown into water. The world would ray in which he had, for a long time, found him- be destroyed by fi re, the city burned, and the self: ‘He had always wondered; he had not come Kaiser would come. She heard all this through out of the wonderment’. The sensory delusions to voices coming from all sides, which she sought to which he had been subjected, in particular, gave escape by furious attention-seeking, and the most rise to this. Since he always remained, by and desperate attempts at suicide and self-harm. A large, oriented about his whereabouts, and the whole team of warders was needed to protect her people in his immediate surroundings, and had from harm. At the same time she saw heads, even preserved a degree of orientation towards shapes, fl ags, and soldiers at the windows. the combined hallucinations, by conceiving them Despite this, she remained completely oriented, as dream images, we see from this example that accessible to support and comfort by medical the importance of the sensory delusions consists, staff, recognized all of the people around her, and as we suggested earlier ( p. 69), of an image of the greedily took medication handed to her. At the outside world exhibiting abnormal accretions, same time she had extreme anxiety in her chest in not corresponding to reality; but that reality is, in relation to phonemes. Four grams of amyl hydrate addition, recognized as such, and so allopsychic had an immediate calming effect; and she herself orientation can still, to a degree, be maintained. said that the terrible speech had subsided, as had In another sense we must still regard this aberrant the nagging feeling of fear. The attack was thus growth as disorientating. However orientation to initially controlled without putting her to sleep. the data actually presented from the outside However, similar bouts of lower intensity were world is not abolished by the hallucinations. I repeated over the next 10 days, and only then did emphasize this because we will meet the same normal interictal behaviour occur. With this experience over and over again in acute mental patient we found that bromide preparations, even illnesses: Patients cannot be deprived of their ori- in high dose, always failed to reduce her psy- entation by sensory deceptions alone, not even chotic symptoms. those combining different senses, unless there is Incidentally, you cannot but recall that state a simultaneous state of signifi cant drowsiness. On that I previously referred to as the decay of the the other hand, a high degree of allopsychic disar- individuality, and explained using the sejunction ray [Ed] can result. I recently had the opportunity process. Here too, two mutually-incompatible to observe one of the most instructive examples groups of ideas oppose each other in full con- of this principle on the ward. This was a 26-year- sciousness, namely the correct notion of location old serving maid W., suffering from epilepsy and people, and on the other hand the fantastic 21 Lecture 21 135 threats which are just as readily conceived. The that he interpreted in this way. We also learned Affective coloration of the latter, it seems, cannot that the idea came to him that he had to suffer for rise up against the former. the sins of others, that this idea was transferred, We will learn later about states of allopsychic so that others had to do the same (p. 114), and disorientation, accompanied by vivid hallucina- that also his family and the ward doctor had such tions. We will not be able to derive the fact of an obligation. Also, the idea of being a saint, and disorientation from experiences that you have that he had already existed several times, domi- just heard about, and they must be viewed as nated him for a long time. Thus, his autopsychic independent phenomena. orientation had suffered, without any loss of In this respect it is instructive that the same memory for his real, personal experiences. The patient K., who has now almost recovered from frame of mind into which he was driven, due to a second bout of mental disorder, at the time of the opposition of two mutually-incompatible his fi rst visit to the clinic 2 years ago, went series—of real and imagined facts—he described through a state for several months of moderate with the word ‘disarray’. We can designate this as allopsychic disorientation, and was totally free ‘autopsychic’ [Ed]. from hallucinations. During that period he was Obviously, the various abnormal sensations in a state of wonderment about everything he and disturbances of general feelings to which he saw or experienced, and regarded everything as had been subjected were likely to provoke an signifi cant; for example, on one occasion, food Affective response, a matter which leaves us with was placed in his hands, another time beside his no room for doubt. We will see later that the most bed, and a third time handed to him from the violent Affective reactions are linked specifi cally other side of his bed; the ward doctor sat with his to perceived changes in the body. Affect will be legs crossed on one occasion, another time with infl uenced more strongly, depending on how far legs outstretched, then on the edge of the bed, physical sensations and emerging feelings depart and another time he sat on a chair. Once when a from what is familiar. Thus we heard the patient pile of laundry was being counted in the corridor describe feeling as if his brain were soft, as if it the patient stood in wonderment, and declared had stretched itself out and contracted again, as if that he would like to stay up all night to see what his head and body were hollow, as if his body would become of the stacked laundry. At that was pulled in particular directions, and as if he time the patient did not notice his own compul- were switched on in a magnetic fi eld. Most of sion to think about every little thing, which made these expressions were evidently just compari- him incapable of any organized activity, an inca- sons, and were those still available to him, in his pacity about which he himself talked: ‘He did embarrassment. From the resulting setting of the not know the ropes about everything that was Affective state of his mind, we can conclude that, going on there; he did not know what he should when, at the time, he attempted to take his own do and should leave alone’. Since food intake life, he was motivated precisely by such feelings. also suffered, he was expressly ordered to eat, Somatopsychic disarray [W] had apparently and then things went better. increased to the point of despair. As we learned, In addition to states of allopsychic disarray at the fi rst outbreak of his illness, the patient also and allopsychic disorientation, we also had to had strong feelings of anxiety. He localized the verify in our patient, with regard to autopsychic anxiety in the region of his heart, and distin- functioning, an ‘errancy’ [Ed] in his orientation. guished it just as precisely from the feeling of The patient told us that during his illness he was heart spasm and cardiac arrest, just as he kept led to believe that in his earliest childhood he had apart headaches from other abnormal sensations been brought up not by his parents but in a dia- in his head. We will often encounter such local- conate institution, and only then had he been ized fear, which we can perhaps understand as given into his parents’ care. He claimed that he in part a manifestation of the somatopsychic could remember entire scenes from his childhood disarray [W]. 136 21 Lecture 21

Gentlemen! We will not go far wrong if we frequent repetition of the word ‘blood’ [W] on regard the series of surprising actions, which we the part of the voices. We will later encounter saw during this patient’s severe illness, as out- the phenomenon that any kind of movement comes of his prevailing mood of disarray; and we made with full awareness by a patient—but not can try to understand them from this point of deliberately—is analogous to autochthonous view. Thus he occasionally drank from a spit- ideas, except that we are dealing with motor toon, and even emptied his bowel motions into objectives or goals, so much so that it is already the spittoon and into the living room; on another helpful to apply a name to such peculiar phe- occasion he left urine in a mess tin, put his clothes nomena. I tend to designate them as ‘pseudos- on back to front, lay down on wet ground in the pontaneous’ [Ed] movements. They are usually garden, and so on. Today we are hearing explana- connected with explanatory delusions. If tions of this from the patient; these are partly patients simply report the fact to us without add- euphemisms. He suspects that he may suddenly ing any explanatory delusion, it is probably only have become very tired; or he explains that he because at the same time, they are far too dis- had been surprised by the urgent need to defae- tracted by his voices. Less accurate than the cate or void urine; and he reacts with disbelief to term ‘pseudospontaneous movement’ [Ed] is a any other explanation. He has also forgotten patient’s information about certain motor defi - many other things, as you can imagine. From cits that he had noticed in himself for a long analogy with other patients however, we have no time. Thus, the patient has not spoken on his doubts that we are dealing here with actions of own initiative for weeks (‘initiative mutism’ disarray [W]. [Ed]) and only seldom, if at all, upon question- Gentlemen! A series of other noteworthy ing (‘reactive mutism’ [Ed]). However the rest expressions of movement in this patient should of his behaviour did not suggest that this was a be judged from a totally different point of view. conscious refusal: Often the patient was seen to For example, from time to time he made appar- make approaches, and to speak, and his lips ent turning-movement exercises in his bed; for were moving without any sound being uttered, several days he sung single senseless syllables and despite obvious efforts. The patient at pres- to himself, and accompanied them with beating ent defi nitely concedes only so much: that there movements of his arms. At the time, he had was no actual paralysis of the musculature that already made statements from which we gath- prevented him from speaking. As for the rest, he ered that in no way did he feel responsible for knows only that speaking was diffi cult, without the corresponding merry mood he conveyed. being able to state the exact reason; he also Even now, he comes up with the same informa- expressly denies that speaking was forbidden by tion. He might have sung, even though he would the voices. Here we hear of both hyper- (para-) not have been aware of it later, and did not know kinetic and akinetic states (as disturbances of how to explain it even now. However, upon identifi cation) in localized areas of musculature questioning, we fi nd out that both singing and as described by the patient himself; he is able to beating time with the arms represented an do this because he can still remember it accu- accompaniment to voices, without being aware rately. However, he cannot describe the state of of his being subject to any direct constraint. In mind in which he found himself producing this the same way he explains the fact that on one strange and incomprehensible phenomenon; he occasion, shortly before admission to hospital, can only express his general amazement about he had thrown himself to the ground and rhyth- it. Yet since he has perceived these phenomena mically shouted with all his might. This too had in his own body when fully conscious—which been no more than a reaction to voices that had is not always the case, because such states are ‘offered him blood’ [W]. The patient explained often accompanied by clouding of the senso- the technical term, ‘to offer blood’ [W] that rium—we can also suspect that a corresponding escaped from him on this occasion, as being the Affective state has been produced, which we 21 Lecture 21 137 can call motor disarray [W]. This provides us disorientation which confronts us will then with a term for a very complicated state of mind, become purer, whether it be allopsychic, auto- involving autopsychic as much as somatopsy- psychic, or somatopsychic areas. chic areas of function: the former insofar as On the other hand, as is easily understandable, movements carried out with full awareness tend the Affective state can also be absent, because to emanate from the entire person, and the latter any ability to respond strongly to acute distur- because involuntary movements must be per- bances of identifi cation is generally reduced, as ceived as alterations to the body (with respect to occurs in defi cit states, found in progressive its position in space). Such motor disarray will, paralysis, presbyophrenia, and hebephrenia. Here in general, necessarily lead to formation of the lack of disarray is often just as distinctive as explanatory delusions. If we wanted to believe is its presence in the other cases. I mention here a only information provided by the patient, we symptom that is often combined with disarray, would have entirely missed the point here. On yet is entirely different, and is essentially a con- the other hand, however, I rely on numerous sequence of autopsychic disorientation: We shall other experiences that do not make it seem acci- call it transitivism [W]. It is based on patients dental that the patient, in discussing his auto- who show no sign of psychological malaise, yet psychic disorientation, has given us hints that are so altered in their entire way of thinking and we can now interpret in the context of reports of feeling that the assumption of identical trains of motor identifi cation problems. He has already thought, which force us towards a correct con- talked about believing that he had to suffer for ception of the behaviour and conduct for other others. These ‘redeemer ideas’ [W] as we can people that no longer holds true for them. call them, occur often among mentally ill Preferably it is their own loved ones whose patients, commonly connected with motor behaviour becomes so weird, strange, and incom- symptoms as explanatory delusions, as described prehensible to the patients that they come to sus- above, in that akinetic symptoms have to be pect that the former must probably be mentally interpreted as suffering imposed by God, the ill. In its purest form this symptom occurs in cer- hyperkinetic ones, in the sense that the patient is tain acute disease cases where a long preparatory an instrument of God. stage is preceded by symptoms which are not Gentlemen! The Affective state of disarray, as actually psychotic. It culminates in instances I you will realize, is a reactive phenomenon, in have encountered a few times, where a patient response to the ‘errancy’ [Ed] in the sense of ori- accompanies his family to a consultation, to entation, limited to reported disturbances of sec- introduce them to the doctor as supposedly men- ondary identifi cation. It is therefore not strictly tally ill. In such incidences closer examination of separate from disorientation, with which it is the patient has always shown me that there have connected in various ways. However it can even been preceding periods of intense Affect, con- occur, as you have seen, when a degree of orien- nected with disorientation. tation still exists, and in this way infl uences the Gentlemen! With the above remarks, of contrast between reality and manifestations of course, I have not given a full description of the disease in the patient. It is to be found only among Affective states of acute psychoses, even less acute psychoses; you will seek it in vain in wholly should it be said that every acute psychosis is chronic psychoses. On the other hand, it reap- invariably accompanied by the same Affects; but pears in the frequent, acute exacerbations of at least you have the material to hand that is chronic psychoses, and gives them the distinct essential so that we can focus on learning about character of acute illnesses. In the case of very illusions and the regularity in content of pho- extensive disorientation, the Affective state may nemes. It turns out that we need to return once be absent for this very reason, and the picture of more to the concept of the overvalued idea. Lecture 22 22

• More about overvalued presentations of any disruption and neglect of clinical services; • The science of illusions his attention and interest are directed to the mat- • Regular content of these ter in question without need for any conscious • Regular content of deceptive appearances effort; in any professional capacity, what we call generally ‘vigilance’ [W] has just such a basis. Likewise, a visual artist quite automatically notices shapes; the tailor eyes up peoples’ suits; the cobbler the shoes; and unmarried women observe the ring Lecture on a man’s fi nger. Here, the increased arousal produced by certain sensory stimuli seems to Gentlemen! depend on the increased value ascribed to par- In an earlier lecture we took frequent repeti- ticular complex mental processes. Under spe- tion to be the basis of the ‘overvalued idea’ [Ed] cifi c circumstances, when the attention of a and, following from this, we even considered Newton turns to such an everyday event as an deliberate practice of certain trains of thought, a apple falling from a tree, this is likewise no coin- process which we must accept to have greatest cidence but is based on the increased interest infl uence in individual education, and for which shown to processes which were hitherto of no the succinct expression ‘channeling’ [W] has concern, as a consequence of ideas currently in recently been used. We need to make this concept ascendance. It is the same with all experiences more robust, insofar as channeling generally goes and discoveries, insofar as they are linked to hand in hand with Affective coloration of the everyday observations. Just how selective this overvalued idea. Professional activities are par- facility can be, for noticing specifi c sensory ticularly likely to generate overvaluation of cer- impressions as a result of the dominance of certain ideas; their Affective coloration is an tain ideas and their Affective coloration, is expression of the fact that a person’s overwhelm- shown by the example of the mother, who, in ing interest is normally directed towards his deep sleep, ignores every other sound, but awak- professional activity. We then observe the ens instantly at the slightest sound from the extraordinary fact that sensitivity to certain very child. We will call this selective process intra- specifi c sensory perceptions is thereby height- psychic hypermetamorphosis [Ed]. We can now ened in a remarkable way. Choosing examples consider that such Affective coloration, and closest to hand, an experienced alienist is imme- therefore the distinct overvaluation of ideas, is diately aware during his rounds of the institution, the most common basis for illusions.

The theory of illusions is based largely on so succinctly the basic infl uence of individual, experiences in the visual sense. The most famil- Affect-laden, coloured—and thus overvalued— iar examples are the interpretation of vague, perceptions for secondary identifi cation in a nor- imprecise, and visual impressions as angst-ridden mal person. Let us imagine the Affect level fantastic sensations, for instance a distant tree increasing by only a small amount, and thus stump as a robber and fl uttering laundry as a clouding a person’s discretion. This is an emo- ghost. Evidently these are deliria of judgment, tional state that we can assume without further that is, clouding of judgment by Affects, such as ado, in many new patients brought to the clinic fear or anxiety. Pragmatically we should distin- against their will; and a series of illusions, that guish fi rstly between two cases: clear versus we see frequently in such situations, then become indistinct sensory perceptions. Clouding of judg- completely understandable. Here, the obviously ment in the latter case occurs as in the examples overvalued ideas are the fact of the patient’s sep- of visual illusions just given, and you can then aration from his family, and pressures applied take the Affective state to be the origin of the illu- along with his becoming an inpatient. It is then sion. However, the question is as follows: By not surprising that distant people, not clearly what process does Affect produce this infl uence? seen, are perceived as relatives; the doctor, as a As we have seen we must attribute to Affective prosecutor; and the clinic, as a prison. Such illu- states the capacity to alter the normal value of sions are common in many acute mental illnesses. ideas, in such a way that certain ideas are over- They are usually transitory in nature and easily valued, while others, by comparison, are under- corrected. In very severe cases, a degree of stupe- valued. In turn, overvalued ideas can be excited faction and manifest inattentiveness may also from the periphery more easily, and undervalued occur, so that inaccurate sensory perception is ones less easily than normal. Overvaluation of replaced by a defective state of the sensorium. Affective concepts—a robber and a ghost in our Then, so long as this situation holds, numerous example—therefore produces an abnormal facili- other such illusions may arise which have in tation of secondary identifi cation, while under- common that they change their content, depend- valuation of remembered images in other sensory ing on the usual rapid change of overvalued per- domains, or even in the same one, complicates ceptions. States of delirium of most diverse any correction. origins provide common examples of this. It is no Now, that Affects can also take on different coincidence that the person with alcoholic delir- natures; or all manner of individualized processes ium believes himself to be among his fellows, of association can lead to overvaluation of ideas, either in the tavern, or in his daily employment; which has precisely the same effect. I know the he believes he recognizes in the doctor his haul- example of a young married man on a business age boss or his drinking companions: Such illu- trip in a foreign city, who made acquaintance sions match his overvalued perceptions. In such with an easygoing woman, and visited a pleasure circumstances a good patriot probably considers garden with her. Then he remembered that his the head warder to be the Kaiser or, if delirium is wife had relatives in the same city; and that, by coloured by anxiety, he imagines the executioner coincidence—as a less likely but still possible and prosecutor. Perceptual inaccuracy, which scenario—she might spontaneously decide to favours the occurrence of illusions, can be made visit them, with the result that she might be in the use of, if it is available, just as long as the patient same city, even conceivably at the same location. is left to his own resources and is obviously in He looked around the people present, and was this so-called twilight state. The same condition quickly so fi rmly convinced that a woman sitting leads to corresponding illusions in states of hys- in the distance was his wife that he did not dare terical or epileptic delirium, and in the so-called convince himself of the truth of his belief by delirium of exhaustion, etc. going closer, but preferred to get away from the Illusions are harder to understand when they place. I hardly know a better example to illustrate occur in someone who appears to be in a totally 22 Lecture 22 141 level-headed state, with attentive behaviour, and partial) primary identifi cation comes to assist this demonstrable clarity of perception. Yet even in internal process! This refl ects only the internal this situation the content of illusions is usually strength of the fabric of the once-acquired, but brought about by certain related, and Affect- laden now-overvalued, concept: ‘brother’ [Ed]. We ideas. In such cases, any kind of real-world event need not deny that in some circumstances even can determine what the patient has evaluated for such a weakness in replication—even defi cien- his false identifi cation. Thus it often happens that cies in a specifi c concept in certain partial per- a mental patient comes to view the doctor, or a ceptions—may be present in mental patients. For warder, or another specifi c patient as a close rela- instance paralytics and people with senile demen- tive, because he sees some kind of existing affi n- tia might declare that straw—due to its yellow ity with him, for instance in his facial expression, colour—is gold, or broken glass, due to its hard- body form, manner of movement, or vocal infl ec- ness and transparency, gemstones. But then such tion. This confusion of persons appears to be sta- defi ciencies should be evident elsewhere, and ble, and is very diffi cult to correct. In one case of this is certainly not the case in the acute mental such ‘person confusion’ [Ed] cited by Kahlbaum patients we discussed earlier. Gentlemen! You [1 ], I suspect with a similar basis that the illusion can see that in conceptualizing an illusion, which was so fi rmly fi xed that the patient failed to recog- is now our task, the difference between clear and nize genuine relatives who met him face to face, unclear sensory perceptions, which initially and he declared them to be imposters. This, inci- seemed essential and important for gaining dentally, is quite a common experience amongst understanding, loses its meaning. In just the same mental patients after prolonged stay in an institu- way, we lose the main difference between illu- tion. It is certainly no coincidence, and perhaps it sions and hallucinations. An illusion now appears is the longing for those nearest and dearest, to us as a hallucination, whose occurrence is brought about by stay in the institution that leads facilitated by chance occurrence of external con- to such misjudgments. Apparently the abnormal- ditions, a conclusion which insightful older ity consists of the fact that the conceptualization authors, such as Kahlbaum, reached long ago. Of of relatives—perhaps a brother—becomes so course, we will accept this proposal only when overvalued that even partial identifi cation, like illusions occur in mentally-ill people; and, for the sound of a familiar voice, has the same effect descriptive and practical purposes, we must as that of an impaired, and imprecise sensorium, maintain a strict difference between illusions and whose function is diminished as in previously hallucinations amongst such people in our clinic. mentioned cases. Normally differences in shape, Similar reasoning also allows us to defi ne those size, facial contour, or expression would hinder hallucinations mentioned previously, which are identifi cation. demonstrably peripheral, that is, formed in the You will ask me: Is there not a defi cit, or a sensory organs themselves—Kahlbaum’s phena- weakness in replication in those partial represen- zisma—so that hallucinations of purely central tations belonging to the concept of the brother, origin can be given no other status. Such phena- relating to the shape, size, and in his facial con- zisms have an important role, especially for taste tours or facial expressions—a weakness of corti- and smell, where the foul taste of oral catarrh and cal performance in Meynert’s [2 ] sense, or of the the bad smell of nasal catarrh become misinter- ‘critic’ [Ed] in Neumann’s sense? Well, gentle- preted as poisons. Again, as we shall see later, man, this assumption is quite unnecessary, if you overvalued allopsychic perceptions of fear are recall the characteristics of overvalued percep- the main feature. tions discussed above. It is suffi cient, as we saw Gentlemen! From conditions just discussed, in the case of hallucinations, for abnormal over- we can readily understand why, as far as the fre- valuation of perceptions by themselves to call quency of hallucinations goes, the orderly rela- forth a process of identifi cation; the more is this tionship highlighted above prevails, according to likely, when actually present (even though only which phonemes predominate by far, and often 142 22 Lecture 22 exist just by themselves. This is especially true ness may be expressed, and corresponding pho- for many chronic mental illnesses. In acute men- nemes, containing grandiose ideas. Later we will tal illnesses we often observe that only phonemes become familiar with the abnormal euphoria of appear initially, and addition of hallucinations in mania. If hallucinations occur here, these are other senses corresponds to the otherwise famil- likewise hallucinatory perceptions of grandiosity. iar increase of symptoms to a certain severity of In situations which are the opposite of mania, illness. Given the intimate connection between that is in melancholia, feelings of deep unhappi- the act of perception and the sensory fi eld for ness develop. Corresponding to this are pho- speech, it is easy to understand that, in order to nemes, which, if they arise, usually convey a broadcast to projection fi elds of the other senses ‘delusion of belittlement’ [Ed]. In this case, which word sounds can bring forth hallucina- visions are most often perceptions of misfortune, tions, a greater spread of the stimulus is required. assimilated as visual images. I have often men- Admittedly, I know that there is a widespread tioned anxiety psychoses, in paranoid states. The belief, especially from the work of Charcot and Affective state of fear leads, exactly according to his school [3 ], that thought processes play out in rule, to certain perceptions of fear, which I dif- ways that differ between individuals, which go ferentiate as autopsychic, allopsychic, and far beyond the individual differences I have pro- somatopsychic. Of these the autopsychic are in posed. It is alleged that thinking is carried out by part identical with the delusion of belittlement in many people only, or mainly in visual images, by melancholics; they therefore include self- others through acoustic images, and by others recriminations, or, grouped as phonemes, words again as motor or word images. Without denying of accusation or insult. Allopsychic perceptions such possibilities, however, I consider them only of fear contain themes of threat and injury. as very rare exceptions, and therefore not to be Corresponding to this, sick people hear that they used in the theory of hallucinations. Hallucinations would be killed, tortured, roasted, thrown to wild of taste and smell are, after phonemes, the next animals, hunted in the snow, or chased naked most frequently observed, at least amongst those through the streets, and so on. Somatopsychic whose mental illnesses are exclusively acute, perceptions of fear may be the basis, for instance which is explained by their being based mainly of a female patient who hears, through a voice, on phenazisms, which must naturally arise more that her globus pharyngis [W] has cancer of the easily than hallucinations themselves. larynx—with a cough as a sure sign—or tubercu- Gentlemen! Only now, after having presented losis, or cool extremities, signifying that she is to you a particular theory of sensory deceptions dying. of mental illnesses am I in a position, by way of a Gentlemen! The most common and most gen- few examples, to comment briefl y on the orderli- eral Affect in this state you will encounter in new ness of their content (as I have repeatedly empha- patients is that of ‘disarray’, evoked by moderate sized). The rule that we deal with here is that the levels of disorientation. This corresponds to the content of sensory deceptions is determined by most frequent content of phonemes. A patient’s the Affective state that prevails at the time. utterances convey this quite conspicuously— Affective, and thus overvalued, perceptions are ‘where am I’ [Ed]; ‘what am I supposed to do’ the ones which are most excitable at that time, [Ed]; ‘what is the matter with me’ [Ed]; ‘I do not and indeed, this applies not only for stimuli origi- even know’ [Ed]—fragmentary utterances one nating in the outside world, and initiated by the hears over and over again. When a patient hears sense organs—as we saw previously—but also slanderous names and insults, or accusations of for central [Ed] aberrant stimuli connected with evil deeds allegedly committed, or notes about the sejunction process. In order to link this to experiences that have never happened, these are something familiar, I remind you of the occur- outcomes of autopsychic disarray. Often one can rence of hypochondriacal sensations of happiness do no more than trace back from the utterances of (p. 107). Corresponding with this, overvalued the patients to this type of phoneme, although ideas can appear, from which feelings of happi- this can be done with some certainty because 22 Lecture 22 143 such utterances allow no other interpretation. I Affective states in acute mental illnesses. I would introduce the following by way of example: ‘I am add that delusions of relatedness are also based not a thief’ [Ed]; ‘I have never poisoned anyone’ on Affective conditions; in this regard I refer to [Ed]; ‘I have not killed children’ [Ed]—and so remarks I made in my 13th lecture. While this on. If the voices deny the patient’s identity which covered mainly delusions of relatedness in endur- leads to statements such as ‘I am called so-and-so ing paranoid states, it will be readily understood but I’m not a princess’ [Ed], ‘I am not married’ that in acute psychoses, such delusions occur [Ed], or ‘I have no children’ [Ed], these are obvi- with far more Affect. In acute psychoses, it is the ously reactions to the Affective state of autopsy- satisfaction of natural needs—intake of food, chic disarray. Allopsychic disarray comes to be elimination of stools, and voiding of urine— expressed in phonemes conveying the importance which favours the appearance of phonemes of location and environment. Patients might hear whose content refers to delusions of relatedness, that they are in a penal institution, in Heaven, in and—most often—disorientating phonemes, an enchanted castle, on a ship, and so on; that the which take on the guise of the vocal infl ections of other patients are dressed up and belong to the those closest to hand, namely the staff in atten- opposite sex, or are policemen in disguise; that dance or the doctors. Taunts and disapproving their bed is not a natural bed; that the bath tub is remarks naturally predominate such as ‘Now he an instrument of torture; or that the food contains is eating again’, or ‘He can eat well, but not disgusting ingredients, or human fl esh, etc. work’. Somatopsychic disarray leads to emergence of In all probability, not only phonemes but all phonemes such as the following: the intestinal hallucinations show an orderly dependence on tract has become overgrown; the body is full of the prevailing Affective state, such as is familiar faeces, or transformed into one solid mass; the to us in the case of phonemes. However much heart is standing still; blood has stopped fl owing; further evidence for this is still required before patients are paralyzed or dead; the head is sepa- completion. That content is determined by the rated from the body, or transformed into an ape’s prevailing Affective state is known best for skull; their arms have been torn off, or are several visions, where it applies especially to melancho- times longer than previously, or instead of two, lia and fear psychoses. Corresponding with the there are fi ve arms, etc. Motor disarray too is very prevailing feeling of unhappiness are hallucina- frequently manifest as phonemes. This emerges tory corpses, coffi ns, eerie black fi gures, funereal most clearly when a patient hears completely proceedings, or, in more fantastic cases, demise opposite commands, such as ‘eat’ [Ed] and ‘don’t of relatives when their house collapses or in eat’ [Ed]. Moreover, commands to adopt a certain drowning, fi re, railway accidents, and so on, but posture, to keep protruding the tongue, to walk usually in a more shadowy form, given that we on all fours like an animal are all hallucinatory are dealing with images. After all that has been manifestations of motor disarray, and likewise said, it is easy to understand why ecstatic visions, when patients are commanded not to swallow, corresponding to religious feelings of happiness, not to speak, not to move their hands. Finally, a refer to the sky, and that they often concern more major part of the so-called impulsive actions, in than visions, but rather dreamlike hallucinations. reality brought about by phonemes, can be explained in the same way. Patients hear requests to free themselves; to smash the window; to go References into the water; to hang themselves; to plunge headfi rst; to tear out their tongues; to rip out their 1. Kahlbaum KL. Die Sinnesdelirien. Allg Ztschr Psych. genitalia; and to drill out their eyes. 1886;23(1 and 2):1–86. Gentlemen! I restrict myself to these examples 2. Meynert T. Amentia. Die Verwirrheit acuter Wahnsinn. which, I believe, are suffi ciently conclusive to In: Deutlicke F, editor. Jahrbücher für Psychiatrie, vol. 9. Wien: Braumüller; 1890. p. 1–112. demonstrate how the content of phonemes 3. Charcot JM. Sur les divers états nerveux déterminés depends on the most commonly encountered par l’hypnotisation chez les hystériques. Paris; 1882. Lecture 23 23

• Presentation of a case of anxiety psychosis reach their conclusion. He also repeatedly • Clinical picture, course, diagnosis, prognosis, suggests that it is difﬁ cult for him to concentrate. treatment The impression we gain from his prevailing • Delimitation from the area of anxiety neuroses Affective state is one of bewilderment, anxiety, • An example of hypochondriacal anxiety and disarray. The fact that such Affective states psychosis complicate an orderly train of thought has long been known, and has frequently been shown to you. On enquiry we learn that the patient complains of unceasing anxiety. If the seat of the Lecture anxiety is in his heart: ‘It wants to crush him’ [W]. He is also breathless, and therefore is sleep- Gentlemen! less at nights. The patient therefore wished to be Patient Sch., who you see before you, came examined by me, and in his anxious and over- only reluctantly to the lecture theatre. He looks hasty manner, made arrangements to undress. around anxiously, comes closer, but hesitantly, When asked why he is afraid, he tells me of his and then greets me as an acquaintance. You see fear of being beheaded; he had also heard that him as a 55-year-old, heavily-built man of poor each day he would receive 50 lashes, counted- nutritional status, with somewhat cyanotic dis- out; he would be expected to eat a roll that had coloration of face and hands, and cool extremi- lain in a fellow-patient’s spitting glass. On ques- ties, fearful in posture and facial expression. tioning, we hear that other patients lying in the Again and again, he repeats in a rhythmic manner same room with him made these statements. a low moan, and also interrupts his speech every Therefore the patient is well oriented and knows so often, when he shows a great need to express he is in a clinic for the mentally ill. However, he himself. When I interrupt him to give you infor- has not judged the current situation quite cor- mation, he resents it. He gives correct answers to rectly; and presumably his viewpoint was already my questions about his age, family situation, and rather limited, as we often ﬁ nd among country home town, but you will notice that due to his folk from his region. He knows me; he recog- Affective state, his concentration is impaired; nizes the audience as students, and thinks that I and he introduces pauses, during which he looks have granted them ‘an hour’ [W], but he believes around absent-mindedly, so that his answers to that all men there want to be ministers of religion, simple questions, which would otherwise be like his son, who is currently a theology student quite prompt, sometimes take a long time to and accompanied him to the clinic. On the ward,

© Springer International Publishing Switzerland 2015 145 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_23 146 23 Lecture 23 the patient also claimed that they would cut off were they joined by those of fantastic threats; and his head; he would be taken to the place where at the same time, there was an increase in the corpses were stored. Incidentally, it is not primar- patient’s restlessness, which became so notice- ily fear from these threats that dominates this able that it was inevitable that he be transferred to patient; rather, we usually hear from him his an institution. At this time, he seems to have complaints about the fate of his family. He reached the most critical point in his illness and believes that all his possessions were gone: His even to have moved beyond it. This is supported son would no longer be able to study. He heard by a reduction in his somatopsychic ideas of anx- the voice of his young son saying: ‘For three iety. Moreover, the phenomenon had been pres- weeks we have had nothing reasonable to eat’ ent, of which there is now no more than a hint; his [W]; he had also seen his son standing in front of rhythmic moans, which had been much more him, with a pathetic gesture. He believes that his pronounced early in his stay, had risen from time family will all die of hunger; the children are all to time to monotonous repetition of the same sickly; his son, the student, was refused life insur- phrase, ‘I, a poor sinner’ [W]. This was occasion- ance due to heart failure. It was his fault; he had ally accompanied by rhythmic movements of his shamed himself by an immoral lifestyle and arms. Also, anxiety seemed to have reached its secret sins of his youth. He had become lazy. He peak at about this time. Eating became diffi cult had also harmed himself by chewing a lot of only at the time when there were these somato- tobacco. The patient tells of an assault, during psychic ideas of anxiety; and sleep had to be which he recognized one of his attackers and induced mainly through sleeping pills. His body reported him. He had probably committed per- weight of 78 kg at the time of admission fell to jury at the time, because it had been night, and he 72 kg, where it is at present; so his food intake could not see clearly. Earlier, when his anxiety has usually been quite suffi cient. was even greater, he also complained that his two As for his prognosis, based on progress so far youngest children had been poisoned, and his and other evidence, we are quite confi dent in wife had taken her life. At the same time this viewing it favourably. The course of his illness patient, who has suffered a hernia, eats only mea- showed an acute origin followed by increase in gerly, and says that he gets abdominal pain after symptoms over about a week, in which paraki- a meal. netic and hyperkinetic symptoms appeared in the Apart from the hernia, no organic disease can form of verbigeration and rhythmic arm move- be found in this patient; and in no way does he ments. This period corresponded with the height look older than his age, but rather younger. He of his anxiety and production of somatopsychic has now been in the clinic for more than a month, ideas of anxiety. Since then independent motor and was ill for about 3 months before that. The symptoms and likewise his symptoms of hypo- ‘external cause’ [Ed] of his illness was said to be chondria have ceased, and anxiety has subsided that the patient, proprietor of a village smithy and in intensity. Moreover delusions of relatedness, associated farm holding, sold his plot of land and and disorientating phonemes with content to the blacksmith’s workshop in order to retire. match have not increased. Thus the intensity of Although this transaction turned out to be quite the basic phenomenon, namely anxiety, runs in advantageous for him, with a smooth transition, parallel with the range of other symptoms; the the idea gradually came to him that he had ruined decline of these phenomena is to be expected, in his family and would impoverish them. Gradually a similar sequence. (In fact the patient became this idea was joined by anxiety, self-blame in ref- healthy in the space of 3 months after the demon- erence to alleged perjury (see above), and the stration, and has remained so for 2 years since). idea that he was a great sinner and was being per- Gentlemen! This clinical picture described is secuted by Satan. These autopsychic ideas of typical of a large number of similar cases, given anxiety existed on their own in the initial period that we ignore a few anomalies which make this of illness, and only shortly before his admission case not quite typical. Perhaps these are peculiar 23 Lecture 23 147 to this individual, as I have suggested. In general, responding abusive phonemes. The content of we cannot deny that the elementary symptom of allopsychic ideas of anxiety is usually a threat to anxiety provides the exclusive source of a dis- life, or of ignominious disciplinary actions, ease, which in many cases produces no symp- abuse, etc. Delusions of reference operate in the toms other than ones attributable to anxiety. We same way. The hallucinations whose intensity is can summarize all such cases of illness as anxiety most prominently linked with very high levels of psychoses [W]. The basic symptom is anxiety, Affect are those of smell and taste, because they usually localized in the chest, especially in the are usually interpreted in terms of poisoning and heart and epigastrium; next most commonly, in lead temporarily to rejection of food. the head; next in frequency to the entire body; Amongst the aetiological factors are alcohol- and regularly, it has a fl uctuating character, and, ism, epilepsy, and climacteric; and anxiety psy- at the beginning, or as the illness abates, an inter- chosis seems to be closely related to growing old. mittent character. Such anxiety regularly leads to As for the duration of such psychoses, they the emergence of various ideas, which therefore may last anywhere from a week to several deserve to be called ‘anxiety ideas’ [Ed]. They months. The shortest course is seen in ‘abortive’ show grades of intensity such that the autopsy- [Ed] cases among epileptics and alcoholics. It chic ideas of anxiety correspond to lower inten- sometimes happens that Delirium tremens [W] sity, and the allopsychic and somatopsychic ones will be replaced by acute anxiety psychosis, with to more severe anxiety. Somatopsychic ideas can its characteristic intense Affect, and with pre- sometimes be missing or even, as here, emerge dominantly autopsychic ideas of anxiety. The only temporarily at the peak of illness. When the psychotic state is then correspondingly short in disease starts, and as it subsides, only autopsy- duration and accompanied by tremors and symp- chic ideas of anxiety are usually present. In some toms arising in the projection system, as dis- cases anxiety persists, accompanied just by such cussed later. In terms of symptoms, anxiety ideas; far more often the ideas are ‘dressed up’ psychosis is not rare, especially in cases of poorly [Ed] as phonemes. At the height of the anxiety resolved heart failure; its time course then tends state, hallucinations can also appear temporarily to be bound up with this situation. in other modalities and, in some of the most acute An actual paranoid stage, reaching the point cases, as in the example of anxiety in a case of where insight into the illness is lost for a long epilepsy described above, can occur simultane- time, tends not to develop. ously in all senses, as combined hallucinations. Motor behaviour of patients is generally deter- Often, only autopsychic ideas are present, at a mined purely in psychological ways through moderate level; or there may even be a combina- Affective states, or the content of ideas of anxiety tion of autopsychic and allopsychic ideas of anxi- and of hallucinations. Usually, most patients can ety, with added phonemes only at times when be treated in bed; however, as anxiety increases, a anxiety intensifi es. Allopsychic orientation is degree of motor restlessness is produced, initially retained but autopsychic orientation is usually as movements expressing anxiety, such as crying, permanently altered, in the sense of delusions of sobbing, wringing of hands, kneeling down, and belittlement. On the other hand, disarray can praying, according to the patient’s individual expand to include the allopsychic area. Hints of manner. In many cases it may lead to tremors, delusions of reference are often encountered at gnashing of teeth, and outbreaks of perspiration. times of intense anxiety; also, disorientating pho- Should anxiety undergo a further crescendo, nemes with such content occur. Common con- patients leave their beds, and walk restlessly up tents of autopsychic ideas of anxiety and and down, probably also forcing themselves. matching phonemes express concern for family Some expressions of movement—or at least bor- members, for the fi nancial situation, and chal- derline motility symptoms—are not psychologi- lenges to personal honour, and there may be ideas cally motivated, such as rhythmic moaning or of belittlement, and self-recrimination, with cor- rocking movements of the trunk (usually both 148 23 Lecture 23 together); endless uniform movements of hands, presence of allopsychic ideas of anxiety or which are repetitive, if not rhythmical; fi ddling delusions of reference. Diagnosis of acute hallu- around with the bed or pieces of clothing; rub- cinosis (see later) is likewise usually easily estab- bing the hands together, etc. There is almost lished. The symptom of anxiety predominates, always a strong suicidal tendency, or a wish to from patients’ accounts, and is also conspicuous die, often expressed with comments such as objectively; and the dependence of phonemes on ‘Make an end to it. Strike me dead’ [W]. At the the fl uctuations of anxiety, so often seen, is a height of the disease, even more severe motility usual characteristic. However, in acute hallucino- symptoms are prone to occur, such as parakinetic sis a characteristic paranoid stage develops very behaviours, rhythmic movements, and verbigera- early, which is not the case for simple anxiety tion. On the other hand, at the peak of allopsychic psychosis. In the latter condition, allopsychic ori- disorientation, increase of sensory symptoms entation remains intact, unlike the anxiety-laden may occur, to the point of anxiety displayed even state found in delirium tremens [W]. Likewise, when approached, and as blind defensiveness. disorientation tends to be found in generalized As a particular form of anxiety psychosis, the sensory psychoses. Therefore, many cases of so-called Melancholia agitata [W] deserves to be anxiety psychosis are indistinguishable from pro- mentioned explicitly. In this condition, there is gressive paralysis, because, from a clinical stand- ever-present marked restlessness; movements are point, one must accept the existence of a ‘paralytic driven mostly, but not exclusively in psychologi- anxiety psychosis’ [Ed]. While the Affective cal ways; sometimes, as described above, they overlay often makes it diffi cult to establish those are on the borderline of an actual motility disor- disturbances of thinking, judgment, and memory der. Above all, increased production of anxiety retention which can almost always be found in ideas can lead surprisingly to pressured speech paralysis, the possibility nevertheless exists that and fl ights of fancy, symptoms that we will key symptoms of paralysis or alcoholism, arising encounter later in a very different clinical picture, in the projection system, are still initially absent, where there can be no mistaking their sensory only entering the picture later in the course. derivation. Also, it seems to be intrinsic to such Gentlemen! Very often you will come across cases of agitated melancholia that autopsychic cases of illness that you might call ‘borderline’ ideas of anxiety outweigh by far any others in [Ed] cases, or cases of mixed anxiety psychosis their content, even though allopsychic ideas may [W] and Affective melancholia [W]. They are never be totally absent. characterized by the fact that neither one nor the In diagnostic [W] terms, the assumption is that other clinical picture exists in pure or complete the illness will often develop further, forming no form. In their outward character, the picture of more than the initial stage of a more complex dis- Affective melancholia is usually predominant, ease picture. Such development takes place in two particularly because fl uctuations based on anxi- ways: to a scenario of complex motility psycho- ety are less pronounced, so that a more continu- sis, characterized usually by the onset of akinetic ous and consistent clinical picture prevails. symptoms, and to one of expanded sensory psy- Subjective defi cits, which befi t Affective melan- chosis with disorientation. We should always sus- cholia, are often absent, while prominent ideas of pect the latter when disorientating phonemes and belittlement, self-recrimination, and other auto- delusions of reference make up more than a trivial psychic ideas of anxiety are present. The domi- part of the clinical picture. nant Affective state is a feeling of misfortune, but Further development can also take place very at the same time, a state of anxiety always exists, quickly, so that the most acute medical condi- which can usually be localized. Expressions of tions such as the so-called transitory psychoses anxiety usually restrict themselves to the simplest [Ed] may result. movements such as crying and occasional out- For differential diagnosis against Affective bursts of despair, but agitation is generally miss- melancholia (see later), it is crucial to prove the ing. Allopsychic ideas of anxiety can almost 23 Lecture 23 149 always be detected, but remain isolated, their Along with this, a combination of hyoscine with importance falling away, so that one must often morphine proves itself to be valuable: half as actively search for them. Likewise delusions of many milligrams of the former as centigrams of reference emerge entirely on their own. the latter. With that dosage one can increase the Forebodings of misfortune prevailing along with daily dose progressively from ¼ mg:½ cg up to wider perceptions of anxiety often remain limited ½ mg:1 cg. For anxiety attacks in epileptics it is to circumscribed areas, as is found with pure preferable to administer a sleep-inducing dose of melancholia. Phonemes play only a minor role. amyl hydrate internally or by enema. Incidentally, Thus a fairly common clinical picture can be treatment of anxiety psychoses gives outcomes characterized adequately in both directions. It just the same as those for psychoses generally, so seems to occur preferentially among very young I refer you to my comments on the subject at the persons and in old age. The diagnosis is therefore end of these lectures [2 ]. not unimportant, because the prognosis of this ill- Gentlemen! In no other area of mental illness ness can be stated more securely not only than in are there so many points of contact with the func- cases of anxiety psychosis, but, in itself, is also tional disorders of the nervous system as the one far more favourable. Cases of this type that I we deal with here. However common the anxiety know all had a favourable outcome. psychoses may be, there can be no doubt that The prognosis [W] of anxiety psychoses per states of anxiety to be classed with the neuroses se [W] would be designated as favourable, since are far more frequent. This raises the following by far the majority of cases such as those outlined question: Are there any sure criteria by which above have progressed towards full health. This one can distinguish anxiety neurosis [W] from an favourable judgment is hindered by the diffi culty anxiety psychosis? This question is of great prac- in making a fi rm diagnosis until some way into tical importance, for it is precisely anxiety psy- the course of the illness. Only when, as in the choses for which doctors are obliged to provide case I just presented to you, the patient has timely security, by committal of patients to an already gone through the critical point of the dis- institution, sometimes involuntarily. Such inter- ease, can we assume it as likely that a transition ference in the personal liberty of another fellow of the clinical picture to a more complex one will human would never be tolerated in the case of no longer take place; and in this too, our hopes mere neurosis. Fortunately the clinical picture I may sometimes be dashed, because, after a stage described now offers more reliable and easily of apparent recovery, development of psychosis identifi able indicators in its complex of symp- with a chronically progressive course may ensue. toms, such that a positive diagnosis of anxiety Such was the case, for example, in a case of psychosis can be made easily, and any doubt senile anxiety psychosis in a 73-year-old woman about the appropriate course of action is thus who I could present to you after a 1½-year course, excluded. However, without doubt, as every- as a typical example of a chronic psychiatric where else in Nature, there are borderline cases, patient with so-called hypochondriacal delusions where there is justifi ed uncertainty about the wis- of persecution [Ed], in the stage of allopsychic dom of such a measure. Here, a physician will be disorientation [1 ]. In this case the clinical picture tasked with ensuring the greatest possible reas- was unfavourably clouded by numerous disorien- surance while monitoring the patient privately. tating phonemes and delusions of relatedness. For this, there is no better way than strict adher- Treatment [W] of anxiety psychoses has the ence to bed rest. This is the way in which the special task of fi ghting the symptom of anxiety. symptom of anxiety itself, as shown above, is to We cannot humanely ask any patient simply to be treated. The well-being of the patient precedes endure a high level of anxiety, any more than we all other considerations, and so the focus must be can for analogous symptoms of pain. In general on practical implications that the patient infers Extractum Opii [W], to be injected subcutane- from his feelings of anxiety, and from subsequent ously in doses of ½ to 1 dcg, is a reliable remedy. unhappiness and anxiety about his own actions. 150 23 Lecture 23

Always remember that although a single symp- herself to be completely orientated about the tom such as anxiety is never suffi cient to produce way in which the institution functions, and psychosis, nevertheless, at least as much value about her fellow patients; and she knows that should always be placed on actions of patients, as the gentlemen present are students who visit the on what they say. Where there are attempts at sui- clinic. I led her to a discussion of her illness. cide, safeguarding a patient by internment in a What kind of illness was it? She could not eat lunatic asylum is imperative even in borderline anything because her throat had ‘grown over’ cases. [Ed] or, as she corrected herself, only very little Gentlemen! I have begun describing specifi c would pass through. Her tongue had grown onto types of illness by choosing anxiety psychoses her palate. She felt with her hand, and also because, on the one hand, cases of such illness showed me that the upper surface of her tongue are relatively easy to understand, and on the touched the palate. She also had a constant taste other, because their points of contact with many of ‘bad luck’ [W] in her mouth, and everything other acute psychoses are so varied that they soon she ate lacked fl avour. Anything she did swal- lead us right into the centre ground of our practi- low in her laborious way, she felt became stuck cal tasks. I need hardly point out that practical in her oesophagus. It piled up in the region of knowledge of mental illnesses in itself has noth- her stomach, and led to feelings of bloating. It ing to do with theoretical assumptions. Therefore had previously been impossible for her to pass the series of our demonstrations is set up mainly any stools, and they now passed only by artifi - for teaching purposes, these being subordinate to cial means and insuffi ciently. practical needs. The patient who I shall now pres- I asked whether things were not already ent to you still belongs, in a practical sense, improving, which she denied. I must comment within the area of anxiety psychoses, but, as you here that she is actually already recovering well. will soon see, will continue into the topic of our She used to be so weak and feeble that she could next lecture. answer only in a toneless, fl at voice; and a dem- This 69-year-old factory worker, Mrs L., as onstration like today’s would have been totally you can see, is a silver-haired woman, who impossible. Due to her severe malaise, at that walks with a slight stoop, with downcast, facial time, she hardly ever spoke about herself, while expression, easily made anxious, and with cor- now she sometimes does so; she had shown no responding attitude. She answers questions that interest in her environment, whereas now she are directed to her promptly, albeit with a rather takes some interest in it. At that time she also faint voice. She tells us her birthday, the date of stated that the canal for passage of her food had her marriage, how long she has been married, grown over completely, and she had to be forci- the date of her husband’s death, his illness, and bly fed, whereas now she can take some nourish- the names of her children; she talks about her ment spontaneously. We also learned, from her only surviving daughter, and tells of her grand- daughter, that she had earlier complained of not children. Also, we learn directly from her the being able to breathe. history of her illness. In the spring of 1896 she This patient cannot specify exactly the nature was diagnosed with a growth in her abdomen, of her disease; at least it was something very bad, which had subsequently been operated on. She and totally hopeless. In the past she had given her had then spent 11 weeks in hospital and was view that it was plague, and that she was afraid of subsequently quite weak but was otherwise infecting others by contact. In this respect, too, healthy. In November she was diagnosed with she has clearly made progress because now she shingles, and for 3 weeks was virtually unable no longer believes this. to sleep. At the beginning of December the pres- When we now ask the patient how satisfi ed she ent illness started. She gives the duration of her is with her treatment here, she replies: Good, but stay in the clinic—from 24th February this it is just not worth it. Why ever should she blame year—which is roughly correct; she shows herself? She was bad and sinful through and References 151 through; she had already attempted to take her accessible and trustworthy. She always keeps own life; she was a monster, a spectacle amongst herself clean, and the only hindrance to this is on men; she deserved to be discarded. Other patients occasions when, as a consequence of her delu- shouted out about her. She had brought her illness sions, she attacks her anus or touches her faeces. on herself by starving herself; during her last ill- Gentlemen! No other symptoms have been ness she had been reckless in treatment of her found in this patient. There remain only her delu- mother. As a further sign of a fantastic delusion of sions based on the abnormal notion she describes, belittlement, I want to mention that the patient restricted just to her body and her personality, refuses to go into the visitors’ room, because she and which thereby determine her behaviour. With should not be seen by others. When preparations regard to the conceptualization of this illness, it is were being made for photography the photogra- very instructive to provide an overview of its pher would be so frightened at the sight of her that course. In fact it turns out, beyond doubt, that the he would drop down dead. Furthermore, she hypochondriacal complaints which still exist had believes that she cannot die, because she is too been present right from the beginning, and had bad; and yet now she says she wants to die and, led gradually to the most severe emaciation of the prior to her admission, she had made two attempts patient—her body mass was 31 kg at admis- to strangle herself because she could bear it no sion—which had precipitated the need for admis- longer. As for her grandchildren, the patient sion to the clinic. believes that they are very ill, perhaps dead, and The other unusual ideas were added only she previously gave us the opinion that they when her illness reached a certain level of sever- would die on her behalf. She even claimed to be ity, after the isolated hypochondriacal complaints the cause of all misfortune, from which she heard, had been present for weeks. Tests of memory as an example, when a friend had burnt her hand. retention and attentiveness gave normal results. She likewise expressed the fear that she would be The information that we received from the patient admitted to hospital because she was too evil. came only as short answers to the questions Although she gives quite coherent information, directed to her. and conveys no outward sign of anxiety, she says on questioning that she suffers constantly from anxiety. Where is the root of the anxiety? In my References head. The anxiety is precisely differentiated from a feeling of excitement in her epigastrium; but 1. Wernicke C. Krankenvorstellungen aus der psychia- according to earlier information, the anxiety trischen Klinik in Breslau, vol. 1, Case 1. Breslau: Schletter, 1899. had been temporarily localized in her chest. 2. Wernicke C. Krankenvorstellungen, vol. 1, Cases 3, 8, With regard to this patient’s conduct on the ward, 9 and 12; vol.2 Cases 5, 21, 22 and 23 are examples of she has always shown herself conspicuous as anxiety psychoses, 1899. Lecture 24 24

• Intestinal, worsening, and diffuse who, by virtue of their educated linguistic somatopsychoses expression, are more erudite. Apparently these • Hypochondriacal refl ex psychoses are Affective states that we have already come to • Severe hypochondriacal psychosis in a drunkard recognize as bodily or somatopsychic disarray. In • Example of paralytic somatopsychosis addition, sometimes, we can distinguish a new • Clinical picture component, something special, anxiety occurring • Treatments of somatopsychic disarray in paroxysms. • Outcomes This circumscribed intestinal hypochondria • Overview of hypochondriacal symptoms [W] is itself localized preferentially near either end of the digestive tract. Corresponding to this, complaints that stand out are fi rstly, a diffi culty in swallowing—considered in the broadest sense, Lecture so that it covers the entire action of transporting food to the stomach—and then, diffi culty in Gentlemen! evacuating stools. In a case of the latter type, we Among the patients who have been briefl y could identify the starting point for hypochon- presented to you, you have become familiar with driacal ideas, as a mucous rectal catarrh sustained an example of those common cases that have by haemorrhoids; likewise, in female patients, a earned the distinctive name of hypochondriacal pre- existing global sensation could often be the anxiety psychosis [W]. Clearly, this is a localized starting point for such a symptom, attributed to intestinal somatopsychosis, based on abnormal swallowing diffi culties. bodily sensations in the area of the digestive As you can see from such examples, it is tract, which can quickly lead to disorientation in beyond doubt that we interpret this as a psycho- a circumscribed area of consciousness of corpo- sensory disturbance of identifi cation in organ reality, specifi cally the intestines. The accompa- sensations, although it is diffi cult—even impos- nying severe malaise is easily understood as a sible—to establish whether it is hyperaesthesia, consequence of somatopsychic disturbance of paraesthesia, or anaesthesia which is present. identifi cation. Our patient identifi ed her state of At a certain stage, emergence of these two dif- mind as anxiety, but more often, corresponding ferent initial localizations comes to the same with the main substantive alteration, the patient’s thing, that is a feeling of repletion or ‘surfeit’ Affective state is reported not as actual anxiety, [Ed] of food: on one hand, starting with food that but as something different, especially for patients is either laboriously swallowed or artifi cially

© Springer International Publishing Switzerland 2015 153 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_24 154 24 Lecture 24 introduced and accumulates in the stomach area; severity, from an increase in the feeling of being on the other, a faecal mass backs up from below, ill, was the more severe event, for the patient then eventually right up as far as the pharynx. The became unclean and claimed not to be able to most common and most important of these abnor- stand, walk, or speak. In fact, these functions mal sensations is refusal of food, which in such were preserved, as could be seen from her chance cases almost always requires force-feeding by responses. oesophageal tube. A heavy feeling of dolour is A 57-year-old female patient, who had strug- always present, quite understandably so, given gled for years with severe food problems, was the feeling of severe physical illness which pre- subsequently diagnosed as having sensations of dominates. This also affects patients’ outlook on intestinal obstruction. Six months later, at the the future: They always believe themselves to be height of her illness, she claimed to be full to the lost and quite without hope. In pure cases of this top with faecal matter, and unable either to sort, actual perceptions of anxiety are restricted breathe or to move. When her illness began, she to the autopsychic area, often in a quite limited had repeatedly expressed her fear of starvation, way, in that patients blame themselves for having with despairing restlessness; but after an inter- brought about or aggravated their illness through current bout of infl uenza she veered towards a neglect of medical advice and medical planning. severe state of fatigue, in which she also com- In the case of a 60-year-old, unmarried woman, plained about slowness and diffi culty in her after a long career in nursing, combined with a thought processes. Subsequent infi ltration of the sad Affective state, she quite suddenly she fell ill upper lobes of both lungs seemed to make the with this form of intestinal somatopsychosis and prognosis totally hopeless; nevertheless, after severe food refusal. After about 6 months of ill- several weeks in this condition, she started to ness, the abnormal sensations in her pharynx convalesce, and after about a year was discharged diminished. However, the dolour and autopsychic to family care as improved. The disease trajec- focus of her anxiety remained, as did the somato- tory in this case can be regarded as purely exten- psychic perception of anxiety about having no sive, and the akinesia then corresponded to a bowel movements, and the illness eventually led peak in that curve. This case was interesting in to her death. that her anxiety, which focused on the heart, was As far as motor behaviour is concerned, in always stated to be a separate phenomenon, and such patients, in pure cases, its motivation suggestions of ideas of autopsychic anxiety tak- remains entirely psychological. In one patient, ing the form of self-recrimination were quite more of an agitated state was observed: outbursts short-lived. of whining and despair, lamentation, hand- Even clearer than in the previous case, the wringing, etc.; while in others, perhaps based on worsening behaviour of a hypochondria with ini- individual differences, there was a moderate fail- tial localization restricted to the genital organs ure of motility, as we fi nd clearly in evidence, was demonstrated in the case that I presented a when people feel severely ill. Either such behav- few semesters ago. This was a 23-year-old Jewish iour can exist in the same way throughout the ill- lady, who had suffered psychotic attacks on sev- ness or one condition can replace the other, or eral previous occasions, sometimes more melan- even agitated behaviour can correspond to one of cholic, sometimes more manic in nature; her several peaks along the trajectory of the illness. sister had been mentally disturbed in a similar Conversely, severe loss of motility, in other words way on two occasions. She had lived with her an intrapsychic akinesia (with psychosensory brother’s family, and looked after his very sick relations), can appear, corresponding to an child with utmost devotion. At the beginning of increasing range of symptoms; indeed I have her own illness she complained of feeling a seen this, for example in the case of worsening solid body in her genitals and was treated by somatopsychosis [W], initially only intestinal. the gynaecologist. The symptom was combined Here therefore, akinesia, derived, according to its with a burning sensation, urinary tenesmus, and 24 Lecture 24 155

pressure, with failure of menstruation. There anxiety only transitorily, at times of extreme were no objective fi ndings. When the sick child excitement and despair, the anxious feelings then died about 2 months later, she began to take on being localized to her breast. the hardest work, in spite of which she soon As for this patient’s motor behaviour, there declared that she was no good, could not work, were periods of outpouring of despair as a result was superfl uous, and was a burden to her brother. of progressive decline of strength. There was her About 2 months later she attempted suicide with delusion of having sinned through having eaten chloroform and was unconscious for several too much; she was lost to all eternity; she hours. A foiled attempt at drowning provided the deserved all the most severe punishments await- occasion 3 months later for her being transferred ing her, such as being consumed by fi re. Similarly to the clinic, where the patient’s delusions of she regarded her stay in the clinic—where per- belittlement have been intensely managed up force she had to be kept at the monitoring sta- until very recently. In the last 2 weeks prior to tion—as a well-deserved albeit minor admission, and during the fi rst months of her stay punishment. Moreover her intelligence was in the clinic, her physical ailments intensifi ed to intact, her orientation fully preserved; despite an extremely desperate state. She said that as a physical weakness there was no slowdown, nor result of unsatisfactory stools, her food had accu- hallucinations, nor delusion of relatedness. With mulated inside her—not faeces, she explicitly continuing weight loss, death ensued after a stated—and had been transformed into a solid 9-month stay in the clinic. mass. This solid mass had penetrated every part A modifi cation of intestinal somatopsychoses, of her body, disfi guring it; only her skin remained which is not rare, occurs in cases in which the in its natural state. The patient had convinced aberrant sensation is localized more towards the herself of this because of feelings of internal airways. In one such case the nasal passages were heaviness, and from palpating herself with her the main site of this abnormal feeling, associated hands. Her body felt dead, as if it had expired, with fear of suffocation; in another case there was and there was no longer any blood fl owing a feeling that the throat had dried up and the tra- through it, although the patient could feel her chea was overgrown, although swallowing and pulse and also hear her heart beating. This ‘solid- nourishment continued undisturbed, and without ifi cation’ [Ed] extended also to her sense organs: any respiratory distress. Nevertheless, the patient, Although she could hear with her ears, her eyes a 42-year-old farmer’s wife, experienced a local- remained fi xed within her head; she could not ized feeling of severe loading in the epigastrium, move them, nor open her eyelids. When she made as if from a stone, which was so severe that she eye movements during the examination, she described it as a ‘death feeling’ [Ed]. Apparently assured us that this would not otherwise have this feeling climbed only gradually up to the occurred, and that she had to turn her head pharynx. The patient tossed and turned with instead. She doubted whether she could smell, internal unrest, whined incessantly, and had most feel, touch, or taste; she tried it with milk, and pronounced tendencies to suicide. Multiple found it to be so. However, she could swallow attempts had already been thwarted. At the time and move her tongue. The patient constantly of observation she had already been ill for a year refused food during this time, and had to be tube- and it was learned that during the fi rst half of the fed. As for bowel movements, she claimed that year she had spoken in self-accusatory terms, and they were insuffi cient, even though infusions or of fears for her family, with even more vehement laxatives—which she willingly accepted by the anxiety. Her husky voice and occasional bouts of way—had had an effect from which she felt coughing led us to examine her larynx, and it instantly relieved. She constantly felt severely ill, turned out that, in addition to catarrh that had led with a sense of absolute hopelessness, and a cor- to swelling of her vocal cords, one vocal cord was respondingly desperate mood in relation to her completely paralyzed. Although suspicion of physical condition. However, she complained of tuberculosis of the larynx had arisen in this case, 156 24 Lecture 24 clearly this did not explain the paralysis of the In one such case, treatment with several hours of vocal cord; and you could even ask whether it warm baths, in which the patient felt relieved was more of a direct consequence of the hypo- of every concern over unexpected moments of chondriacal sensation arising in the laryngeal embarrassment, had a sustainable, long-term suc- innervation, in other words, an effect of abnor- cess. I need not emphasize that these cases are mally altered sensation in an organ which at the distinguished by absence of any local changes, same time serves motility, in the sense of com- and of any symptoms arising in sensory nerves or ments made earlier (p. 132). The possibility was the spinal cord, while the patients’ history of then considered that the catarrh was only a conse- persisting cystitis or gonorrhoea is not without quence of defi cient motor activation, as the end signifi cance. result of morbid sensation. I submit that the uni- Certain cases of defaecation hypochondria are lateral nature of the vocal cord paralysis does not related to hypochondriacal neurosis in a similar support this explanation, and a different view of way: The main burden on patients, and likewise this rare condition is closer to the truth. Vocal the fear, with its sequelae, is similarly eliminated cord paralysis and catarrh were perhaps the com- by controlling production of stools. mon outcome of a latent, undetectable cause, and Gentlemen! Not unexpectedly, circumscribed only the paraesthesia of abnormal organ sensa- intestinal hypochondria can also be localized in tions was the starting point of circumscribed— the female genitalia. A typical case of this kind, and in due course, clearly symptomatic—intestinal who I presented in the clinic, concerned a somatopsychosis. 22-year-old serving girl who, before her illness, Gentlemen! In light of the above comments, was of normal intelligence, but always easily symptoms of paralysis in cases of circumscribed excited, and inclined to outbursts of anger; her bladder hypochondria are much more likely to be brother was mentally ill when he died. After understood as psychosensorily induced akinesia. bouts of anger, she was said to have had repeated These cases mark a transition between hypo- seizures of an unspecifi ed nature. At the time she chondriacal psychosis and neurosis, in that they presented here, she had been suffering for about encroach even less than the previously described 2 years—though with several long intermis- ones on the rest of mental life. Moreover, treat- sions—from a burning sensation, which was not ment in our institution can often be avoided, the directly painful but was yet described as quite more so since the numerous subjective com- unbearable, in the genitalia and internally in the plaints associated with paralysis of the sphincter lower abdomen. This burning was not continu- muscles are usually limited to certain times of the ally present, but recurred persistently. It was day, the rest being symptom-free. Particularly worse towards evening, and was simultaneously burdensome is the feeling of urinary pressure associated with low back pain, headaches, dizzi- sometimes connected with a tendency to involun- ness, and nausea. At the same time she com- tary ejaculation: The latter are also able to occur plained of anxiety in the epigastrium. The illness without erections. Patients are therefore in con- was accompanied by unhappiness, low mood, stant fear of causing embarrassment; besides this, and hopelessness; and her facial expression, and localized feelings of anxiety can exist in the epi- her apathetic behaviour altogether, conformed to gastrium. Outside the spasm, the patient may this mood. At the time of her menstruation, there appear mentally normal; however, during the were fewer complaints; before and after it, there attacks they suffer from more or less severe auto- was lower back pain and some discharge. Special psychic notions of anxiety and despair to the mention must be made of the patient’s motor point that they become tired of life, with a ten- behaviour. While she usually stayed in bed, dency to suicide. These patients usually organize depressed and apathetic, occasionally there were their way of life so that incidents of the type outbursts of totally unmotivated, senseless rage, described cannot arise; professional activity and when the patient screamed, lashed out, bit, and dealings with other people suffer as a result. scratched, quite unaware of her surroundings. 24 Lecture 24 157

The patient subsequently had no recollection of cause of her behaviour. The pain generally fl uctu- these instances, which did not last for hours; and ated; and in the oft-repeated periods of several each time, they were initiated by an increase in days’ exacerbation, could be localized spasmodi- abnormal sensations in her genitalia; then came, cally in the region of the uterus and the parame- like a type of aura, a feeling as if the body were trium, connected with terrible feelings of anxiety dying, with consciousness fading. These motor rising right up to the heart, which were described expressions bear the stamp of senseless rage, and along with ideas of her being incurable, and with would be correctly understood as a type of refl ex suicidal impulses. The patient screamed and response to violently-increased organ sensations, moaned loudly, and required monitoring due to and thus as hyperkinesia induced by psychosen- her outbreaks of despair. At one time she could sory means, via a short circuit. At the time of be calmed with soothing words, but more often observation she was suffering from ulceration of chloroform had to be administered. She did not the cervix and vagina. The beginning of her ill- come up with any fantastic names for her illness. ness was allegedly related to a delivery and sub- Objective fi ndings in the genital organs led to the sequent metritis. As a result of her tantrums, this conclusion of previous masturbation (erosion of patient had to be transferred to a nursing home. the vulva and vagina with mild catarrh and blad- Although the reported symptoms are close to the der complaints). There was also slight retrover- clinical picture of epilepsy, typical epileptic sei- sion of the uterus and chronic severe constipation. zures were never observed. Sleep and food intake were continuously very Except for bouts of motor discharge just con- disturbed. The patient, a sales assistant in a cloth- sidered—attributable to twilight states in the so- ing store, was the daughter of a well-known called transitory psychoses, as discussed later—a eccentric father; and, after a severely hysterical circumscribed intestinal somatopsychosis, with attack of irritability, during which she struck out its origin specifi cally in the genital organs, is fea- blindly and shouted fearfully, brought about by a tured in this case. It is correct to note the close dispute with her boss, she was admitted to hospi- relationship of tantrums with those of epileptic tal. Six months later, she too was moved to a and hysterical twilight states, but this will not nursing home, as permanent improvement could prevent it being suggested that permanent abnor- not be achieved. The tantrum that we observed mality of intestinal sensation is also the starting occurred around the middle of her stay in the hos- point for the acute transitory seizures; and thus pital, allegedly caused by anger. Here, too in my such seizures appear to derive from a refl ex psy- opinion we might be forced to interpret the short- chosis induced by the genital organs. However, in duration transitory psychosis arising in the rest of this transitory condition, disturbance of identifi - the clinical picture as in no way different from cation then spreads to all three areas of con- the previous case, since the motor discharge sciousness, while the motor discharge retains the again corresponded with widespread somatopsy- character of a psychosensory condition, fully chic disarray. Incidentally, this patient was dis- characterized as somatopsychic disarray. This charged from the nursing home after 6 weeks, approach has the advantage of providing a uni- allegedly completely recovered, probably as a form view of the illness itself. It is supported result of the powerful impression that transfer mainly by the fact that an increase of localized there must have had on her. complaints always preceded the tantrums, but Gentlemen! That idea that sense organs too also by experience in similar cases. For example, can give rise to abnormal organ sensations and quite separately I observed a very similar tantrum thereby to circumscribed hypochondriacal symp- in a 20-year-old girl who constantly brought to toms or somatopsychosis is shown by the follow- light severe unhappiness with suicidal tenden- ing instructive case. A 71-year-old physically cies; and when she once relaxed her guarded spry woman who, up to 9 months ago, had served nature and expressed herself openly, remarked as a nanny and on closer examination showed that, quite defi nitely, her abdominal pain was the no signs of weakened intellect or senile mental 158 24 Lecture 24 disorder sought spontaneous admission to our bone conduction; against the skull or mastoid hospital because she was afraid that she might process the clock was not heard at all. An commit suicide. During her stay in the clinic of improvement of her mental condition in the last more than 4 months, she always presented the 2 months clearly ran parallel with favourable same symptoms, right up to the time of her previ- results of ear treatment using the Politzer [W] ous discharge: On admission, she moaned to her- method. At the time of her discharge the noise self about anxiety in her heart. Her chief was certainly still present; there was also a dis- complaint, however, was a noise in her head. The proportionate feeling of illness in relation to this, noise was constant; and increased at times of and fear of recurrence of the old situation. complete silence, so that she preferred to remain However, anxiety, unhappiness, self-accusations, at the rather noisy monitoring station. This noise and suicidal ideas had been eliminated. She could was subjectively extremely unpleasant, gave her hear whispered speech in both ears at fi ve metres, no rest, interfered with her thinking, and com- and bone conduction also appeared to be pelled her attention. When the noise was bad, improved, albeit worse in the right than the left. restlessness in her heart and anxiety also occurred. I will try to describe to you one of the strang- Also present were severe unhappiness, hopeless- est cases of somatopsychosis, according to notes ness, autopsychic ideas of anxiety with a self- from my time employed in the Asylum accusatory content—which at the same time she Department of the Charité, this being pervasive rejected—insomnia, fear of silence at night when and also acute (in terms of external confi gura- the noise increased, and thoughts of suicide. She tion). The 46-year-old worker N. was admitted as had an attentive face, no defi cits of any sort, and a delirious patient to the Asylum Department of good retention in memory. She looks after her- the Charité on 6 December 1876. He had previ- self, but sleeps with the aid of sleeping pills. ously been admitted on 8 March the same year According to the patient and her family, this con- into a secure unit and after 3 days was transferred dition had developed slowly over 4 months. to the Delirium Department, but was discharged Initially, only the noise in her ears was present, from there on 31 March as recovered. The few which is why she consulted several ear special- data available from the time giving the diagnosis ists. Then the restlessness and anxiety in her heart of Delirium tremens [W] seemed doubtful, but started. She ran back and forth a lot, and could many things showed that he had severe hypo- stand it no longer. Finally, she deliberately chondriacal diffi culties (semen fl owed from him reduced her food intake and had suicidal ideas. continually, he suffered burning in his mouth, his The condition was always worse in the evening, larynx had been removed); and, apart from which was confi rmed in the clinic. In the clinic, marked tremor and other objective signs of alco- her food intake was good, and over the last 2 hol abuse, he presented familiar visual hallucina- months her body weight has increased from 52 to tions, amongst others. His restlessness and 55 kg. Results from hearing tests and ear exami- current delirious behaviour were put forward as nation were interesting. There were old changes the reason for his readmission. His alcohol con- in both ears; constriction of the tympanic mem- sumption was only moderate, before which he brane more on the left than the right (old Otitis was alleged to have had complete allopsychic ori- media [W]). On admission she understood speech entation, and intact memory of his earlier stay. whispered at 3–3½ m.; it was also shown that her His face was deep-ridged and grief-stricken, with hearing improved or worsened according to the an anxious, yet sometimes still-smiling expres- intensity of the noise. Over the fi rst 2 months sion, an increased respiration rate due to his anxi- there was a clear decrease in her auditory acuity. ety, no hand tremor, only a light lingual tremor, This was noticeable even at ordinary conversa- with perpetual moaning and talking to himself. tional levels; for whispered speech, auditory acu- Hypochondriacal offerings included that his ity decreased to 30 cm on the left and 20 cm on brain could have been frozen; he couldn’t speak; the right. Here, we discovered particularly poor his jaws might have been so loose that his throat 24 Lecture 24 159 would be divided; to him, his tongue appeared to tation to surrender. Often he piled himself into a have grown and fell down outside; and he had corner, hiding, singing to himself of similar expe- lost his hearing. Such utterances were often made riences, like those mentioned above, but never without apparent Affect in a peaceful, conversa- with actual motor symptoms. Gradual resistance tional tone. He does not answer for a start despite and blind defence against any actions prevailed; a talking very loudly, but soon after, says, in a strait jacket became necessary; his cleanliness whisper ‘He could hear already, but there was no and strength declined. Multiple injuries were tension in his ears’, and grasps with his fi ngers in incurred from the movements described above, the external auditory meatus. He answered my including his violent beating of his own face with question about headache in the affi rmative. He a clenched fi st, etc. Finally, refusal of food, alter- poked his tongue out, after he had suggested that nating or simultaneous with his insisting that he this would not work. For past medical history, he could not swallow, he drove us away, in animal- indicates only that it had been remarkable for him like manner, with bared teeth, so that you were for some time, but up until recently he had acted afraid of being bitten, and that he then swallowed as a house servant. His pupils were fairly narrow, whole what he had bitten. After a restless night, equidistant, and widened only a little, when his in a sudden moment of calm, he died, on 4 May eyes were shaded. He claimed that he had no 1877. The autopsy revealed, apart from a very face; his head was as hard as stone. Other com- strong, virtually unbroken thickening and opacity plaints: his rectum had been torn out; his head of the pia over the convexity, Hydrocephalus — was back-to-front with the face backwards. both internus [W] and externus [W] as the main Similar complaints, shifting in content and tem- fi nding; countless calcifi ed trichinae in all his porarily corrected again during the whole dura- muscles, especially those of the neck. Under the tion of the illness, among them the delusion of deep fascia of the supraclavicular region, an ill- the reversed position of the head being surpris- defi ned, pus-soaked body was found, the size of a ingly fi xed. Apparently there were no hallucina- pigeon’s egg, apparently corresponding to an tions, which he could speak of, accessible on fi rst abscessed lymph node, and continuing upward asking. Gradual refusal of food was motivated by into the deep musculature and gradually disap- the patient having no stomach, and he would get pearing. His intestines were unchanged, except no air. Tube-feeding was often required. Sleep for the signs of general marasmus. was achieved only with the aid of sleeping pills. Gentlemen! The expressions of somatopsy- Most striking motor behaviour occurred through- chic disarray which showed up in this patient’s out the duration of his illness. Soon he used the motor behaviour were so strange that they have side rails, separated by gaps between neighbour- remained indelibly in my memory. In part they ing beds, like the rungs of a ladder, so that he can be understood from the autopsy fi ndings, and could get about; sometimes, standing in bed, he in particular, we can infer an internal connection let himself topple over backwards, into and between the pus focus in the deep muscles of the beyond the bed; at other times he violently threw neck, and the peculiar—often perilous—jumps, himself out while rotating his torso, usually with by which he attempted to correct the supposed the motivation that his head would turn right way perverse orientation of his head. We are entitled round. Frequently, he expressed his discomfort here to interpret the underlying psychosensory by whining so disturbingly that he had to be kept disturbances of identifi cation as abnormal par- in seclusion, and at other times strikingly stoic, aesthesia of position sense for the head, induced even with a characteristically smiling manner, psychotically. often monotonously recounting previous experi- Alteration to the external confi guration of the ences—reminiscent of verbigeration: ‘N., do you body confronts us in no less instructive a manner, want to stay here?’ ‘No, sergeant’ whereby he in a case that I would like to outline to you only explained that he had been an NCO, and now briefl y. It concerns a 35-year-old former offi cer very much regretted that he had refused the invi- of high nobility, with development of a marked 160 24 Lecture 24 organic syndrome. For 3 years now, his life has cases as regular examples of psychosensory been temporarily in discord; over the last 6 paraesthesia of the organ systems involved. The months he has been in a bad way, which is when old theory of positional changes in the colon as I got to know him. During that time he slept the cause of mental illnesses now appears to badly, with occasional bedwetting, along with some extent understandable, and even, with the Impotentia coeundi [W]. Apart from low-level constraints just given, closer to reality in indi- ataxia of his legs when lying in bed, a dubious, vidual cases. The clinical picture is always deter- but enduring speech disorder, and traces of a mined essentially by psychosensory disturbance right-sided facial paralysis, there had been no of identifi cation of organ sensation, for which it detectable symptoms of paralysis, although there is often uncertain whether paraesthesia, anaes- was an old infection. Specifi cally, attentiveness, thesia, or hyperaesthesia is present. memory, and judgment were good; there was Localization of the morbid sensations [W] is no fainting, but frequent deep breathing. often quite vague and diffuse, as is particularly Unhappiness, subjective inability to work etc., common for example during initial stages of pro- matched these complaints, related exclusively to gressive paralysis, when severe malaise can be his own body, which he himself says he can no traced back to terrible, indescribable sensations longer understand. His body itself has changed, throughout the body. Moreover, it can be very becoming thick and foul-tasting, like a lump of diverse, affecting almost all body areas, includ- dough, his nose has become a red cucumber, his ing sense organs. However, pure somatopsycho- tongue and mouth are swollen, and he could not sis can be identifi ed when the resulting substantive open his mouth wide enough. His stools were change leaves the allopsychic area intact, in other quite inadequate—he was full right up to the words, the origins of the substantive changes can- middle of his trachea; eating and drinking were not be found in the outside world—as for exam- performed, without any sense of taste, merely out ple, when the sensation of stabbing instruments, of a sense of duty; there was a constant unsa- electric shocks, palpations, etc. always go beyond voury, slimy taste in the mouth; his neck and the range of pure somatopsychosis, or equally throat were hot and dry as though burned out. He those of somatopsychic delusions of relatedness. denied any real feeling of anxiety. Due to the On the other hand, the autopsychic area shows continuation of these complaints he had to be itself always to be involved, to varying degrees, transferred to a mental institution because of his corresponding with the Affective state induced dangerous abuse of his caring, self-sacrifi cing by anxiety or somatopsychic disarray. A despair- wife; and he went there, and within a few months, ing depressed mood, unhappiness, hopelessness, a rapidly progressing paralysis developed. and autopsychic perceptions of anxiety of the Gentlemen! Those examples of hypochondri- most varied content are always to be found. acal psychosis or somatopsychosis that I pre- Surprisingly phonemes are very often missing sented may suffi ce to show that we are dealing and, where they do occur, serve only to summa- with an area where individual cases show very rize in words the ideas of autopsychic anxiety different characteristics. We want to try to sum- and the bodily sensations. Explanatory delusions marise characteristics common to them all, in are usually, though not always, present. Through order to defi ne their demarcation from other psy- them, those sensations get their fantastic interpre- choses. Turning fi rst to aetiology [W], we see that tations. Thus the concept of mental disorder is quite often the content of a disorder of aberrant often already accessible to the layman, such as identifi cation is determined by a detectable phys- when there are complaints about worms in the ical illness. Nevertheless it may not be a simple brain, or a frog or bird in the body. Anxiety, with cause-and-effect relationship, because the same its favourite location in the chest, the head, or the diseases of organs can be seen countless times entire body, is an almost invariable accompany- without resulting in any form of psychosis. On ing event. The more pronounced it is, the more the other hand, it is permissible to regard such actual ideas of anxiety assert themselves; and 24 Lecture 24 161 they can become so dominant that it is justifi able difference between hypochondriacal psychosis to separate certain cases of somatopsychosis as and neurosis. However, another case, I would ‘hypochondriacal anxiety psychosis’ [Ed]. The claim beyond doubt to be one of mental illness: a recently introduced Mrs L. (p. 150 seq ) was an general failure of motility bordering on immobil- example of this. Also, these cases remain well ity, without any other disturbance of intelligence, characterized, due to the absence of allopsychic driven by an unbearable tickling sensation in the anxiety ideas and delusions of relatedness. intestine, again without fantastic interpretation. The motor behaviour [W] of this patient can Anxiety psychoses both in pure cases and in be understood in psychological terms, as depen- hypochondriacal anxiety psychosis and also the dent on his sensations and bodily malaise: at somatopsychoses are relatively simple types of times, more agitated, at other times, reduced vir- illness, dominated in their entire course by the tually to motionlessness; his speech follows a same complex of symptoms. The trajectory of similar pattern. Those sensations that result from their illnesses can often be constructed just as self-harm, through food refusal, suicidal well from the intensity as from the range of their impulses, and actions of somatopsychic disarray, symptoms, for which the Affects of anxiety and assume special importance. Some such acts are motor disarray will be decisive factors in the specially emphasized, since they compel our intensity curve. Where the range of symptoms interest by their enormity. Belonging among remains the same throughout the illness, which is these are ripping out the tongue, tearing out the often the case for localized intestinal somatopsy- genitals, ripping the body orifi ces, boring out the chosis, the curve is purely one of intensity. Cases eyes, and crawling into a fi re hearth. Some abnor- where there is a spread of abnormal feelings from mal movements can emerge from paræsthesia of one circumscribed region of the body towards the position sense, as we have just seen, in the additional organs result in a curve based on the example of patient N (p. 158). range of symptoms, which may be independent It is a mistaken notion, although one held as of the intensity. The relationship of the two authoritative, that the distinction of hypochon- curves to each other may determine the prognosis driacal mental illness from hypochondriacal neu- [W], where an increase in range without any cor- rosis is based on the fact that fantastic or responding increase in Affective intensity seems explanatory delusional ideas are missing in the to be an unfavourable pointer. Moreover, in all latter. In contrast the distinguishing feature here cases, prognosis depends primarily on a patient’s is whether or not the hypochondriacal feelings nutritional status, but only in the sense that resto- exert any infl uence on the patients’ actions. ration of a certain body weight is a prerequisite Patients who, out of fear of succumbing to sui- for healing and averting a lethal outcome. Good cide, themselves seek out a mental institution, nutritional status at the onset of the illness by no like the above-mentioned Mrs B., will have to be means guarantees a favourable course. Invariably, considered mentally ill, but without all the fan- there is a threat to life. For paralytic and hebe- tastic interpretation, just as do all those who phrenic somatopsychosis, severe organic loading refuse food. Otherwise the exclusive focus on is taken to be prognostically unfavourable when morbid feelings can make patients unable to the limits of hypochondriacal neurosis are apply themselves to all manner of tasks, and, par- exceeded and an undoubted mental illness is ticularly, to their personal needs. The sensation present. Nevertheless, overall, acute somatopsy- that, in breathing, the lungs rub against each choses must be included amongst treatable men- other, with vivid accompanying pain but with no tal illnesses. objective fi ndings, formed the main complaint of Whether a treatable paranoid stage occurs in a patient, who made no fanciful interpretations, pure somatopsychoses can be learned only from but was totally immersed in his severe feeling of further clinical observations. On the other hand, illness, which made him incapable of any activ- in cases whose acute character is conditioned ity. You could fairly use this case to exemplify the more by their Affective colouration than by their 162 24 Lecture 24 temporal course, progression to a chronic mental When moderate muscular exertion, as in stand- disorder seems to be quite common. ing, walking, and sitting, brings on a severe feel- Gentlemen! I would like to mention briefl y a ing of fatigue, and thereby ideas of complete loss common combination of localized intestinal of strength, and of approaching death, this is also hypochondria with the clinical picture of based on hyperaesthesia. The notion of develop- Affective melancholia, which I have yet to ing pulmonary phthisis and therefore being des- describe. The hypochondriacal sensation we deal tined to die is likely to arise from muscle pains in with here is mostly intestinal or, in women, often the thoracic region. It may imply feelings origi- stems from a global feeling, or from the sexual nating more in the intestines, when the claim is organs. These illnesses merit the name made that the lungs are ulcerated or putrefi ed; Hypochondriacal melancholia [W], a term other- sometimes there is also a misinterpretation of wise much abused, characterized by very favour- mucus, expectorated from the throat or nasal pas- able prognosis once treatment is appropriate, that sages, often accompanied by a corresponding is, to be undertaken within an institution. olfactory hallucination. Gentlemen! According to our course curricu- The brain is a particularly rich source for lum, I now pass over to a brief description of hypochondriacal sensations. Often you meet the hypochondriacal symptoms, whether or not they idea that it moves about within the cranium: occur in isolation or combined with other symp- descriptions include sloshing, fl owing, seeping, toms, and whether or not explanatory delusions or trickling sensations. The feeling is often con- and other sequelae [Ed] are present. When the veyed that the brain is shrinking, drying out, functioning of organs, which usually goes unno- glowing, or being eaten away. A tingling, crawl- ticed, reaches perception and is accompanied by ing sensation may be ascribed to the brain sur- abnormal sensations, we have examples of psy- face, and to small animals. The feeling that the chosensory hyperaesthesia [Ed]. Digestive activ- brain is attracted to some external agency leads ity in the stomach or intestines after a meal to the notion of apparatuses and persecutors. belongs here. Increasing from a slight feeling of A patient described various nerves that ‘straight- unease to totally fantastic ailments, this symptom ened up’ [Ed] within his brain; he compared is frequently found in mental illnesses, usually them with wax candles of varying lengths and linked with explanatory delusional ideas, that indicated the precise points where he felt them. harmful substances have been mixed in with the A buzzing, roaring, or thundering is often said to food. Often, a genuine gastritis is the starting arise inside the brain itself and not in the ears. point for aberrant identifi cation, leading to com- The feeling of hollowness must be based on plaints of a heavy feeling, as though a stone lay in very strange sensations, where patients specify the pit of the stomach. Localized anxiety in that ingested food falls into the void. One patient Affective melancholia often has such an origin. expressed the idea that his diaphragm was bro- The feeling of burning, seething, tugging, smoul- ken, so that air reached the abdominal cavity with dering in the gut, the chest, or in the abdominal each breath. Such strong sensations are particu- cavities occurs commonly among the mentally larly common among paralytics. ill. The heart is the starting point of many com- It is a specifi c characteristic of paralytics, for plaints: Sometimes it beats too violently, some- patients to announce that workmen are sitting in times too little: It seems, to the patient, to stand their brains, carrying out a particular exercise, still, with blood faltering in the veins. In one of and dispatching fully laden vehicles; when Kahlbaum’s patients a painful sensation in the patients assert that they have a regiment of sol- heart was related to having seen a fl ame in the diers, or a factory, or a church tower within their stove: Her heart might have ‘burnt out’ [Ed]. body, or a number of brandy barrels under their Muscle pains often underlie a very severe feeling skin. Amongst very specifi c sensations, but ones of illness, as proven by occasional examples of that also occur normally, are announcements by rapid onset, resolved by relief of muscle pain. mentally-ill women that they are pregnant, or 24 Lecture 24 163 have just given birth, or that they are suffering his own face to show that he felt no pain. Pains of severe abdominal pain. hypochondriacal origin are common amongst Moreover, alterations of their external features mentally ill people. They complain that they are are commonly felt. Most often, the cranium is driven out of their beds, by the stabbing of sharp specifi ed as being soft and yields to pressure; at knives, that they are electrifi ed, tormented, tor- other times you are told that the chest is sunken tured, their limbs broken, etc. The pains are often or misshapen; the shoulders are not in the right described in greater detail as burning, glowing, place—sometimes they are shoved upward and piercing, ripping, and clubbing. Painful muscle sometimes have slipped down; limbs are abnor- tensions are explained as electric shocks. One of mally thick or long. A young lady believed that Kahlbaum’s female patients complained, ‘What she was abnormally ugly and had been given an are you drawing out of me?’ when she saw a ape’s skull. She gave an approximation of its warder distributing soup. Undoubtedly, these are form, with a midline sagittal crest, and she all examples of psychosensory hyperaesthesia of claimed that in the mirror she recognized an ape’s common sensation. I have heard, from patients face. An acutely ill patient claimed that he felt his who had the habit of holding themselves bent for- left leg on his right side, and his right leg on his ward, in a lying position with their head raised left; a female patient that she had more than four from the pillow, that they felt that, without sup- arms, of very different lengths. Another patient port, their head would sink too far backward. became ill in a most-acute manner, with bouts of Remaining in an abnormal position—which we extremely severe somatopsychic disarray and will often come across later in a particular group disorientation. Although restrained by several of patients—probably has its origin in disturbed strong men, he could barely be prevented from position sense. Such behaviour might be similar boring out his eyes with his fi sts. The bruises, to that in the so-called hypochondriacal paraly- suffused with blood, remained after the attacks, ses, an example of which I recall from a right- covering the eyeballs, which, fortunately, were sided hemiplegia with mutacismus from the not injured, and showed the site of his worst sen- Charité. Autopsy fi ndings from this case were sations, which nevertheless the patient could not negative. remember. However, he stated during a so-called The feeling of cohabitation about which lucid moment that the worst thing about his female mental patients very frequently complain attack had been the indescribably horrible feeling should be viewed as a more complex form of psy- of no longer knowing what position his head, chosensory identifi cation disturbance of common trunk, and limbs were in relation to each other— sensibility. Only occasionally can one obtain fur- whether above or below, right or left. A few ther details about this; and it is then either the attacks of this type left behind profound idiocy. sensation of a hard body moving up and down Starting from a strong family taint, the patient inside the vagina or a combination of dream-like perished within a year from progressive paraly- hallucinations, where tactile and general sensa- sis. The idea of being abnormally small or abnor- tions are combined in the whole experience of mally large recurs frequently, especially among cohabitation. A similar process is described by paralytics. Also, the delusion of any kind of male patients as ‘palpation’ [Ed] or ‘envelop- physical transformation, such as a woman chang- ment’ [Ed], and is then projected onto the outside ing into a man or being transformed into an ani- world. Generally, complaints of sexual abuse are mal, seems to be based in part on feeling of the heard very frequently from male patients. body confi guration to be modifi ed. More indeterminate paraesthesias of common When patients describe themselves as being sensibility, probably combined with abnormal blind and pretend not to be able to see, we have to muscle and organ sensations, are those of ‘being interpret this as a psychosensory paraesthesia. attracted’ [Ed], that is with their entire body, in a We know for example of the insensitivity to pain particular direction—a sensation that occurred from the above-mentioned patient, who slapped refl exively in a patient, when he looked at the gas 164 24 Lecture 24 lamp burning beneath the ceiling. Furthermore, the garden and rocked himself on branches that there may be the feeling of fl oating, of being were far too weak, so that a dangerous fall seemed lifted up or falling, possibly to some extent as an inevitable. Bringing in a fi re engine only led him abnormal manifestation of vertigo, and also the to shift his position, and therefore had to be aban- delusion of being able to fl y. This was retained doned as useless. However it all ended happily, for months in one case that I observed in the because the patient climbed down by himself Charité and led, among other things, to the awk- after he had been left completely alone, and the ward situation that the patient climbed a tree in garden had been cleared. Lecture 25 25

• Acute hallucinosis using some form of mirror system, because he • Presentation of a typical case during the heal- believed that he had also noticed a light shining ing process and could see his persecutors—although this was • Aetiology quite impossible because of the location of the • Danger of relapse windows—and he heard their voices—presumably they were using a telephone, installed without his knowledge. Moreover, since he also heard common swear words, he left the room to ﬁ nd a Lecture policeman, who would give him peace of mind. However, since he did not ﬁ nd one in the vicinity Gentlemen! he went to a nearby tavern, and ate his supper The patient I present to you today is the there. Then he left the bar and met a policeman to 32-year-old businessman K. As you see, he is a whom he made his request. The policeman went well-fed man, apparently totally level-headed, with him and said that he saw nobody, nor did he who can tell us himself why he has come to the hear anyone making scolding remarks; he advised clinic. He came to us in the evening 5 days ago, him to go to sleep. Everything was peaceful as voluntarily, seeking refuge from alleged persecu- long as the policeman was there. He then went to tors. He lives at the opposite end of the city and is bed, but soon noticed that the old game was start- the owner of a grocery shop, connected to a bar. ing up again. He now heard his thoughts repeated; Opposite him lives a watchmaker, who is proba- thoughts were even intruding upon him, and bly to blame for the whole fracas. He presumes indeed the chief of police seemed to want to this, because the latter had spoken out shortly ‘extract’ from him thoughts whose content was before, very unpleasantly, about the dismissal of a ridiculous, on the basis of which his punishment clerk by the patient, and because the watchmaker would be given. It seemed to him as though a tele- was the main spokesman for ‘the whole group’ phone led into the garden, and his thoughts were [Ed]. While sitting quietly in his room that eve- being collected by people in this way. As he lay in ning doing his books he suddenly heard their bed, he felt as though his face was illuminated. As voices, ‘Now he is reckoning the accounts’; then a result of hearing vulgar swear words, and life- he also heard the total sum, which book-entry he threatening statements such as: ‘The fellow has should take in his hand, and what he would write. eaten supper and should be executed’ or ‘People He concluded that someone was watching all his were standing outside who wanted to beat him movements, and knew his thoughts, probably to death with stones’, he was overwhelmed by

terrible fear and got up from his bed to go and repeated by the crowd of people. Derogatory seek shelter. On the street he was greeted with judgments about doctors, about the Kaiser etc., ‘Hello’; everybody seemed to know him, every- who were a long way away from him, had been body ran after him, ‘Here he comes, there he is, ‘set in his head’ in the fi rst days; later he had heard the scoundrel, the liquidator, into the Oder with corresponding voices. The foul language and vul- him!’ In his fear, he ran aimlessly through the gar words that he had heard on the way here were streets, constantly hounded and persecuted by the sometimes individual voices that he recognized, crowd behind him, and at length, he went breath- and sometimes were screaming in unison, as if on less and dripping with sweat into an alehouse near command. ‘Now he will go in the moat’. But he our clinic. There he bought a cognac and asked thought, ‘No, certainly not’. He heard of a dis- for a rope to hang himself. As a result, it was rec- patch from the Kaiser, ‘Within eight days his head ognized that he was sick and was directed to our will fall’; saw the telegram handed over to the clinic. He spent the fi rst night here for the most prosecutor. Several times the criminal bell had part sleepless. He well knew where he was and rung, as if he were now going to his death. felt a little safer, but he could still hear the crowd The patient showed that he was perfectly ori- screaming outside, wanting to drag him to the entated, knew the doctors, each of the warders, Oder and throw him in. At one point it seemed to and the other patients, and had never projected him as though three elephants had come into the the voices onto any of these people known to room, but he would probably have been deceived. him. It was always the crowd of people ‘out A powder (Phenacetin 2.0) was then given him to there’ [Ed] of whom he spoke. On questioning he sleep. Here in the clinic, he knew well that noth- stated that he had often seen the people outside, ing would happen to him; however, he assumed with the watchmaker included amongst them, that he would be handed over if people came to who was always there. He was surprised that the get him. On questioning, he indicated that he people sometimes remained even during his meal would still prefer to end his life in order to escape times and did not keep their distance. He has the fear of his impending fate. He gave clear heard voices: that there is poison in the food; that information about his business affairs, but wished he should not eat, but nevertheless he did eat, to meet his ‘last orders’, and he stated his inten- admittedly in the hope of escaping a worse death tion to ‘follow without resistance’. Fear is suf- in this way. The patient is uncertain that he has fused throughout his body, accompanied only had sensations of taste and smell to match this occasionally by heart palpitations and the feeling content. When he was given paraldehyde in the of pressure in the pit of his stomach. He explains evening as a sleeping aid, he heard a voice say- the fear resulting from the voices, which he hears ing, ‘This will please him, that he still gets continually. Literally they declaim expressions cognac’. As for abnormal sensations, this patient such as: ‘For God’s sake. Is not executed. That’s declares that it often happened that he felt him- right, the ratbag; now he’s laughing, the doctor is self to be electrifi ed; he also believes that there writing. That’s just nonsense, that everything is must be a powerful electrifying machine some- written down (referring to management of medi- where. Several details of this patient’s auditory cal history); that’s a malingerer. Insane he may be, hallucinations are interesting. He complains of but he is also a malingerer. What do we think of continual ringing and buzzing in his ears. These such a malingerer? K. is a malingerer. K. you are are joined by rhythmic ringing as soon as his not listening, you are a malingerer. What does it head rests on the pillow, in the ear of the same mean, that everything is written down? The doc- side. He has repeatedly stated that the rhythm of tor is a good man. The doctor is a fool. The doctor the ringing has synchronized his pulse; and he is an ass’. The patient has repeatedly heard the then hears voices in the other ear. As for his doctor’s injunction: ‘Beware, lest anyone is behaviour on the ward, you often fi nd him scolding outside’. Likewise questions were often kneeling at the side of his bed; he offers up his addressed to him, and his own thoughts were last prayer, as he is soon to be ‘taken away’ [Ed]. 25 Lecture 25 167

He also often leaves his bed and stands listening situations we see attempts to systematize towards at the doors. He never loses his focus, and encour- a uniform explanation of the phenomena that agement always rapidly succeeds in calming him. frightens patients, and this, just a few days after Sleep is brought on only with a sleeping draft, or, the acute onset of psychosis. We shall soon see as in many similar cases, a dose of 2 g of that this rapid systematization is quite characteris- Phenacetin. tic of the current illness. It is based undoubtedly Let us summarize the essential features of the on the relative intactness of formal reasoning abil- clinical picture: We have here a physically well- ity, as we have since seen; and that during the nourished, prosperous man, who is probably in a demonstration the patient was free from voices position to give information in a level-headed and was never distracted by them. Visual halluci- way. However, from his manner of speaking, he nations take second place, appearing preferen- conveys restrained Affect; he is ‘focused’ [W], as tially in combination with auditory hallucinations, he says himself, yet is tormented by perpetual and have a delirious quality. Other sensory delu- fear. Also, his speech is sometimes hasty, and his sions, with the exception of those of skin sense (as vocal tone a little shaky. His outstretched hands electricity!), did not occur. This patient is fi rmly soon start to tremble. The main symptom we convinced of the reality of his perceptions, know about are phonemes, whose content, corre- although there is no loss of his orientation, and he sponding with his anxious state, is partly of a assesses his current situation properly, while con- threatening nature and partly expresses his fi ned to the clinic. The contradiction arising from reduced personal status (that is, part allopsychic this is not lost on the patient, as is revealed even in part autopsychic notions of anxiety). He hears the the form of a phoneme which he tells us. Namely most defamatory claims about him personally, he has heard, ‘If he were in prison, he could be shameful insults, and threats; he describes how he taken by force; but because he is in the hospital, is being hounded to death, and even now awaits one must wait until he comes naturally’. an ignominious death. He makes most defi nite Gentlemen! This patient represents one of the comments about the fact that his medical condi- best-defi ned forms of acute psychoses, which, if tion has become very acute, and within a few you follow the practical advice for clinical analy- hours has risen to a high level; furthermore, he sis, deserves the name Acute hallucinosis [W]. has heard voices, and, as a result, is overcome by For some such cases the aetiology is well known: anxiety. When he fi rst met all those people the Abusus spirituosorum [W] in the case of together on the street, and when, as though by Delirium tremens [W] (see: the following lec- agreement, he heard shameful suspicions ture), and yet what a different clinical picture! screamed at him, that fi xed in his mind the fi rst We also learn from our patient that he had been comprehensive anxious idea: that it might all be drinking heavily for several years, as a result of over, for his business, if these people made him anger about his business—in recent times mainly out to be so bad. The severe anxiety only came cognac. He had already long been suffering from later, when he was chased down the street. headaches, dizziness, and restless sleep; and now Attempts made by the patient to provide an expla- there are the lawsuits, which he submits. nation are remarkable. He is convinced that a tele- However, the onset of psychosis was quite acute, phone had been placed in his home; he talks of a as the patient himself portrayed so vividly. On the ‘mind reader’ and describes a corresponding basis of experiences from similar cases we can apparatus that he has allegedly seen: a lamp with suggest a favourable prognosis, and expect a a mirror above it, trailing electric wires. He complete recovery in the space of a few weeks. assumes that there is a specifi c starting point for (The patient was discharged as recovered after a these persecutions, where he refers to the watch- 10-week hospitalization, and since then - 4 years maker as the ‘people’s stirrer’ [Ed], and implies ago - he has remained healthy.) However this is that the latter’s motive is wanting the patient to defi nitive, only if there is steadfast avoidance of suffer for the dismissal of a clerk. In all these alcohol. Without this, we should expect, without 168 25 Lecture 25 hesitation, the occurrence of relapses of a gradu- knees and begged for his life. The tremor of his ally increasingly severity, with a fi nal outcome of voice and lips when speaking, the tremor in his incurable chronic psychosis. Cases originating hands, and the bloated, pale, and sickly appear- without alcoholism or other intoxicants, while in ance of this excessively obese patient indicate a other ways quite analogous, do not appear to sub- further advance in his state of alcoholic degener- ject patients to risk of relapse. ation. In a hasty, precipitate manner he reported To complete the clinical picture, I remind you that, shortly before, he had moved into a new of an example of such a relapsed acute hallucino- apartment. When he looked out of the window sis, who I presented to you several semesters ago for the fi rst time, he noticed that the people went in the clinic. This patient, the 45-year-old trainee to and fro in such a peculiar manner, and looked and hack lawyer W., now incurably mentally ill, up towards him and made such remarks, that he has been transferred to the provincial secure unit was able to gather from this that his entire past at T., and was found, at the time of the demon- had been made known to all these people. In the stration, in the third relapse of his illness (over street people were then yelling out behind his the course of 1½ years)—the last relapse from back, singing satirical songs, and whistling at which he had been discharged as ‘cured’ [Ed]— him, ‘Lawyer of the right, lawyer of the left, peo- while the fourth relapse, 1¼ years later, ended as ple’s advocate, villain of a trainee, scoundrel, ras- an incurable mental illness. This patient W., a cal, the villain has raped his own daughter. The former elementary school teacher, had been sen- prosecutor will throw him out. Into the well, and tenced to 3 years in prison for a crime against under the water with him; he should be pumped morality and had thereby been torn away from full and cut open; then into the puddle with him; his normal life. Nevertheless since then, he had put him to death’. He heard the worst things struggled through, as an honest and decent about his wife and daughter as well. ‘Bitch, old trainee, and had started a family. Gradually how- whore, procuress, taken away to the penitentiary. ever, he developed problems in feeding, and suc- They should be sewn into a cowhide and sent out cumbed to hard liquor, which, 2 years before the to beg’. Among the voices he recognized were, in time of his clinical presentation, had led to onset particular, those of two policemen who lived in of his fi rst mental illness. This showed a clinical his house; but children’s voices, animal sounds, picture of acute hallucinosis similar to the one and beating of drums were mixed in as well. you have come to know through patient K. Six Dogs barked, ‘Wenceslas is coming, Wenceslas months after the fi rst attack, he was released from is coming, Wenceslas is already here’. In addition a provincial lunatic asylum as ‘recovered’ [Ed]; the patient complained that somebody had but 9 months later, his fi rst relapse occurred as sprayed something in his face through the win- suddenly as before, and he was treated in our dow and poured sulphuric acid into his cognac, clinic, for less than 3 months, before he recov- so that his head was splitting apart—because he ered. Just over 3 months later came the second felt as though his head was swollen. This patient relapse, from which he was discharged as recov- experienced the same hallucinations in the clinic: ered after 2 months’ treatment; the third deleteri- He heard voices, sometimes from the street, ous relapse came, as already mentioned, 1¼ years sometimes from openings in the air heating sys- later. During the intervening periods he always tem; he believed that he had been sprayed with regained full insight into his illness. I now remind morphine from the latter. On the ward he lay qui- you of the clinical picture that we had before us etly in bed most of the time, ‘ready for anything’ at the time; it was signifi cantly more diffi cult [W], because he anticipated at any moment to be than that of patient K. This patient could also taken for execution. Occasionally his anxiety give us well-considered information about forth- increased with fear to the level of mild motor coming events prior to his admission. But occa- restlessness when people approached him, espe- sionally his level of Affect rose to such extremes cially at night, and when he came out in a vigor- of anxiety and discomposure that he fell to his ous sweat. From the outset he had developed a 25 Lecture 25 169

‘tracking system’ [Ed]: As a hack lawyer he had defamatory and fantastic threatening content of often pleaded for his clients in submissions to the phonemes, and the preponderance of auditory state prosecutor; all his persecutions were as hallucinations. responses to this, and the police were involved as As regards the aetiology [W] of acute halluci- well. They wanted to ruin him in this way and nosis, chronic alcohol intoxication is established deprive him of his livelihood. Despite the feroc- in the vast majority of cases. However, there are ity of the episode, it was only short-lived, because rare cases where alcohol abuse can defi nitely be after 8 days, some reassurance developed, and ruled out; in one such case there was a strong gradually, over the following weeks, he gained family predisposition to mental illness. Where perfect insight into his illness. It is noted that a alcoholism is found to be the aetiology, the causal characteristic feature was that he had come vol- relationship is quite different from that in untarily to the institution because he felt unwell Delirium tremens [W], because acute hallucino- and feared the onset of Delirium tremens [W]; sis occurs mainly after serious binge drinking; and in his preceding relapse, and even earlier, he delirium on the other hand, as is well known, had made suicide attempts. Moreover, this occurs after periods of abstinence. patient, despite fi rmly-held delusions, never lost Diagnostically [W] the clinical picture can be his orientation about where he was staying and differentiated more precisely in three directions: his surroundings. A marked stage of paranoia, namely from Delirium tremens [W], the most which is of varying duration, usually lasting only common form of alcoholic psychosis; from sim- a few weeks, always seems to be present in those ple acute anxiety psychosis; and from cases cases where recovery occurs. Recovery involves which develop chronically from the outset, which elimination of the hallucinations, despite tena- I characterized earlier (pp. 102, 103) as chronic cious retention of the system of delusions already hallucinosis. The illness is easily differentiated formed. Usually however, the Affective state of from Delirium tremens [W] because of the point anxiety gradually recedes, while hallucinations of difference from the former—the fundamental remain. Nevertheless, as the general condition symptom of allopsychic disorientation in its strict returns to normal, there may, as a façade, be a sense. Yet occasionally transitional cases do chronic state of physical persecution ideas, or of occur: It may be that hallucinations in temporary a ‘tracking system’ [Ed], which, after existing for combinations tarnish the image of acute halluci- weeks, may well astonish inexperienced on- nosis and also temporarily evoke the restlessness lookers, by its sudden disappearance. A patient of associated with Delirium tremens [W]; alterna- this type, having survived an acute stage, during tively, in otherwise well-characterized Delirium which a suicide attempt had been made, could be tremens [W], the clinical picture approaches that looked after at his home, under supervision of a of acute hallucinosis, because of the preponder- warder; yet he believed his house to be surance of threatening phonemes. The differential rounded by police, and was under constant sur- diagnosis from acute anxiety psychosis can eas- veillance by telephones that had been installed, ily lead to confusion, because of the main point in and by an optical apparatus. common between the two, which we should Gentlemen! The clinical picture about which acknowledge: the abusive and fantastically you have now learnt is so common that I have no threatening character of phonemes, and that they doubt that it is already familiar to most alienists. arise out of ideas of anxiety of an autopsychic Nevertheless, it has not been emphasized strongly and allopsychic nature is undoubtedly common enough that it is an independent clinical picture, to both. But with anxiety psychoses, ideas of to be distinguished from related conditions. I still autopsychic anxiety namely those of belittlement fi nd the best description to be that in Marcel’s quite often predominate, these being grouped not thesis [ 1 ] where, in particular, the following fea- so often into phonemes, as here. Furthermore, the tures apply to the clinical picture: the acute mode whole clinical picture of acute hallucinosis is of origin, the prevalence of suicide attempts, the less-powerfully infl uenced by fl uctuations in the 170 25 Lecture 25

Affective state than in the case of acute anxiety sleep and nutrition, and to alleviate occasional psychosis. In addition however, an indication that fi ts of anxiety, using opium. In alcoholics, abso- a patient is suffering acute hallucinosis is that the lute abstinence is required—a mere restriction voices come fi rst, and states of anxiety appear [Ed] of use of alcohol is usually not enough to only later. However, although the claim is made prevent occasional excesses and consequent that in anxiety psychosis the relationship is the relapses. opposite, this relationship may be reversed in The prognosis [W] seems to be most favour- acute hallucinosis too often for it to serve any able after the fi rst attacks of this illness, apart practical use. A specifi c characteristic of acute from exceptions, which are soon to be discussed. hallucinosis seems to be the occurrence of pho- The more relapses that have occurred, the more nemes on a grand scale, their content being auto- doubtful does a favourable outcome become in psychic and allopsychic delusions of reference. the strikingly colourful clinical picture, and even- Finally, the rapid, comprehensive, and indeed tually a relapse is transformed into an incurable allopsychic falsifi cation of content, and the emer- chronic hallucinosis. It always seems that the gence of a manner of being persecuted physi- relapse can be blamed on continuing alcohol cally, and usually soon directed against specifi c abuse. As we will come to know from most sim- persons of groups of persons, are highly charac- ple psychoses, acute hallucinosis is often just the teristic of acute hallucinosis, while in acute anxi- initial, more-or-less ‘pure’ [Ed] stage of a rapidly ety psychosis, except for certain less common accelerating sensory psychosis, which deserves cases with chronic progression (see: notes, the name acute progressive hallucinosis [W]. p. 149), this is absent. The separation from Mostly, such cases of illness already show more chronic hallucinosis based on the clinical picture ominous characteristics from the outset: The is always easy [2 ], as soon as the acute mode of patients behave more adversely, are less accessi- origin has been established securely from the ble to treatment, and are fearful of being case history. The only reason for confusion here approached, without any admixtures of delirium could be the fact that an aetiology of alcoholism to explain this. Phonemes are not so predomi- also frequently applies to chronic hallucinosis, nant, but tactile, olfactory, and particularly taste while the systematic character of physical perse- hallucinations play a major role; and, correspond- cution mania—which, according to a currently ingly, the notion of poisoning is prominent, widely held opinion, should happen only in which, in practice, makes this so dangerous. chronic and incurable cases—is also a feature in Nevertheless, the predominant features of acute acute hallucinosis. Incidentally, cases of chronic hallucinosis, the preserved allopsychic orienta- alcohol-based hallucinosis seem to obtain their tion, and the absence of any formal thought dis- special character when combined with defi nite order can persist for weeks, until an increase in signs of degeneration, which are always in the defensive reactions and the occurrence of new context of chronic psychosis. symptoms marks the progression of the illness. The course of the illness [W] is satisfactorily In these cases motor symptoms always seem to characterized by the purely acute and rapid rise appear quickly, along with a state of severe con- followed by the descending path of the disease fusion with disorientation in all three areas of curve. consciousness. Treatment [W] of acute hallucinosis, at least during the period of the acute symptoms, is possible only within a mental institution. This has References been repeatedly pointed out, because of the risk of suicide. As an exception, in the paranoid 1. Marcel CNS. De la folie causée par l’abus des bois- stage, treatment is possible in private situations, sons alcoholiques [dissertation]. Paris: Imp. Rignoux; 1847 but with very careful monitoring. A strict bed 2. Wernicke C. Krankenvorstellungen vol.1, Cases 10, regime must then be imposed, to ensure adequate vol.3 Case 3, on the other hand. Lecture 26 26

• Presentation of a patient with alcoholic attentive nature of his answers the only surprise delirium is that he does not know how he came to be here. • Clinical picture He believes he has been here only today, whereas • Aetiology he was admitted in the evening, of the day before • Diagnosis yesterday. What is this place? An offi ce of the • Treatment Upper Silesian Railway Station? Does he know • Post-mortem fi ndings me? Yes, I am the chief stationmaster or station inspector. Why is he here? To provide information about his identity and possibly to be put to service. He promises faithfully to do his full duty. Lecture Who is this audience? Offi ce assistants, sched- uled to start the negotiations. The ward doctor, Gentlemen! who has treated him so far, is shown to him: ‘He The 35-year-old plumber H. (discharged as knows the gentleman very well; he is the station recovered 8 days after the presentation) who you doctor, who treated him for rheumatism some see before you initially makes an orderly, sober time ago, and had always warned him against impression. He answers questions put to him drinking’. The patient is made aware of his hos- promptly and apparently deliberately. When pital garb: ‘These are hospital clothes prescribed asked, he gives an outline of his life story, talks by the doctor because the smell of liquor perme- about his life in the military and where he served, ated his ordinary clothes, which would hinder his how he fared, the name of his captain, the com- working’. On questioning about liquor consump- missioned offi cers, a number of his comrades, tion, he says that he spends 50 Pf a day on drink, where he later found civilian work, the company but, conniving, he denies that he is a drinker. he now works for, when and who he married, Examination of the patient therefore reveals how many children he has, their names, and total misjudgement of the immediate situation, where he now lives. He has ready access to com- his understanding being replaced by terms for the monly accepted knowledge. He knows the key most common ideas in his daily life. Results of dates of the last war; knows about Bismarck, the clinical examination so far can be summa- Moltke, and the three Kaisers; his participation in rized as saying that we are dealing with a patient the election; shows himself to be well orientated who, in contrast to near-completely preserved about city streets; can describe the course of the autopsychic orientation—up to the last 2 days— Oder, etc. From his quiet way of speaking and the presents severe allopsychic disorientation.

You will notice, as soon as we leave him to gives a prompt reply of ‘about eight metres’ [Ed]. himself, how his attentive, collected, and fully He approaches a wall about two metres distant, alert nature changes: He begins with his eyes and on being invited to go up close, he then stops, wandering about, he stands up, bends down as because he can go no further. About the nature of though he were looking for something, appears to the obstacle, we can learn nothing more defi nite pick up objects, goes to the wall and manipulates from him. it with his hands, braces himself against it; in If we want to characterize the singular nature short, he seems to be completely ‘absent-minded’ of the hallucinations that we see him experienc- [W] and in a delirium. A spoken word suffi ces to ing, we recognize at once their similarity to bring him back to an attentive state and makes dream experiences. As in dreams, the hallucina- him return to his seat. tions are not limited to a single modality, but We ask him whether he recognizes the picture combine hallucinations in several senses, such on the wall (a portrait of Th. Meynert with his that entire experiences giving a full impression of signature beneath); he responds promptly that it reality are thereby witnessed, heard, and felt by is Kaiser Friedrich, and the signature the patient. We have referred to this type of expe- ‘Theodor Meynert (autograph) rience as ‘dream-like hallucinations’ (p. 122) Med. Dr. Theodor Meynert. [Ed], because of their similarity to dream experi- k. k. Hofrat o. ö. Professor a. d. Universität ences, noting that they occur in cases where a Wien etc. sleep-related clouding of the sensorium occurs, gestorben den 31. Mai 1892.’ which is why they can be summarized under the is read as follows: name of ‘twilight conditions’ [Ed]. Does such a “Theodor Mehlquot twilight condition exist in our patient? Given the Paul Theodor Theodor Mehlquot periods when the patient, left to himself, forages, k. k. Kauf . u. k. k. Prcesser a. d. Unterurdish in you must answer in the affi rmative, despite his Wunde. eyes being open, and retaining their ability to abgeordnenedeten. gesalbten 31. Mai 1892.” move; but the answer is very different for those times when the patient, fully awake and attentive, We encourage him to fi xate his gaze again on answers every question directed to him and—as the wall, and then ask him what he sees: ‘Military, he assures on questioning—experiences no hal- the Kaiser is there, they are at drill’. Does he hear lucinations. In such periods, which can be anything: ‘They are shouting Hurrah’. On ques- extended at will, he still completely misunder- tioning, and while he continues to fi xate on the stands the situation, which, quite logically, leads wall he describes all the infantry formations that us to reject the obvious assumption that his dis- should be practised. Suddenly he begins to laugh: orientation is a by-product of hallucinations, ‘Bismarck is riding on a porcupine’. Now we especially when we take note of the fact that his draw the patient’s attention to the fl oor. He is to misjudgment of the situation is a very stable see what is moving down there: He bends and characteristic, remaining the same in its content begins to collect ants and mites, which he then for hours and days, while hallucinations are sub- empties out of his hands and onto the table. Since ject to continual change. One might also think his attention is now directed to the table top, he that there is impaired function in the sense organs claims that there are also horses and Krupp’s can- themselves, for instance, as a detectable distur- nons there, but in tiny form. From his movements bance of vision and hearing that could bring it can be inferred with certainty that he believes about his disorientation. But apart from the fact in the reality of events he describes. He disre- that we see no analogous impairment in any other gards any contradictions which might occur to a mental patients in suitable cases, we are led to a healthy person, with remarkable lack of judg- direct proof that no such disorder is present, our ment. Thus, when asked in relation to the military patient having normal visual and auditory acuity. drill how far apart the soldiers should stand, he So this patient gives us an instructive example of 26 Lecture 26 173 disturbed secondary identifi cation, a relatively fumbles with his clothing, begins to undress, rare opportunity to observe, as a spectator, the knocks on the wall, braces himself against it, rubs very process of this identifi cation disorder. and polishes it, and is constantly busy. All such What we see here in uncommonly pure form movements are indeed accompanied by tremors, should be classed as psychosensory anaesthesia but they are functional and coordinated, and or paraesthesia. The allopsychic disorientation obviously adapted to certain situations in which can be understood easily as a necessary conse- the patient believes he has found himself. They quence of the disturbance of identifi cation. His stop instantly, as soon as we call him, and with failure to recognize people and situations hap- sharp questioning he is brought back to full con- pens according to principles emphasized earlier sciousness. As you know, people tend to desig- (pp. 140, 141), and undoubtedly falls under the nate this physical restlessness as ‘occupational heading of optical illusions. However, this fail- delirium’ [Ed], which is thus fully explained by ure—his non-recognition—remains as a very the ever-changing combined hallucinations. remarkable feature, because concepts such as the Motor symptoms occurring independently are hospital, the clinic, and the auditorium are well foreign to typical Delirium tremens [W]. known and familiar to him—as could be shown Also, we are entitled to attribute another main in a later experiment. symptom of Delirium tremens [W]—total insom- Gentlemen! As you will have noticed we are nia—to the stimulating effect of the dream-like dealing here with a typical case of Delirium tre- hallucinations. At least the onset of spontaneous mens [W]. We will therefore not go wrong if we sleep defi nes, quite literally, the period when the attribute such symptoms to the toxic effects of combined hallucinations cease, while the allo- alcohol. This toxic effect can, of course, become psychic disorientation and belief in the reality of manifest only by either irritating or paralyzing the the dream-like experiences may continue for nerve elements. Apparently we see in his allopsy- days—but of course with cessation of pre- chic disorientation a failure corresponding to existing restlessness. paralysis; and we may assume that those compli- We now return to our patient again, to demon- cated arrangements of mutually associated mem- strate several other important symptoms. On our ory images which allow recognition of the very fi rst examination you will have been sur- immediate situation have become paralyzed or prised by the quavering, uneven tone of his voice; inexcitable. It is then perhaps not accidental that likewise, you will probably have noticed during the irritant effect becomes so clear, in that analo- his occupational delirium the conspicuous tremor gous arrays of memory images, corresponding to in his movements. When he speaks, that same whole situations and experiences, emerge sponta- tremor becomes noticeable in his lips, and all neously, and with abnormal clarity. When such over his face. As you can see, when his tongue is paralysis and irritation combine to infl uence—as protruded, there is also a marked tremor. But this we say—these allopsychic elements of conscious- is not the only speech disorder: We also notice ness, we see the specifi c peculiarity of this illness. that, with all the more diffi cult words, there is a It is almost pathognomonic for Delirium tre- coarser type of speech disorder, normally found mens [W] that we fi nd, in sharp contrast, well- only in two other well-known diseases, meningi- preserved autopsychic orientation. Only at the tis and progressive paralysis. This is called time of crisis is there any autopsychic defi cit. syllable- stumbling. In order to establish this Incidentally, the above features do not exhaust symptom we use certain test words, in an expedi- the symptoms of Delirium tremens [W]. In fact, ent manner, such as ‘civilization’ [Ed], ‘army right now, during my discussion of this case you reorganization’ [Ed], ‘Guiglelminetti’ [Ed], and have the opportunity to observe another impor- ‘extraterritoriality’ [Ed]. Also, we encounter tant primary symptom, namely the peculiar rest- hints of paraphasias in our patient, as soon as we lessness of this patient. Left to himself, he is subject him to a reading test; and the writing constantly doing something: He looks around, test gives a very similar result, as with many 174 26 Lecture 26

paralytics, namely ‘paragraphia’ [Ed]. Finally, I haunting pursuer, the rising and rushing water, must mention that many patients, when protrud- snakes, crabs, rats, and other disgusting vermin, ing their tongue, are clumsy and awkward in a are often the origin of ruthless attempts to escape manner that is otherwise intrinsic only to the or become inducements to suicide attempts. above-mentioned severe illnesses. As you will When alcohol abuse deserves to be punished, it is have seen, the patient has a somewhat wry face: bestowed in abundance, which leads to delirium The right Facialis muscle at rest has less tone than with such fearful colouring. the left, and tests of function also reveal a sag of The patient’s restlessness is then transferred cheek musculature on the right side. Not infre- with similar characteristics to these hallucina- quently, deviation of the tongue is also observed, tions: rats, snakes, and toads are warded off, indicating unilateral hypoglossal paresis. thrown out, stripped; sitting and swimming In addition to these direct symptoms of paral- movements are made, any obstacle in the way of ysis, the general frailty of the patient catches our his attempts is moved with the utmost effort, or attention. Since he has served in the army, we the patient slaves away—lying exposed in bed— make him perform an about-turn and note that he to rip or slough off any alleged fetters he feels. staggers. Likewise, his movements when per- Such anxious deliria are accompanied by profuse forming more complex tasks, such as climbing perspiration, as an easily understandable conse- on a chair, are awkward and clumsy. The hall- quence of purposeless muscular work. mark of a more severe clinical picture is then In general, such delirious patients only rarely confi rmed by his accelerated pulse (120), which express themselves verbally. In most cases patients is small and soft, with a demonstrable fever (tem- limit themselves to slight murmurs or remain in perature of 38.5°), a heavily coated tongue, and complete silence, giving voice only occasionally, slight tenderness in the stomach region. Since all with commands or cries for help, showing that other organs were found to be healthy and the they are not mere spectators but are themselves stools showed no abnormal constituents, we set- acting within their pseudo-experiences. tle on the presence of a febrile gastric catarrh. The redeeming approach of sleep thus tends Because of the conspicuous heart failure due to to signify that the Affects of such pseudo- the patient’s nutritional status, we must regard experiences, as well as the restlessness, gradu- the prognosis as doubtful. However, we will ally subside, and moments appear when a patient attempt to strengthen his cardiac function by is clearly drowsy, until, fi nally he is over- administering camphor and counter any immi- whelmed by real deep sleep, often in very nent collapse from strong liquor. uncomfortable positions, a sleep in which there The clinical picture presented by our patient is may be some initial twitching movements, but related to his predominantly cheerful, jovial, and which gradually becomes of such depth that jocular mood—the same character we saw in his even the most frightening noises and intense combined hallucinations: Think no further than shaking fail to rouse him; and then, any neces- ‘Bismarck on a porcupine’ [Ed]. This predomi- sary moving or change of position can be under- nantly bright colouration indeed seems to fi t the taken without affecting his sleep. The duration majority of cases, but is certainly not universal. of the sleep is often quite extraordinary—up to In a large minority of cases, especially—so it 24 h or more. Light rhonchi and stertorous seems—those with a severe course, fearful ideas sounds when breathing do not disturb him, if no and hallucinations outweigh the others: the devil, other signs of danger are present. hangman, black men, robbers, wild animals are Gentlemen! In the patient just presented, you hallucinated, and matching fearful scenes are are witness to a typical example of that acute experienced, or even the walls closing together or mental illness that bears the name Delirium tre- threatening to collapse, water rising higher and mens [W] or Delirium potatorum [W]. Prevalent higher, and so on. Combined tactile and auditory as this illness is, there is a complete lack of any hallucinations, such as a fi re, an approaching and accurate description of its essential features [1 ]. 26 Lecture 26 175

Therefore, let us pause for a moment on this mental illness picture under very different condi- subject. The fundamental importance of Delirium tions, consider the following: tremens [W] is based in part on its well-known aetiology. Delirium tremens [W] can be classed 1. In meningitis with its main focus on the con- aetiologically as the most common form of acute vexity of the hemispheres: Here it is indeed alcoholic intoxication psychosis, amongst which usually found, as in febrile delirium of infec- you should also include the most acute form of tious diseases, that when the above picture of alcoholic psychosis: a pathological state of psychosis is reached, an increase of bodily intoxication. symptoms is also required in order to enable This latter pathological state, a special form of the diagnosis of meningitis to be made; how- transitory psychoses, should undoubtedly be con- ever, in exceptional cases, where these other strued as an actual psychosis; however, it differs symptoms are not recognized for weeks, the from Delirium tremens [W], only in its duration clinical picture of Delirium tremens [W] is all of no more than a few hours, compared to the that exists, while autopsy reveals clear fi nd- latter which always lasts for at least several days. ings of meningitis on the convexity of the I will fi nd an opportunity later to return to the brain. In one case of this kind, diagnosis was matching symptoms of pathological intoxication fi nally made, shortly before death, by the fi nd- when I take the opportunity of talking about simi- ing of a blood-red discolouration of the lar transitory psychoses. However, apart from Papilla optica [W]. such transitory psychoses and Delirium tremens 2. Furthermore, the picture of Delirium tremens [W], the same poison produces two quite differ- [W] can be produced by other intoxicants, ent illnesses, namely acute hallucinosis (see: the such as chloroform, ether, and belladonna. previous lecture) and the so-called polyneuritic 3. Every stage of progressive paralysis can taken psychosis, two acute mental illnesses where we on the appearance of Delirium tremens [W]. cannot deny the aetiological connection with 4. Sometimes acute presbyophrenia (see: the fol- chronic alcohol poisoning, any more than we can lowing lecture) cannot be distinguished from deny the other fact, that the same illnesses can be Delirium [W]. seen with totally different aetiology. We will see 5. In very rare cases Delirium tremens [W] later, when discussing polyneuritic psychosis, occurs as the fi rst acute episode of a subse- that this illness coincides with Delirium tremens quent chronically progressive psychosis [W] in terms of its respective allopsychic disori- characterized by grandiose followed by perse- entation. You might want to conclude from this cutory delusions with intact formal logic. that allopsychic disorientation and the toxic effects of alcohol have an unconditional cause- Let us return to the specifi c aetiology of and-effect relationship to each other. However, Delirium tremens [W]: You are well aware that such a conclusion would not be justifi ed because the present illness occurs only as a consequence on the one hand acute hallucinosis, even if of of long-continued alcohol abuse and can itself alcoholic aetiology, lacks this symptom, and, on thus be considered as a sign of alcoholic degen- the other hand, the symptom is present in a pro- eration. In this regard, Delirium tremens [W] nounced way in presbyophrenia, the mental ill- seemingly lays claim to being a symptom of ness whose aetiology is specifi c to senility. These degeneration, in a more exclusive way than con- remarks may show you how wrong it is to attempt ditions of pathological intoxication occurring to classify mental illnesses purely on their aetio- occasionally in individuals prone to nervous dis- logical basis (p. 104). The accuracy of this view eases, after a single session of drinking unaccus- is proven most clearly by the fact that even tomed quantities of alcohol. A second factor, Delirium tremens [W] is not exclusively alco- taken to have a signifi cance similar to alcohol holic in origin. At least, to reinforce the facts, if abuse, applies quite generally, when any kind of you wanted to deny the occurrence of the same external condition—usually illness, or surgical 176 26 Lecture 26 intervention—brings about forced abstinence from this, the condition of the heart should also be from alcohol. This is generally taken as the usual identifi ed as a principal factor, even in uncompli- cause of the outbreak of such a disorder, and it is cated delirium, for, in a not-insignifi cant fraction customary to take this into account; so that mod- of such cases, after apparently good general fi nd- erate further liquor consumption is prescribed ings, the end is a sudden, quite unpredicted col- whenever injuries or intercurrent illnesses occur lapse. Then, when the autopsy fails to show major in alcoholics. In my experience however, such an degeneration of the heart—which sometimes hap- opportunistic precursor is often absent, and we pens—the only assumption we have left is that of encounter many cases where Delirium tremens an effective envenomation of the heart. [W] occurs unrelated to any complication, not Diagnosis [W] is easy if you have the whole even gastritis. On the other hand such a compli- picture to survey, as just described. The picture is cation, when detected, does not always lead us to so characteristic that experienced clinicians permit continued consumption of liquor in the would hardly ever go wrong in making the cor- habitual drunkard. Even so the damage done by rect diagnosis from the overall impression given enforced abstinence applies in the majority of by patients. However, only a detailed analysis cases. That this is quite different from acute hal- would give you a more secure grasp, and here it lucinosis in alcoholics has been emphasized pre- is particularly the contrast between well- viously (p. 170). preserved autopsychic orientation and severe Regarding complications, [W] epilepsy allopsychic disorientation that provides a deci- requires special mention. Epileptic seizures in sive criterion. No other illness that I know pro- tipplers are a sign of alcohol-induced degenera- vides such a striking contrast. Change in the state tion in the brain, just as is Delirium tremens [W]. of consciousness provides an immediate differ- According to experiences in our clinic, there is a entiation, according to whether patients are left to certain regularity in their timing, since they tend themselves, or their attention is held by talking to occur 36–48 h before the outbreak of delirium with them, asking questions, or while examining following an excess; but if complete abstinence them. Their facility for quite prompt, attentive has been achieved, seizures are permanently dialogue might be found in no other condition avoided. In the clinic itself, alcohol-related epi- where there is equally deep, dream-like fogging leptic seizures are always limited to the fi rst few of consciousness. In post-epileptic twilight states, days following admission. If, as often happens, this facility is particularly absent. Finally, the we therefore have to document during admission tremor and its admixture with the above- the aftermath of an epileptic process—the mentioned signs of the involvement of the projec- tongue-biting etc.—then we have the task, if at tion system, namely the speech disorder, can be all possible, of ensuring complete abstinence. used for diagnosis. Bonhöffer has pointed this out, as almost routine For differential diagnosis, the conditions men- practice. tioned above (p. 174) come into play, especially I need not point out the myriad other random the rare cases of meningitis of the convexity and complications or incidental causes which come the far more common progressive paralysis. into question when treating Delirium tremens Gentlemen! Treatment [W] of Delirium tre- [W]. Amongst the top few here is pneumonia, a mens [W] provides a physician with the most particularly dangerous development at times of diverse tasks, depending on the type of complica- critical deterioration. Whether the course is tion or their occasioning causes. I will have to favourable or unfavourable in such cases depends neglect further comment here, restricting myself critically on the behaviour of cardiac muscle. If, just to answering the following fundamental as is common, this reaches a severe grade, as a questions: When, and based on what indications, result of the prevailing degeneration in a drunk- is it necessary: (1) to administer sleeping aids, ard, then fatal pulmonary oedema is often and (2) to isolate patients? We need not discuss unavoidable despite all stimulants. But apart that coercive methods should not be used on 26 Lecture 26 177 delirious patients, or on other mental patients; their surroundings. But even in the latter case, an surgical complications alone justify this prohibi- experienced warder permanently stationed by the tion, yet some circumstances may make it man- bed is often preferable to seclusion. For the vast datory to break this rule. majority of patients, bed treatment at a nursing Gentlemen! Administration of hypnotics in station is the only proper method, and at a our clinic happens, as I already mentioned, only moment’s notice, can be stopped, and shifted to as an exception, because we have learned that seclusion if you are satisfi ed that calm will pre- prematurely induced sleep completely lacks the vail, which is currently delayed or prevented just effectiveness of naturally occurring sleep and by effects of the surroundings. Most patients does not prevent delirium following its usual sleep, as mentioned above, at the monitoring course. We have even seen interruptions by sleep station and continue to sleep despite all the being ineffective in this. If everything takes its disturbances [2 ]. usual course, we wait until spontaneous sleep Pathological fi ndings [W] in Delirium tre- occurs. But in the case of patients who come into mens [W] point to a certain kinship, according to treatment with their strength or nutritional status clinical symptoms, between this illness and pro- already reduced, we induce sleep as often as gressive paralysis. This similarity is claimed deemed necessary, according to their status; and because in Delirium tremens [W] the projection we prefer to use paraldehyde (dose 3–6 g), and system is also affected, as it is in progressive under some circumstances also chloral hydrate paralysis. Resulting symptoms include tremor in (1.5–3 g) or opium or morphine injections (on the vocal and speech musculature, stumbling average 0.1 of the former, 0.01 of morphine). If over syllables, hints of paraphasias, awkwardness the delirium becomes prolonged, without the nor- of tongue and mouth movements, the often- mal fatigue setting in, or the pulse begins to present deviation of the tongue, and the awk- become soft and small, or other signs of exhaus- wardness of more complex movements. tion appear, we see this as an indication for Gentlemen! If you remember our fi rst clinical administering paraldehyde, and have never seen meetings, when I sought to give you an idea of an adverse effect, even with larger doses of this the possible localization of mental illnesses agent, up to 10 g. Depending on this, morphine or (p. 7), you will know that such a mixture of opium may be indicated while chloral, due to its symptoms points to the involvement of the pro- hypotensive effect, will naturally tend to be jection system, which, for us, was the character- avoided. Rather, in particularly diffi cult situa- istic of progressive paralysis. We now recognize tions, inhalation of pure ether can be appropriate in Delirium tremens [W] an illness that in this to achieve sedation and sleep. regard is similar to progressive paralysis. If we now turn to the second question, that of Accordingly, it is also possible at post-mortem seclusion, under some circumstances the answer [W] to detect the disease in the projection sys- may depend on whether a suitable seclusion room tem. This is seen at least in those severe cases, is available. It cannot be suffi ciently stressed that where there are no other complications, and lead any risk of suicide or self-harm inherent to the to death. In the cortex of the central gyrus and in seclusion room must be avoided, so that not just Broca’s gyrus, abundant signs can be found of any room, but only one provided with all safe- incipient white matter atrophy, which are also guards against this danger must be chosen, such restricted to the radial fi bres from the cortex as those available in every lunatic institution. In becoming thicker towards the medullary pyra- general, seclusion comes into question only with mid, leaving the tangentially running ones within delirium coloured by anxiety; and it is then the cortex intact. A similar medullary degenera- required if the anxiety increases substantially or is tion has become apparent in the vermiform pro- maintained, due to misunderstandings on the part cess of the cerebellum, indeed exclusively in the of the ward staff, or when patients—supposedly white matter layer. More sparse but nevertheless defending themselves—make sudden attacks on undoubted signs of medullary decay are then 178 26 Lecture 26 found in the pyramidal tracts and dorsal columns chronic malfunction symptoms, not stimulus of the spinal cord. It is thanks to Bonhöffer [3 ] symptoms. However, the combined hallucina- that such important fi ndings have been made, and tions seem to refer to stimulus events in the sen- their signifi cance appreciated. sory projection fi elds. Broca’s gyrus and central Bonhöffer’s fi ndings have been raised in a few sulci, as known sources of the motor projection particularly diffi cult cases that also distinguished system, revealed the expected changes, accord- themselves clinically, where the patients appeared ing to the observed symptoms of paralysis. to have lost the spatial orientation of their body. You can read the relevant description in the original. Bonhöffer suspected that this phenomenon References was related to an alteration in the cerebellum. In any case, it remains extremely instructive that the 1. Bonhöffer K. Der Geisteszustand des actual sensory projection fi elds present no such Alkoholdeliranten. Psych Abhandl 6 Breslau: changes of this kind, a fi nding which can be gen- Schletter; 1898. eralized without compunction from the type of 2. Wernicke C. Krankenvorstellung vol. 1, Case 4 is also an example of Delirium tremens . cases that have come to autopsy. This applies 3. Bonhöffer K. Klinische und anatomische Beiträge zur however, insofar as we quite generally have Kenntnis der Alkoholdelirien. Monatsschr Psychiatr to expect tangible pathological fi ndings from Neurol. 1897;1:229–51. Lecture 27 27

• Chronic and protracted alcoholic delirium chronic nature of these cases shows certain • Polyneuritic psychosis features that can probably be put down to an • Presbyophrenia added component of alcoholic degeneration. • A case of acute asymbolic allopsychosis These features include very severe loss of memory retention (but with a relatively intact store of past memory), disorientation—probably derived from this with respect to the immediate situation, Lecture and occurrence of confabulations, whether these are reported spontaneously, or are invented by Gentlemen! the patients themselves to ﬁ ll in noticeable lapses I have already mentioned that a short-lived in memory for the recent past. It has already been paranoid stage is often observed after a person in emphasized that acute symptoms—hallucina- an alcoholic delirium wakes from the critical tions, and resulting restlessness and insomnia— sleep. This phase seldom lasts longer than hours, are absent from this chronic delirium. It is still or 2 days at most, and is well characterized by possible, even in chronic alcoholic delirium, for continued impairment of orientation and falsiﬁ - health to be restored if the patient’s general con- cation of consciousness, and by belief in the lived dition can be improved, and, with continued reality of the dream experiences. However, in abstinence, other signs of cachexia and degenera- exceptional cases, even after an intervening stage tion can be reduced. If this favourable outcome of sleep, a state essentially the same as this para- cannot be achieved, dementia ensues, with pro- noid stage can persist for weeks, months, and gressive dwindling of memory content and grad- beyond—cases that can be described as ‘chronic ual loss of initiative. alcoholic delirium’ [Ed] [ 1 ]. Chronic alcoholic Protracted Delirium tremens [W] is to be dis- delirium [W] develops either in the manner of an tinguished from chronic delirium, and is simi- acute Delirium tremens [W] or as such a state larly curable. Here, acute symptoms of combined which does not proceed with a distinct form, but hallucinations and restlessness can often persist more often as repeated abortive episodes limited for several weeks. Any debilitating factor, such to shorter periods of a few hours or less. An ini- as chronic suppurations, tuberculous bone pro- tial stage occurs, of variable duration, mixed in cesses, chronic pulmonary tuberculosis, or even with traces to varying degrees of acute delirium, cirrhosis of the liver, can form the basis for such which never seem to be totally absent in cases of a protracted course. An alternative outcome for chronic alcoholic delirium. Furthermore, the this protracted delirium, as seen in such cases, is

© Springer International Publishing Switzerland 2015 179 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_27 180 27 Lecture 27 often death resulting from the underlying debili- before. In like manner, neither did she know how tating diseases. Protracted delirium can form a she had come to the auditorium, and that she had transition to so-called inanition deliria [Ed], but been carried up two stories, nor did she know the is usually differentiated from these. time of day and whether she had had lunch or not. Gentlemen! Our knowledge of chronic However, she thought that the latter was possible Delirium tremens [W] prepares us to learn about because she did not feel hungry. When I asked two further well-characterized types of illness, what she had done yesterday, she declared ini- without my having to present you with examples. tially that she would have to think about this, but It will suffi ce to remind you of two earlier then recounted with all certainty and detail about patients. You will remember the 41-year-old wife an excursion with the family of the feudal estate of a master tailor S., who I presented to you some to a local brewery and park in a neighbouring time ago as an example of polyneuritic psychosis village. She also recounted various experiences [W], and who had to be carried to bed because from past days. She remembered precisely hav- she was unable to walk, due to an atrophic paral- ing put the children to bed the night before. She ysis of her legs of a polyneuritic nature. It was had been with this feudal lord for 16 years and easy to gather psychological evidence from her had gone back temporarily because the lord was because she showed herself to be completely unhappy with his staff and she was unable to help level-headed and attentive, and examining her her husband during the time of unemployment. level of attentiveness by testing her domains of Here we encountered the third conspicuous experience gave normal fi ndings. More surpris- symptom: confabulation, or accretions of falsi- ingly, we soon encountered a combination of four fi ed memory. You will recall that I alluded to the familiar psychotic symptoms. The fi rst was allo- connection of this symptom with thought defi - psychic disorientation: The patient had no idea cits. However, the extent of this memory loss where she was; she believed that she was a sub- surprised us, for it extended far beyond the period ject of an earlier fi efdom, and in the country as a of acute illness, going back years. There could be temporary assistant; looking out of the window no doubt about the fact that such a defi cit she recognized the towers of the neighbouring existed—as revealed most strikingly when I town of R.; she mistook me for the family doctor, pointed out to the patient the contradiction the attendant nurse as his maid, and the medical between the paralysis of her legs and that she assistant as the son of her sovereign. She regarded claimed to have gone for a walk for several hours the current scenario as the session in a law court yesterday. The origin of the paralysis was a total where she was to be heard; in the auditorium she mystery to her. believed that she recognized members of the Gentlemen! As you will remember, I have court familiar to her from R., and several youth- pointed out that such a loss of memory for the ful acquaintances. She instantly recognized all duration of her illness, that is, for the period when other concrete objects and utensils. Her second her retentiveness in memory had been lost, symptom was a highly signifi cant defi cit in mem- appeared easily understandable (p. 48), but also ory retention. The patient forgot in a moment that a so-called retroactive amnesia (p. 40) was what she had just said. A three-digit number, a evident in this case. The patient still believed foreign-sounding word which she should have that, as before, she lived in R., whereas she had retained after interposing a short question, was actually moved to Breslau with her husband sev- already forgotten, and a little while later, she had eral years ago. She remembered all too well her even forgotten that such a task had been set up. marriage and her maintaining friendly relations When she was shown an ophthalmoscope—an with her former community of R. Likewise, she instrument unknown to her—a short time later, gave entirely correct information from further she looked at it with the same interest that she back in her past life. She could easily prove that had been shown on the fi rst occasion, and she still retained knowledge learned at school, declared that she had never seen anything like it insofar as could be expected of people of her 27 Lecture 27 181 age and circumstances. Admittedly, in mental will explain the fact that no trace of disarray was arithmetic she failed completely, because, despite present, in obvious contrast to the severe allopsy- reliable multiplication of one number, she always chic disorientation. However, a mood of fear can forgot the other; however, working on paper she be inferred from her misjudgment of the sur- could solve arithmetic problems with several- roundings as a local court, this being easily digit numbers properly. understood, given the circumstances of a clinical As for the case history, we learned that at the presentation. Similarly, the totally apathetic and time she presented, this very ill, almost waxy- impassive behaviour of the patient in the ward, looking woman had suffered for 6 months from without Affect, indicates a certain mental defi cit. frequent uterine bleeding. A particularly heavy It remains only to say a few words on the pre- blood loss over 4 weeks had preceded the acute cise time of origin of the illness. In our case, we outbreak of her illness. Weakness in her legs had lacked suffi cient information about it; and, to started earlier, with pain and paraesthesia. We judge solely from our own observations, the typi- obtained a report of the exact time of onset of her cal clinical picture of a hyperkinetic motility psy- acute mental disorder, which was very inaccu- chosis had been occurring intermittently. From rate. Apparently, a short-lived state of mental dis- experience of other similar cases, it seems as order had occurred, at times even of delirious though, most often, a form of twilight state exists, excitement, especially at night. Here, only in the with motor restlessness and hallucinations, fi rst few days did she show an exquisitely mostly reminiscent of delirium tremens [W], but coloured motor restlessness (with simultaneous not following the typical course; that is, a deliri- mytacism!) Then, gradually, the state that I could ous stage occurred in the acute phase of illness, to demonstrate to you began to emerge; and it has which is added the more chronic state as now existed virtually unchanged for months, but described, usually of much longer duration. This has gradually merged into an acceptable level of then decays more gradually. In my opinion, this recovery, since, 6 months later, the patient could latter stage alone is characteristic and decisive in be discharged back home as ‘improved’ [Ed]. making a diagnosis, due to its specifi c make-up As for the aetiology of the case, we initially from the above defi nitely observable symptoms. emphasized mainly the patient’s repeated blood Regarding the ‘polyneuritic’ [Ed] symptoms of loss. This was supported not only by her medical the illness, in our case they were very pronounced history and appearance but also by the blood test, and had led to a total inability to walk and to for we could determine a haemoglobin content stand. The paralysis was fl accid, tendon refl exes (Gowers) [2 ] of only 55 %. Later however, we were absent, and musculature was universally gained useful information from the patient that very pressure, sensitive—with quadriceps and over the last couple of years she had been drink- peroneus muscles predominantly affected, bilat- ing a lot of Bavarian beer, and also, in recent erally. In the muscles most affected there were times, large quantities of corn schnapps and degenerative changes, and everywhere marked cognac. reduction in electrical excitability. Sensitivity Gentlemen! As you can see, we are dealing was seen most clearly at the terminal phalanges, with a clinical picture that, despite its acute and position sense was also particularly involved. development, has seen subsequent addition of On discharge from the hospital, restoration of certain defi cit symptoms. I mean the loss of function was already so far advanced that she retentiveness in memory, the retroactive amnesia, could stand and walk without support. and the severe memory impairment. Therefore The picture of polyneuritis is not always as you probably cannot speak of actual dementia, if pronounced as in this case; more commonly there you want to be strict with this term. The animated is only a diffuse wasting of muscles, slight reduc- face, the attentive character, and the demonstration of electrical excitability and tendon refl exes, bly well-preserved attention are conclusive proof slight tenderness of the muscles, and a tendency in this regard. Nonetheless, the existing defi cit to spasm. In other cases, even the polyneuritis, 182 27 Lecture 27 from where we get the name, is completely delirious form of polyneuritic psychosis. On absent from the presenting psychosis, a point to examination it was revealed that the four symp- which I will return. For the time being, let us hold toms peculiar to the chronic stage were simulta- fast to the disease concept of ‘polyneuritic psy- neously present. A similar case, still under my chosis’ [Ed], since, if the harmful causative agent care, had been combined with major surgery, a is removed, the prognosis is generally favour- gastroenterostomosis that had been successful, able. In the vast majority of cases, restitution and is currently convalescent. As in these two develops, even if only very slowly. However, a cases, an association of severe psychic effects proportion of cases do become lethal within a and physical interventions triggered the onset of few weeks. Without doubt, this course of events illness; thus, a proportion of cases characterized depends on the causative agent responsible, and it as so-called symptomatic [Ed] or inanition psy- is precisely in this respect that alcoholic poison- choses [Ed] offers the same clinical picture as ing seems to herald a relatively favourable out- polyneuritic psychosis. However the most con- come. Here it seems to follow a course similar to vincing example of our viewpoint on polyneu- that of the polyneuritis itself, which, as you know, ritic psychosis is the virtually identical clinical most often underlies the deleterious clinical pic- picture of presbyophrenia. ture of acute worsening paralysis or Landry’s [3 ] Presbyophrenia [W] is a specifi c mental illness paralysis. Oddly enough, I have never seen such of old age, in the sense and with the restriction severe cases of polyneuritis accompanied by with which we recognize aetiological classifi ca- polyneuritic psychosis. Incidentally, given the tion of mental illnesses. That is, if we differentiate number of cases, alcohol poisoning is probably it from polyneuritic psychosis, it is encountered the fi rst to be considered, followed by the metal- exclusively among the elderly, and in many cases, lic poisons, namely lead and arsenic [4 ]. no alternative aetiology can be found. However, it Gentlemen! I have repeatedly pointed out that, makes up but a substantial fraction of the psycho- in psychiatry, correlations between the clinical ses associated with senescence. Like polyneuritic picture and aetiology are recognizable only to the psychosis it occurs in two forms: an acute deliri- extent that certain clinical conditions have a ten- ous form, and a chronic one. The latter consists of dency [Ed] to follow certain harmful agents. On the same components as the above-described pic- the other hand an exclusive [Ed] association of ture of polyneuritic psychosis; we can consider it this nature is refuted by daily experience. So it is to be incurable, even after long-persisting treat- with the building up of the clinical picture of ment. You encounter the same symptoms of allo- polyneuritic psychosis, which is initially purely psychic disorientation without disarray and loss of empirical. Granted, this very naming is inclusive, ability to retain memory, but with retained atten- in that very different noxious agents can be con- tiveness, confabulation, and retroactive amnesia. sidered to be the aetiology, just as for polyneuri- In addition there are often changes of mood, espe- tis. However, we again see certain proof of the cially of two varieties: One consists of euphoria, correctness of our position on this, because which is incongruent in relation to reality, and the exactly the same clinical picture can be encoun- other a ‘choleric’ [Ed] mood, these two being per- tered without polyneuritis, as I already men- manently intermingled. You will remember the tioned. This is especially true of the variety where two examples that I demonstrated to you. One was delirium is manifest. I recall such a case, involv- 78-year-old Mrs H., who expressed her well-being ing a doctor’s wife, whose child was leaning by a certain talkativeness and, because she still against the compartment door during a train jour- considered herself to be a young girl, showed fi ts ney - the door not being completely closed - and of bashfulness, which was comic in effect, given the child fell out; while she, in her fear, could do her age. The other, 84-year-old Mrs K., is memo- nothing better than leap after him. She suffered a rable to you as markedly loudmouthed, who pro- serious head injury and, after she regained con- jected herself with the fi lthiest manner of speech, sciousness, presented the typical picture of the and accused her neighbourhood of the most 27 Lecture 27 183

fantastic mistreatment. Apparently these were presented only an average picture of polyneuritic confabulated memories, based on misinterpreted psychosis, but on a second occasion as asymbolia. experiences and hypochondriacal sensations. Both However, an independent asymbolic form of patients had in common the fact that, by their acute allopsychosis does [Ed] occur, albeit very facial expression, gestures, verbal utterances, and rarely, as the following case shows. It involves a their energy, any suspicion of pre- existing demen- 43-year-old teacher, N., who was admitted to the tia is immediately refuted. The acute or delirious clinic on 10 February 1887 and 7 weeks later (29 form of presbyophrenia was essentially the same March) was discharged as recovered. The out- as the chronic form, with the possible exception of break of his illness occurred extremely acutely, retroactive amnesia. However, there is also a mod- after the eventful nursing and then death of his erate degree of restlessness, insomnia, and inter- wife, which had severely affected the patient. For mittent hallucinations, especially in the visual several days subsequently he had wandered sense. On the whole, it suggests a signifi cantly around neighbouring villages totally disorien- attenuated and correspondingly long-drawn-out tated, with vivid hallucinations; and he was Delirium tremens [W]. I remember a case of this brought to the clinic by his village friends bound sort, where, in a 76-year-old woman—previously hand and foot. In the clinic he behaved quite very active—the illness proceeded so favourably badly, only rarely and unwillingly giving us any that the patient could continue a very extensive information, and apparently misjudging the staff business for many years. In cases that recover, and the situation. This could be seen not only which occurs frequently, the duration of the illness from his sparse answers, but also mainly from his is from 4 to 8 weeks. In other cases it merges behaviour. While he apparently saw and heard imperceptibly into the chronic form, or it remains adequately, presented no neurological symptoms, as a simple senile dementia, which is also always and had full control over his movements, use of the end stage of the chronic form. the most common objects appeared totally unfa- Gentlemen! The cases of disease that you have miliar to him. He put his head into the food bowl, come to know so far have the common feature of tried to put his pants on as a shirt, and did not allopsychic disorientation and therefore deserve know what to do with a knife, fork, and spoon. the name acute allopsychoses. Among these, Later he learned to recognize the food bowl, and acute hallucinosis stands out by the fact that it is held it in his hands. He found himself constantly the process of activation by hallucinations, which, in an Affective state of allopsychic disarray, which over time, leads to disorientation, so that the ini- stayed within moderate limits. However, because tial paranoid stage allows disorientation to emerge it usually led to diffi cult behavior in this patient, it in a pure form. On the other hand, in Delirium hindered detailed examination of his mental con- tremens [W], polyneuritic psychosis, and presby- dition. This much can nevertheless be said with ophrenia, allopsychic disorientation from here on certainty, that not even traces of aphasia were ever appears as a symptom of the actual breakdown. I seen. From his occasional responses it could also refer you to earlier presentations with regard to be concluded that for simpler questions his com- delirium tremens [W]. Regarding polyneuritic prehension of speech remained intact. With regard psychosis and presbyophrenia, one is tempted to to motor behaviour a corresponding state of mod- incorporate general ability to retain memory loss erate restlessness prevailed, without addition of along with allopsychic disorientation for both ill- any actual motor symptoms, but mostly matching nesses. We learn that this is, unequivocally, not the idea of helpless motor impulses. He shifted [Ed] the case (for example) in a case of post- back and forth in his bed, adopted the strangest epileptic allopsychosis [5 ] with good memory positions, built a kind of cage with pieces of mat- retention. Also, it sometimes happens that the tress, fumbled with his shirt, took it off, twisted allopsychic disorientation seems to be aggravated the blankets together, etc. It was very diffi cult to to the point of ‘asymbolia’ [6 ] [Ed]. Thus, I could move him when getting him out of bed, appar- demonstrate a patient who had previously ently because he had become familiar with this 184 27 Lecture 27 abode. A pronounced anxious Affective state was References seen only when a change of his situation was brought about, while at other times, a moderate 1. Kiefer E. Über einige Falle von chronischen state of disarrayed Affect, or even an air of fl at- Alkoholdelirien [dissertation]. Breslau; 1890. 2. Gowers WR. Apparatus for the clinical estimation tened Affect, was all that could be seen. The of haemoglobin. Trans Clin Soc Lond. 1879;12: patient had to be coerced into looking after his 64–7. bodily needs; otherwise he soiled himself, appar- 3. Landry de Thézillat JBO. Paralysies. Gaz Hebd de ently the result of disorientation. Hallucinations Méd 1859;6:472–4. 4. Wernicke C. Krankenvorstellungen aus der could not be ruled out completely, although they psychiatrischen Klinik in Breslau. Breslau: Schletter; were certainly not abundant, and in no way the 1899. vol. 1, Case 17, and vol.2 Case 9 are cases of forerunner of his periods of restlessness. With polyneuritic psychoses. remission of such symptoms, this patient started 5. Wernicke C. Krankenvorstellung vol. 2, Case 7. 6. Wernicke C. Krankenvorstellung vol. 2, Case 9. to convalesce. Lecture 28 28

• A case of acute autopsychosis based on hysteria. secondary identifi cation in the third area of • Description of autopsychic disarray. consciousness that we differentiated—that of • Examples of alternating consciousness, the personhood. In other words, just as our schema ‘second state’ of French authors. assumed centripetal conduction extending via the • Episodic drinker. next sensory projection fi eld into associated pro- • Cure of one such by bromide treatment. jection fi elds, can it also apply to interrelation- • Acquired moral insanity, a special form of ships forming much more complicated associative autopsychosis. complexes? Clearly an answer can be provided • Example of one such case of recurrent behaviour. only from experiences in the clinic, since our whole schema can claim to be no more than a convenient aid for representing symptoms objectively, which is so extraordinarily diffi cult in our Lecture fi eld. You will have already gathered from introductory comments at the beginning of our dem- Gentlemen! onstrations that it has become necessary, just as The examples of acute mental illness that I with somatopsychic and allopsychic disorienta- have presented to you so far can be regarded as tion and disarray—and we had also got to know relatively pure and simple cases of acute somato- of motor disorientation and disarray—that we psychosis and acute allopsychosis, since the main acknowledge autopsychic disorientation and dis- elementary symptoms in the fi rst consisted of array as effects of acute psychoses (p. 135). disturbances of secondary identifi cation in per- Disturbances of identifi cation, analogous to those ception of physicality; and in the second in per- in the fi elds of physicality and of the outside ception of the outside world. These disturbances world, can [Ed] also be found in the autopsychic of identifi cation themselves involved exclusively fi eld; and this enables us to differentiate a special the sensory domain, that is the relationship of s to group among the acute psychoses: the acute A in our schema, even if, in detail, the subgroup- autopsychoses. ing of symptoms as either anaesthesia, paraesthe- I have repeatedly stressed that, in the area of sia, or hyperaesthesia was often left in doubt, and consciousness of personhood, it is no longer open to discretion. If we are to pursue previously possible to use any spatial concept of eligible developed ideas about psychological mecha- pathways. However, naturally, that will not stop nisms in a consistent fashion, we come to the us from recognizing that, in the overall complex question: Are there analogous disturbances of concept of personhood—the sum of all memories

© Springer International Publishing Switzerland 2015 185 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_28 186 28 Lecture 28 as I defi ned it earlier—if all contrasts with the slept well and lost her headaches. One evening, two other areas of consciousness (as the sum of after working hard in the garden, she felt upset, all memory images) are to emerge correctly, sub- sensitive, annoyed by everything. Next day she divisions can be made, which are feasible, genu- was still morose, and felt so nervous that several ine, and determined empirically. They should times she had to hold back tears: ‘Withal a thun- therefore be recognized. Examples of this are derstorm hovered in Nature.’ The following night character, and personal areas of interest—like she awoke suddenly, after a vivid dream with a professional and family interests—that are quite feeling of anxiety, and such a strong heartbeat often independent of one another. Furthermore, that she had to press her hands ‘fi rmly over her we have to assume that, contained within the sum heart to stop it from springing out.’ She felt dizzy, of all memories is a more limited complex, which and had the feeling that her mind was fading, and appears to each person as ‘personality’ [Ed] in a as if her head was covered by felt. She tried to narrower sense, and which is experienced as a open the door or window to escape, but found unit. Disturbed identifi cation with respect to this that everything was locked and had to restrict complex can come about without any demonstra- herself to putting cold compresses on her head. ble impairment of memory, in the sense I defi ned ‘So she felt like a prisoner and wandered to and earlier. It must then remain in doubt whether fro for hours in the confi ned space, sometimes diagnoses applied to sensory perceptions— looking out letters from her family, at other times hyperaesthesia, paraesthesia, and anaesthesia— holding up a mirror in order to reassure herself of still have a place. I would rather avoid attempting her own identity [W].’ Next morning she felt very such distinctions. Expressions such as ‘psychic ill, still almost totally sleepless, and suffered par- anaesthesia’ [Ed] and ‘psychic hyperaesthesia’ ticularly from an hourly, violent fear. The thought [Ed] etc., that you will fi nd in other authors (I that she would lose her mind did not leave her mean Griesinger [1 ] and Emminghaus [ 2 ] in par- the following day, and made her insensitive to ticular), naturally have quite different meanings; everything, everywhere seeming too confi ning but also, because of their subjective implications, for her, and she had to get outside as much as in my view, they are not appropriate choices. In possible. Moreover, being left alone led her to a what follows, I see a most instructive example of state of fear, and the journey home in a railway highly acute autopsychosis, almost apoplectic in compartment was particularly terrible; she felt nature, in which both the Affect of autopsychic that she had to leap out of the compartment. disarray, and the aberration in autopsychic orien- However, the night after she came home, she had tation are seen in very pure form. In places I use her fi rst good night’s sleep. Then her condition actual recorded words and oral accounts of this stabilized, and continued throughout the years highly educated and uncommonly expressive with minor variations in intensity; and I will female patient. attempt to describe it to you in the patient’s own Miss v. F., currently aged 50, was in my care words. for several years, and can now probably be con- To this end I quote some diary notes, recorded sidered as recovered, apart from certain subjec- at my request from the summer of the year fol- tive complaints. Until the start of her illness, she lowing her illness. had suffered only mild hysterical manifestations, ‘After my sad experience the matter rests, that namely tension headaches, unexplained bouts of I am constantly beset by an intellectual inability weeping, and a feeling of great fatigue. During to grasp my own being, mentally and physically. the unusually hot summer of 1886 she was Efforts to achieve this cause me unending tor- detained for 2 months in a charitable institution ment, and I have to give up the attempt to fi nd the in a big city, because she was hyperactive, and key to the enigmatic intellectual phenomenon, in suffered a great deal from the heat. Not until July which I am repeatedly unsuccessful. I am not could she go into the countryside to a family aware of myself, must always prompt myself who friend, where she recovered over the fi rst 2 weeks, I am, what my name is [W]. I try to be self-aware 28 Lecture 28 187 from the inside out, all in vain; and likewise These always brought a feeling of coercion. It looking at my outer person, and this is completely was often as if her head were being compressed, foreign to me and beyond my consciousness; and or everything was contracting internally. so this condition has caused terrible torment. The Only after several years of what she perceived same thing happens for my past. I know that all to be a wholly intolerable state, was there gradual the events, my experiences, did happen to me, but improvement, and in 1890 she felt almost well it is as though another, a stranger to me, had again. Following the menopause a relapse experienced it. My speech is mostly also totally occurred in 1894, but not nearly as violent as dur- foreign to me, as if another person were speaking ing the fi rst episode; and, even now, 3 years later, out of me; yet this symptom began only towards she is not fully recovered. However, her general the end of winter. Familiar old intimate relation- condition is only slightly disturbed, and she ships with family and enjoyments seem intangi- appears to be thriving, and is still remarkably ble, and far removed from me; the dearest, youthful. best-known people often seem foreign and To leave no doubt about the importance of this strange to me. For a time, I felt identical to my case, I have to pass the following comments: sister Olga. Strangers and new people are not so Although her self-control towards the doctor scary to me, and they can temporarily bring me always remained adequately preserved so that out of myself.’ she always seemed competent socially, her feel- ‘By looking at my limbs I always hoped to ing of unhappiness often rose to unbearable regain my consciousness, but this effort always heights, with reckless outbursts of despair ended with the feeling of having seen something towards her relatives. For years there was the familiar, without being able to be conscious of most profound world-weariness, and our fear of the unity of my body and mind. When taking a imminent suicide was allayed, not just because of walk, especially in winter, I wandered around its being forbidden by her religious convictions: often in a state of utter unconsciousness. Then Religion gave her a certain solace. She had cut again, I have been transformed into a totally for- herself off from dealing with people for years, eign being. Terrible were the days—which all not only by her own wish, but also because her seemed turned into weeks during the winter— situation required it; and it was only because of when I was so nervous that I did not move, did the great sacrifi ce and personal attachment of an not even dare turn over in bed, because the level older sister who shared her isolation, that made it of consciousness required for this caused me possible for the patient’s treatment to be carried such anguish. This went so far that I always had out outside a mental institution. From all of this it to sit with my back leaning against something, appears that her clinical state was an actual men- because I could not have my back free without tal illness; and, notwithstanding the well- the question arising whether it still belonged to preserved formal mental activity, in no way could me. I am sensitive and irritable to a high degree; she be construed as a ‘borderline’ [Ed] case bet- often obnoxious and unbearable, despite self- ter classed amongst the neuroses. control. Probably I want to discover something From our point of view the case is also very that is unfathomable … for I have always felt as clear, because it presents a typical example of auto- though I were composed of several people, none psychic disarray and disorientation. Addition of of whom was the right one, that is I myself. It is somatopsychic disarray and disorientation should best that I live quite mechanically, or suppress as not distract us from this view, but will, on the con- much as possible my quest to fi nd myself. The trary, strengthen it. Manifold abnormal sensations worst days are those where restlessness and anxi- of which she complained belong here only in part; ety join me in this search.’ In addition the patient in other ways their importance is probably that of describes severe headaches, sometimes as pres- independent, hysterical concomitants. sure in the middle of the head, at other times as With regard to the aetiology of this case, you throbbing in the temples, and also backache. will not complain about its being placed with the 188 28 Lecture 28 multiform picture of ‘hysterical psychoses’ [Ed]. normal, the other aberrant, can follow each other A decisive criterion here would be the internal in multiple successions; and memory will then relationship between the symptom picture and always reach back just to the same-sense phases, other undoubted hysterical mental illnesses, so that consciousness of personhood actually about which I speak soon. With regard to the breaks up into two—and in rare cases more— present case, given that the course of illness was such groupings. These groupings, being indepen- continual and, taking a long-term view, it was dent of one another, owe their co-existence in a clearly abating. Periodic fl uctuations in its inten- brain to some extent merely to chance. sity were indeed felt very strongly in subjective Independence of one personage from another is terms, but remained quite mild in objective thereby defi ned not just by the selection of cer- assessments. There was never any talk of tain memories, but also by the fi elds of interest, ‘exchange’ [Ed] of symptoms as is alleged to be likes and dislikes, personality traits, etc. A previ- characteristic of hysteria; and there were no ously irreproachable character can, in the ‘second actual hysterical stigmata such as fainting, sen- state’ [Ed], adopt the state of mind of a bestial sory disturbances, ovarian neuralgia, etc. criminal [3 ]. Although I do not deny the theoreti- Gentlemen! In the literature—indeed not only cal interest in these most enigmatic states, this the psychiatric but also the scientifi c literature— should not affect their factual status. However, you will already have encountered cases which they appear to be partly artifacts of hypnotic sug- bear a certain internal relationship with the one I gestion, and are also so rare—I have, for exam- just described; I mean the states of dual, or alter- ple, never been faced with such a case—that they nating consciousness, from the psychiatric side, need not detain us, given the urgent requirements often unwisely described as ‘twilight states’ [Ed]. of the clinic. It is suffi cient to have mentioned it. However, the latter name should be reserved On the other hand, rather more often, we see solely for those acute psychoses where there is sporadic bouts of such an état second [W], and stupefaction of the sensorium per se [W], and indeed, it seems, exclusively in the context of therefore an actual clouding of consciousness to hysteria, epilepsy or degenerative conditions due an appreciable degree. This is not the situation in to alcohol. Over the course of a year no fewer cases hitherto described—the sensorium is appar- than four such cases were admitted to our clinic. ently well-preserved; on the other hand, to some Perhaps only one of them belongs in the ‘twilight extent, there is a break in continuity in conscious- state’ [Ed] category. ness of personhood, such that two personalities, On the night of 11 June, 1896, a 23-year-old very different from each other, override each businessman was admitted. He complained of other, the one appearing in place of the other. In anxiety, gave vent to allopsychic delusions of ref- this case, memory of the abnormally modifi ed erence and allopsychic ideas, was poorly orien- personality, that is the experiences, actions, and tated, and felt that he was being persecuted. It thoughts are either completely lost—as an was learned that on 31 May he had had an autopsychic memory defi cit for the time in ‘absence’ [Ed] lasting half a minute, accompa- question—or remains just as a synoptic, blurred nied by peculiar disorders of movement. On 1 memory, or one extending only to individual June he had left home where he lived with his actions and experiences during this time. What parents, and had not returned since. A scab on the interests us here, however, is not the memory left edge of his tongue suggested that he has defi cit, but the state of mind at the time to which recovered from a recent seizure. By 14 June, the memory defi cit refers which, on account of its there had been complete calming, and the begin- signifi cant deviation from consciousness of per- nings of insight into his illness, but an almost sonhood in the normal state, has been called the total loss of memory for the period between 1 and ‘second state’, état second [W] of French authors. 12 June, except for very sporadic fragments of Such changing states (which, at the same time memory. At the end of July he was discharged remain steady in themselves), one of which is as recovered. He was not a drinker; had no 28 Lecture 28 189

signifi cant burden of epilepsy, and had never so- called Semmelwochen [W], was admitted on 1 before suffered an epileptic attack. Up to the time September 1896 and, on admission, presented of admission he had not been regarded as ill. with mild motor restlessness, slight tremor, During this time he had rented his own apart- insomnia, complaints of anxiety, tension head- ment, and had stayed for 2 days with a girl with ache, and traces of acute alcohol intoxication. He whom he had a relationship. In any event, a num- could go back in memory only until 18 August, at ber of very complicated events occurred during which time he had left Wolgast to take up another this time, which led to much deliberation; a men- position in Breslau. For the time between he had tal illness noticeable to lay people would have total amnesia. On the ward he appeared apathetic, come to the surface only shortly before his indifferent, without any need to busy himself, admission. This seems to highlight the period of and with a subjective diffi culty in thinking transition to the abnormal second state from his through complex tasks, while his retention mem- normal personality. Complete restitution of the ory, attentiveness, and judgment about his fellow- memory defi cit never occurred. (Readmission of patients, were fairly normal. the same patient on 3 January 1898 followed a The fourth case involved a 19-year-old maid, suicide attempt on the open street. His memory whose father was epileptic, who had herself suf- defi cit lasted 3 days, a period for suspected fered sporadic epileptic attacks over the last 1½ tongue-biting. Meanwhile he has been healthy.) years, and had left her employment before a A second case involved a 26-year-old Jewish series of epileptic attacks, and then wandered businessman from Alsace. He was admitted on round for hours. Recollection returned only for 19 September 1896 in a slightly dazed, and the start of this pre-epileptic twilight; while, for severely exhausted state; he claimed to be Felix everything subsequent to that, nothing. Faure, President of France, and 3 weeks before, Naef [4 ] describes a quite remarkable and he had set out with his bicycle on a tour from instructive case from Forel’s observation. This Paris to Lille–Luxembourg–Basel–Constance– involved a 32-year-old educated man with a Ragaz–Innsbruck–Vienna–Warsaw–Breslau. severe hereditary affl iction, who was himself After a deep sleep, the following day, he had full always extremely nervous, who had held a posi- insight into his illness. He was discharged home tion in the Australian civil service for several on 14 October. Of his tour he stated that he had months, travelled on offi cial business to a town in covered it ‘half in a daze’ [W], and for some the interior, and became acutely ill, probably stretches had also used the train. His recollection from an attack of dengue fever. To return to his of it was a blur. Nevertheless, one must assume normal place of residence he sets out by railway; that this profoundly deaf, and visually impaired but arriving there after a 36-h journey, knows man had completed his tour without harm; that he nothing further about his intentions; believes that has carried out a series of complex actions appar- he is in a strange town; is seen by a lady who he ently in a conscious state; and apparent signs of knows, without recognizing her; travels on to a mental illness have come to light only as a result second harbour town that must have been famil- of excessive strain. According to his statement, iar to him from his inward journey, but does not he came from a problem family; he often drank recognize this either; and travels back to Europe, absinthe to excess, and following binge drinking where he stays for several aimless weeks in had even had to spend 10 days in St Anne 6 years Zürich; and only from a newspaper article report- ago. The delusion of being President of France ing the conspicuous disappearance of the func- and of his being appointed to Warsaw by the Tsar tionary in question, does he reach the assumption fi rst came to him in Vienna. He had good recol- that this report might concern him. When he lection of the period prior to his departure from comes to the attention of Forel [5 ], he has an Paris. almost total memory defi cit for a period of about A 44-year-old businessman, who for many 8 months, which includes not only his experi- years had suffered bouts of drunkenness, the ences in Australia and the outward and return 190 28 Lecture 28 journeys, but also the time of applying for the and a nervous twitching of the eyelids in the position and his preparation for the application. poorly-nourished patient. In a highly ingenious manner, with the aid of You see, gentlemen, that cases of the so-called hypnotic suggestion, Forel succeeds, over several ‘second state’ [Ed] can be very different, one from months’ treatment—admittedly including an another. In duration they may last only a few attack of hysteria—to fi ll in the memory gaps. hours, or sometimes several months. They are Evidence was put forward that the so-called twi- usually initiated by an epileptic, hysterical or hys- light condition dated back only to the attack of tero-epileptic, or cataleptic attack, or an actual fever, and that the memory defi cit reaching fur- twilight state, be it of hysterical or of alcoholic ther back is therefore to be regarded as the so- origin. Only heavily affl icted people, the so-called called retroactive amnesia. The details that degenerates, are exposed to this disease. What interest us more here, are mainly the description remains is a memory defi cit that is either total, or of the ‘second state’ [Ed], still present at the time permits only cursory recall, sometimes including of observation, although in the process of abat- as an added defi cit, a form of retroactive amnesia. ing. Certainly, a thorough investigation along As with all mental illnesses, recovery is marked lines that were not considered would have been by insight into the illness; recovery of the mem- highly desirable, yet we can still extract much of ory defi cit, important though it may be in practical value. Immediately after starting the return trip, matters, is therefore without signifi cance. If we he may well have been mostly in a state of stupor; look to give it a closer clinical defi nition, it is the later, during the entire, complicated journey and sudden appearance of altered content of con- during his stay in Zürich, he must have made a sciousness in the domain of personhood, undoubt- relatively normal impression. On the ship he pre- edly signifying an acute autopsychosis. sumably used a false name; perhaps at the time Interrupted continuity in consciousness of person- an even greater part of his personality had disap- ality is totally lacking here, and appears only tem- peared. Memory of the travel experiences, which, porarily during the recovery period. Such total it turned out, he could still recall under Forel’s autopsychic disorientation, with which would treatment, was in very summary fashion, limited come the possibility of a new personality different to a loose juxtaposition of the most striking inci- from the earlier one, also implies the Affective dents, without his being consciously aware of state of autopsychic disarray, so characteristic of motives for his actions, except for the one obscure the illness described fi rst, and which is totally objective, to reach his home country. In this case lacking here or only appears temporarily during he spent his time aboard ship in walking and restitution. Even when there is such loss of conti- reading; for example he read Dickens’ novels. He nuity, there is an underlying defi cit condition. We led a similar, but more vegetative life in Zürich, can sense this as a type of ‘levelling’ [Ed] of ideas, where he stayed for several weeks, without con- a lack of the more sophisticated ideas making up sidering that he had relatives and a home country the normal personality, resulting in a modifi ed nearby. It was only the newspaper article that and easily understandable, but diminished charac- awakened in him the Affective state of autopsy- ter. Motives for action always seem to be directed chic disarray, and which prompted him to seek just towards specifi c situations, as the simplest medical help. According to his description, his selfi sh motives (Compare this with the above- memory retention in this ‘second state’ [Ed] must cited dissertation from my clinic.). Detailed have been greatly impaired. Attentiveness was knowledge of the symptomatology is, unfortu- not specifi cally tested, although amnesia for the nately, very incomplete and complicated by the period of the second state can be understood as a fact that patients of this type, who convince lay consequence of impaired attentiveness, and was people as being healthy, do not come under expert interpreted as such by Forel. It is also worth men- observation at the time of their illness. In any case tioning that there was a temporary disturbance of this type of illness can be distinguished rigorously sleep, all kinds of hypochondriacal sensations, from actual twilight states, which are easily 28 Lecture 28 191

recognizable by stupor, and some degree of allo- but do not include the vast majority of cases psychic disorientation. Twilight states always here. Grounds for grouping these amongst peri- offer more than the manifest symptom complex; odic manias, a view which is widely accepted in often, as I like to point out, they may represent an current psychiatric nomenclature, are totally intensifi ed version of the same, this coinciding lacking, especially since actual periodicity is largely with their aetiology. I suspect that rela- detected in very few cases; and, if you want to tively good attentiveness and poor memory reten- validate the popular expression ‘drunkard’ [Ed], tion may be found in all relevant cases, perhaps note simply that, through external circum- also with concentric narrowing of the visual stances, the opportunity to drink alcohol and fi elds. Corresponding to the ‘mental narrowing’ seek out like-minded company, is repeated each [Ed] of the personality to a mainly selfi sh set of quarter year, in certain social classes. In many ideas, there usually seems to be slight lifting of cases it is just that the fi rst glass of alcoholic mood, and an unusually fl ippant view of the situ- beverage becomes no more than a challenge to ation, if not a tendency to brutality. Accordingly, exceed it. Most likely, the periodicity may fl eeting grandiose ideas can appear. Therefore, apply to those cases for whom alcohol is used there is an undeniable kinship with the picture of to mitigate anxious feelings; yet the number of mania in which, however, you should recognize a such cases is exaggerated. totally different illness. Thus when questioned on this point, the These are cases of the so-called ‘reasoning above-mentioned (p. 190) patient from our clinic mania,’ [Ed] which may belong here, a type of gave the following response: ‘I cannot say that I mania that is manifest only from a patient’s so- have ever had the feeling of being forced [Ed] at called manic discourse. If such states recur fre- this or that time of day to drink a glass of beer or quently, people may speak of ‘periodic mania’ a brandy; I do not have such a feeling even over a [Ed], a doubly erroneous term, since there is no period of months. However, it does happen that, question of either periodicity or of real mania. In when in I am energized by strong liquor, I hanker these so-called periodic manias, it is often found, after another drink. In several cases I found especially in reports from French authors, that, in myself in social groups which I would have never attacks, the same conceptual content always sought out, had not my healthy thought processes recurs; and, resulting from this, likewise, the been subverted by consumption of such strong same behaviour, often matching in detail. I recall drink. I have never been able to see clearly the a case of this kind in which a clerk pretended to beginning and the end of such situations; and it is be a doctor; and he apparently repeatedly carried only later, when friends tell me of incidents in out sophisticated fraud; and always acted in the which I did the most childish things, that it same manner, so that the police eventually recog- appeared almost incomprehensible that I, as a nized the perpetrator of this type of fraud. Later, decent and—in my opinion—mentally healthy the case became clearer, when the patient lapsed man, had got into such situations. Thus, clarifi ca- into epileptic idiocy. It is therefore regrettable tion of these matters later on has been totally that clinical knowledge of the so-called ‘second impossible for me.’ This man admitted that he state’ [Ed] still leaves so much to be desired, pre- was a nervous, obstinate and irritable individual, cisely because of the importance of such cases in suffered heart palpitations at times, and was eas- practical forensic situations; and it is obvious that ily infuriated by business annoyances. He had forensic cases are not suitable material from once stayed away from his business for 14 days, which to derive the symptomatology of particular yet, in spite of this, was given high credit from mental illnesses. Simulation of a memory defi cit his superior, who had been affected by this. Even as such suggests itself to criminals of any kind, more unambiguous is the information that I and is easily accomplished. received from a high-ranking judicial offi cial Conditions are just as complicated in the case about his status related in this fi eld. This 47-year- of the so-called drunkards (‘Semmelwochen ’ [W]) old gentleman from a heavily-affl icted noble 192 28 Lecture 28

family had, 16 years earlier, experienced Status illness. In my opinion the same should be related epilepticus [W] for several hours. For 5 or 6 years to the concept of the second state, which is unam- he had occasionally suffered periods of agitation, biguous in itself—yet currently always too nar- initiated by restlessness and heart anxiety, where rowly defi ned—I am unable to fi nd a better, he spent 2 or 3 days away from home, hung equally descriptive, short name. I have already around several taverns, showed off, made riot and emphasized that in our sense it involves acute, outrage, and was careless in the company he disorientating autopsychosis, including a defi cit chose. He had only a very sketchy memory of which has a specifi c degenerative basis. these times when he felt ill. This was repeated at This might be the place for me to respond to irregular intervals. Since he was obviously over- an objection that you could easily make. Is the worked in his profession and his dietary intake sudden onset of such a defi cit, where personal had reduced, I initially recommended him to take identity is so totally modifi ed, even possible, a break for recovery on the Riviera, with the unless memory of the normal state, at least of result that he remained clear of such attacks for a the recent past as in Naef’s case, has been com- year. After this, there were 6 months of growing pletely erased? Retroactive amnesia would then excesses, and occasional states of nocturnal anxi- have to be proven in any event, as a necessary ety in between. As a result, he was recommended precondition for our illness. However, already systematic bromide treatment, initially with large we note that the above case of the bicycle tourist doses and later with diminishing ones. In the lacked this symptom; and in general we can early days of this treatment, small bruises could only say that it is so diffi cult to understand that be detected repeatedly on his tongue, pointing to such a changed personality can exist along with previous probable, but very mild—and therefore at least a tolerable recollection of the normal— overlooked—nocturnal seizures. The favourable yet it is an indisputable fact. The so-called outcome of this treatment confi rmed the conjec- ‘drunkards’ [Ed] are proof of this. One such ture that the condition was a form of epilepsy. patient can be the best father of a family; but in The pathological intoxication that was men- his altered state he can, without hesitation, leave tioned earlier does not belong here, but rather in his family in need, knowing exactly the position the actual twilight state, as do most of the short- in which he left them. His mistake is based on lived pre- and post-epileptic psychoses. his having concluded by analogy that his family Gentlemen! You will notice that the cases takes life easily, just as he does himself, and that belonging to our group of illnesses have not yet God will provide at times of need. A vivid been brought together is a unifi ed way. There can description of this altered concept in a drunkard, hardly be a greater contrast than that between the is to be found in Dostoevsky’s Raskolnikov. twilight states and real mania: Nevertheless, you The judicial offi cer mentioned above had so lit- will fi nd in the literature cases which seem to tle memory defi cit for the immediate past that belong in our present group of illnesses, that are he might even be aware of dates falling within sometimes associated with one, and sometimes this time period; and throughout the duration he with the other of these opposing terms. If you are was fairly profi cient. One explanation for this surprised by such a proof of the prevailing confu- remarkable contrast between the sick personal- sion of terminology, sad to say, this is not an iso- ity, and simultaneously, the remembered healthy lated example: We come across this in almost all one, can also be found by assuming a toxic areas of our discipline, for lack of robust defi ni- effect, which is indeed very close to the concept tions. Hence, as I constantly regret, it is impossi- of a drunkard, though not actually found. At ble for me to recommend to you one of the such times one can speak of a ‘split personality’ best-known textbooks of psychiatry for your pri- [Ed], a case analogous to my earlier description vate studies. This digression, gentlemen, is not of the state of decay of individuality, which superfl uous: It shows us rather that we need to can be explained by assuming the process of keep looking for an appropriate name for our sejunction. 28 Lecture 28 193

Gentlemen! It is likely to astonish you beyond Explanatory delusions arising from resistance on measure if I were at this moment to remind you of the part of family or wider society to the changed cases of the so-called acquired ‘moral insanity’ moral behaviour may come next, in the form of [Ed] or ‘moral madness’ [Ed], and likewise to delusions of persecution. bring this into consideration here. You know that A description of these states in detail would this is about cases of illness which lawyers, unfor- lead us too far astray; but I want to touch briefl y tunately supported by clashing opinions, have on the aetiology. In this respect, a connection been particularly reluctant to recognize, which, in between processes of development and recovery our own view, has diverted attention from much in the organism is quite unmistakable. If we of both the factual reality of these aberrant condi- decide to call these cases moral autopsychosis tions and their theoretical basis. Unfortunately, it [W], we can distinguish a ‘hebephrenic’ [Ed], a must be admitted that the tendency to make the ‘climacteric’ [Ed], and a ‘senile’ [Ed] form of cases conform to a particular scheme has also moral autopsychosis. Soon a menstrual form, usu- seduced individual professional colleagues to ally lasting only a few days, might be recognized. ignore certain facts and to defend the view that a Incidentally, I do not doubt that other aetiological state of defi cit in the ‘moral’ [Ed] area must be factors, hereditary and degenerative in nature may connected with one in the intellectual area, which also play a role in this, and that other harmful is to be recognized as aberrant. However, this effects that can otherwise lead to onset of acute assertion does not hold a candle compared to the psychoses, such as head trauma, can have the facts; it can probably only come from the miscon- same effect, in exceptional cases. That this conception that one has transferred the characteristics cerns actual psychosis, or, in other words, an of chronic—and especially the cases of innate— expression of abnormal brain activity, and not just so-called moral idiocy to those which are more- persisting moral aberration, is proven for some or-less acute in origin. On the other hand, the such cases by the fact of their curability. However, latter often lack so much as a trace of intellectual the climacteric form seems predominantly—and disorder. It becomes understandable to us, if we the senile form invariably—unfavourable, the lat- consider the above-indicated (p. 191) elementary ter eventually blending gradually into senile symptom of ‘levelling of ideas’ [Ed] as their basis. dementia. The clinical picture described by In fact, almost all other elementary symptoms can Kahlbaum of heboids or heboidophrenia based be missing, including even, in most cases, internal purely on empirical criteria, seems to me to restlessness and irritable mood. This levelling of belong with some of the cases here. The relative ideas is what gives it a certain similarity to mania, curability of the illness has already been pointed for we shall see later that it accounts for a major out by Kahlbaum. symptom of the latter illness; however, what is With regard to the course of the disease, it is missing here are all the other equally important likely to depend on the aetiology. For example, I symptoms belonging to this clinical picture, such saw a highly acute outbreak in a 15-year-old girl, as fl ight of ideas, pressured speech, abnormal below average intelligence, who had been euphoria etc. If you remember, the normal supe- affl icted by her father’s drunkenness. The later rior status of certain ideas forms the basis of char- course developed as a certain period of promi- acter and morality; that likes and dislikes have the nent illness (lasting 7 weeks), and then abating same origin; that therein we fi nd the only inhibi- towards a basic insight of the illness over the next tion to set limits on the predominant selfi shness few months. Over the course of 3 years there which drives people in their natural state; then were three subsequent recurrences, of slightly you will understand that elimination of such lower intensity and somewhat shorter duration, higher values produces a change of personality following the same course. Melancholy moods which, when extended to the realm of morality of occurred during intervening free periods, so that, likes and dislikes towards certain people, reveals for a time the thought of a ‘circular psychosis’ ruthless, egotistic drives with great clarity. [Ed] was entertained. However, this idea soon 194 28 Lecture 28 had to be abandoned, when people wanted to state of mind presented by Miss v. F., who I defi ne ‘circular psychosis’ [Ed] as a regular alter- described fi rst, showed us the failure of secondary nation between mania and melancholia. On the identifi cation, autopsychic disorientation, and the one hand, a melancholy ‘phase’ [Ed] was out of Affective state of autopsychic disarray that derived the question, since it was usually a mere tempo- from it. Then we had states of interrupted continu- rary, transient fi t of melancholy mood, which ity of personal identity; and we recognized the so- could as well be really the impact of insights into called ‘second state’ [Ed] of French authors; and the illness. On the other hand, there was the likewise we perceived a state of defi cit as not con- abnormal condition, connected with excitement, trasting with the healthy condition and therefore albeit temporarily, but certainly not manic. This lacking the Affective state of autopsychic disarray. was rather outweighed by the moral defi ciencies, The common, severely-neurotic degenerative lack of obedience, lack of respect for ward staff aetiology formed a mediating state between these and doctors, and even for the older fellow two states, which are otherwise so different. patients; above all, the lack of discipline; the Furthermore, we learned to recognize cases of the most pronounced individualism; lack of appreci- so-called periodic drunkenness, in which sudden ation for any kindness shown to her; lack of occurrence of a changed, always diminished per- shame or feelings of civility; propensity for foul- sonality was assumed to be due to internal aberrant mouthed and obscene language, with correspond- processes, as was the so-called second state. I ing behaviour to the point of gross uncleanliness. mentioned that people had tended to attribute these Actual pressured speech, fl ights of fancy, and cases to periodic mania. Finally we found that the hyperactivity never existed. In fact, even the acquired moral insanity represented a totally anal- patient’s condition, initially presumed to be a ogous defi cit state in the autopsychic area, such congenital defi cit that would have increased by that one can validly admit the existence of an acute the time of puberty, was interpreted as a ‘moral ‘moral psychosis’ [Ed], and subsume amongst its degeneration’ [Ed]; and even a stay in a correc- cases some of the so-called periodic mania, but tional facility was considered. The mother’s testi- also the so-called ‘reasoning mania’ [Ed]. For this mony, according to which she had been a latter category, physical changes accompanying good-natured and well mannered child until the onset and loss of sexual maturity, and of senile outbreak of her illness, was initially given scant involution, prove to be decisive infl uences. In the credence because of the apparent shortcomings next patient demonstrations, in contrast to these of the mother. Characteristically, there was abso- defi cits, we will deal with certain irritative phe- lutely no trace of shame during a pelvic exam, to nomena in the autopsychic area. which her gross uncleanliness had given rise. However, it was the total change that occurred later in her behaviour, when she became a mod- References est, demure girl, and was diligent and helpful at the monitoring station, which taught us about our 1. Griesinger W. Die Pathologie und Therapie der psy- misconception. As for the intellectual develop- chischen Krankheiten für Ärzte und Studierende. 3rd ed. Braunschweig: F Wreden; 1871. ment of the girl, her judgment and store of school 2. Emminghaus H. Allgemeine Psychopathologie zur knowledge at age of 18 years lagged somewhat Einführung in das Studium der Geistesstörung. behind expectations, similar to that of a 14-year- Leipzig: FCW Vogel; 1878. old girl in the same situation. In her physical 3. Bohn RWT. Ein Fall von doppeltem Bewußtsein [dissertation]. Universität Breslau; 1898. development on the other hand, she had not 4. Naef M. Ein Fall von temporärer totaler teilweiser ret- lagged behind, and during the entire time of rograder Amnesie. [dissertation]. Universität Zürich; observation she menstruated regularly. 1898. Gentlemen! If we take a look back at cases of 5. Forel A. Untersuchungen über die Haubenregion und ihre oberen Verknüpfungen im Gehirne des Menschen illness classed as acute psychoses, we can bring und einiger Säugethiere, mit Beiträgen zu den them together in as much as they are all character- Methoden der Gehirnuntersuchung. Arch Psychiatr ized as defi cits in the autopsychic area. Even the Nervenkr. 1877;7(3):393–495. Lecture 29 29

• Acute expansive autopsychosis due to autoch- duty and his task to remove from the Kaiser a part thonous ideas of his government. Accordingly, he considers • Disappearance of thoughts as an elementary that his being detained here is an injustice and an symptom act of deprivation of liberty. Despite this, you can • Obsessive neurosis see how soberly and considerately he passes • Obsessive psychosis judgment, from the fact that in no way does he • Audible thoughts as the basis of an ascending put our behaviour down to ‘bad faith’ [Ed], but form of acute autopsychosis suggests a mistake on our part only with the politest warning to us not to approach too closely. I drew his attention to the fact that when he entered the hospital 3 months ago he came volun- Lecture tarily, and felt ill; therefore as we hear, he was probably well aware of the purpose and provision Gentlemen! of the institution. He has to admit that fact, but The 38-year-old municipal secretary we now vividly regrets having done it, because he is examine today has been difﬁ cult to motivate, and sure that he was wrong to have done so. Rather to bring to the lecture theatre, but eventually he when he had been ill earlier, he had been nervous, declared his willingness, as he says, to provide a but was now so healthy, so strong, and more efﬁ - service to science. You see a thriving, seemingly cient in every way than before. On questioning, healthy man with impeccable manners and intel- we still hear that, up to the time of his being ligence manifest in his facial expression and detained, he felt completely happy, and did not speech. Given his situation, the unusual level of doubt that the doctors would gradually see the general education, which he soon betrays, is error of their ways. I must acknowledge, more- explained by the fact that he had studied philol- over, that his general health has been excellent in ogy; and, very shortly before his Staatsexamen the last few weeks. During his stay his body [W] had to take a different career path for health weight increased from 63 to 70 kg. He has no reasons. There is no sign of formal thought disor- doubt that the Kaiser will receive him with open der from him. He feels healthy. Nevertheless, the arms. How does he know this? An inner voice need to detain him here in the clinic, despite his tells him. As we see from a piece of paper, this objections is based on the fact that we have rea- inner voice compares the patient with the dai- son to fear that, as soon as he is free, he will go to monion [W] of Socrates, ‘who people have also Berlin and seek out the Kaiser; for he feels it his now declared insane’ as the patient casually

© Springer International Publishing Switzerland 2015 195 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_29 196 29 Lecture 29 remarks. From more detailed characteristics of Gentlemen! The illness that we are concerned this voice we learn that it is not localized, has no with here arose very acutely, yet the day before particular vocal quality, but might include certain his admission, he was carrying out his offi ce work words from time to time, and—which is the main satisfactorily. We learned that the patient, whose thing—is based on divine inspiration. The patient mentally ill father had died in a mental institution, also harbours fears that we doctors are heading had for years expressed his fear of becoming towards severe divine punishment because of our mentally ill. A brief bout of severe nervous agita- delusion. He does not doubt—and this is also evi- tion had occurred 17 years ago, just before an dent from his documents—that he is placed in exam, and had impelled him to give up philologi- direct communication with God, and receives cal study, as being too strenuous. However, he revelations and enlightenments from Him. He was said to have been very capable mentally. denies hearing voices, as do other mental patients, When the patient himself sought admission to the nor has he ever experienced face-to-face appari- clinic he was agitated, as the delusions of gran- tions. I argue with him that, if injustice is being deur appeared, which he himself acknowledged done to him here, this does not lead to the conclu- as being abnormal, and he asked for help so that sion of a special providence from God. Then he he did not become insane. His face was markedly explains that it is quite likely that the thought has congested; the skin of his entire body was cya- been assimilated here, and had in due course notically discoloured; a rapid pulse of 120, small been given to him by an evil spirit. He could only and soft, not quite regular; subjective complaints regard his time here as probation imposed upon of heart palpitations; and objective evidence of a him; he nods approvingly when I remind him of right ventricular enlargement reaching to a fi n- an analogy with other heroes and prophets. As ger’s breadth to the right of the right sternal mar- you have already heard, he has no grudge against gin. Examination of the nervous system revealed us doctors, yet is convinced that we believe that no pathological fi ndings, other than when he we have our duty to do; but he emphasizes the articulated more diffi cult words, his speech stum- difference between his spiritual concept and our bling a little and rather fl at—matters of which he materialistic one, which of course would exclude himself was well aware. However, that was never belief in God and spirits. The patient is confi rmed seen later. Moreover, the feeling of illness was not in his belief by an experience from childhood, in constant, but so irregular that, soon after, he which one night, as his grandfather lay seriously declared that he was [Ed] the Kaiser; demanded to ill, he awoke to see a woman clad all in grey, dis- be addressed as ‘Wilhelm’ [Ed]; and even in the appearing through a half-open double door. His admission room itself wrote a note with the words: mother had seen the same phenomenon and could ‘To arrest. Wilhelm.’ During the course of the day confi rm it, and at that very moment his grandfa- he repeatedly asked to be released, because he ther had died. When we attempt a psychological was not sick and not until evening did he defi - account of this well-known type of half-wakeful nitely let his grandiose ideas drop. Despite 3 g. hallucination, he just smiles. He is weighed potassium bromide he spent the night in sleepless- down, as we have seen, by his writing and, he ness. The following day he had full insight, and confi rms, with his big plans for the future. As only occasionally complained that such foolish soon as he gets to government, he intends to bless thoughts were troubling him. The nights became all the world; to install the senior physician with better and the palpitations subsided. On the eve- 30,000 Marks as his personal physician; to build ning of the fi fth day he was temporarily restless a golden bridge over the Rhine near the again, demanding his discharge in order to go to Niederwald monument as a symbol of peoples’ Berlin; but soon after, he confi ded again his great eternal freedom—the gold represents the purity distress that the unhealthy ideas had returned. At of the mind—and take the money for this from the same time there was an increase in cyanosis, the Julian Tower. Certainly he carries a whole with pulse increasing up to 130, with return of series of nonsensical fantastic ideas that he is palpitations. Over the following days there was concealing from us. improvement and the pulse dropped back to 88. 29 Lecture 29 197

However, with the least effort, palpitations and evidently in remission from his illness and pre- cyanosis returned. Treatment with digitalis, pro- sented with no psychotic symptoms, apart from longed bed rest, and regulation of sleep by paral- increased need for sleep; but he described with dehyde and trional had such a favourable effect great precision the phenomena of the illness from and the patient’s condition improved to such an which he was recovering, and that was the reason extent that thought was given to his being dis- I presented him here. However, 14 days later a charged. His body weight had increased by about state of excitement ensued, which, as the patient 6 kg. Six weeks after admission, one evening, later stated when his judgment had returned to there was a sudden relapse, initiated by an anx- normal, was a repetition of his earlier state, but at ious, bewildered facial expression and a plaintive a much lower intensity. This brought about a few cry: ‘The ideas have come back’; and after a few sleepless nights, and the state completely sub- minutes, again he had the intention of going to sided in about 8 days. This second burst was also Berlin to see the Kaiser, along with vehement connected with striking vasomotor disturbances, demands for him to be discharged. He was hurried congested face, cyanosis of the extremities, and anxious in his nature; in visible discomfort; increased perspiration, and increased heart rate. occasional gesticulating towards his heart; com- From then on, full insight into the illness quickly plaining of palpitations; his pulse up to 128; a returned, so that he could be discharged as recov- congested face; and general cyanosis. The distur- ered after 3 months; and, up to now, 1¼ years bances of his general condition subsided again after discharge, he has remained in good health after a few days, but the grandiose ideas remained, and is again active in his previous occupation. We and seemed to gradually assert themselves more learned from him that his fi rst attack, of 10 weeks strongly. At the time he felt he could rejoice over duration, began with poor sleep and irritable the abundance of his ideas; at times he could not mood. Then a feeling of anxiety appeared in the sleep; he showed, what he called a ‘freshness of cardiac region, lasted for 2 days, and put him in his mind’; and he boasted about his possession of state of fearful agitation, ‘as if he should go into total self-control. In the week of the relapse he the Oder.’ After about 4 days, this feeling gave lost about 1½ kg in weight, but since then, gradu- place to another mood, ‘the opposite of the previ- ally made up this loss, and has now increased it by ous one,’ such a happy feeling ‘as if the Holy a further kilogram (The patient recovered 8 weeks Spirit were within him.’ This was located at the later and was discharged with normal heart self-same spot as the feeling of anxiety that pre- limits.). ceded it. The patient found it diffi cult to give a Gentlemen! Those of you who heard me ear- more detailed description of this feeling: lier will remember a very similar case of illness Sometimes he described it as ‘ramparts in his that I presented 1½ years ago. At that time it chest’ [Ed] and sometimes as unusually light, involved a young 22-year-old mechanic named free breathing. At the same time ‘strange Sch., who was discharged as recovered after a thoughts’ [W] came to him and he realized that 4-month stay with us. He also came to the clinic he had become another person, as he suspected, as a voluntary patient, because he thought he was enlightened by the Holy Spirit. He noticed that he mentally ill. In his opinion he had been ill for had acquired special abilities, believed that he about 10 weeks, and this matched details from had invented a machine for perpetual motion; his acquaintances. At the time of admission his believed that he had the ability to immediately complaints were: a headache; a feeling in his distinguish ‘noble and ignoble people’ [W]; head as though he were drunk; palpitations which believed that he was able to infl uence people in occurred during attacks; also dizziness in his the manner of a hypnotist, so that they would do head and inability to think, ‘he feels so jaded.’ what he wanted; and made a plan to transform his Objectively: He had a congested face, reddened employer’s business into a corporation. At the conjunctiva, and a slight cyanosis, the latter same time he appreciated that he was not doing exacerbated by walking around his room. Pulse well at his work, and that his thoughts were not not accelerated, cardiac fi ndings normal. He was well focused on the matter; and that those around 198 29 Lecture 29 were making fun of him, declared his plans to be Yet even in this respect insight into illness rapidly nonsense, or told him they did not understand returned, and the only complaint, which was lost him. For 3 weeks, these were the only strange over the course of the next week, was that so thoughts of which he was aware, and then he many thoughts came to him. At times of greatest heard them taken over, and pronounced by a fi ne excitement the localized feeling of happiness was female voice; and then the ‘rampart’ [Ed] existed again present; however, the patient did not hear a again in his chest. Consciousness of his being voice during this second attack. Of importance is inspired by the Holy Spirit now overcame him the fact that this patient grew up with orthodox more clearly. The voice also let him know of the religious views, as evidenced by letters from his attitude people took towards his plans, whether, parents, and by the fact that his calling to the for example, they wanted to join the corporation priesthood had initially been recognized by them; or not. At night, the voice spoke to him, and often and moreover there was violent opposition to his continuously disturbed him in his sleep. Once he being admitted voluntarily into the clinic. We heard three voices, coming out of his chest, and learned later that he had always been somewhat simultaneously saying good night: two strong peculiar, and that during his illness, fantastically voices and one fi ner voice. After that, he had grandiose ideas had beset him, for instance that become tired and went to sleep. An unusual he had offered millions to his colleagues. Up to abundance of words came over him; the words the time of his discharge, his bodyweight had presented themselves ‘involuntarily’ [W], and it increased from 56 to 65 kg. seemed to him as though the Holy Spirit were Gentlemen! The two patients that you have speaking ‘out of’ [Ed] him. He preached for come to know apparently have this in common: hours; on one occasion, he spoke in verse, and that their autochthonous ideas, about which you fi nally, a few days before his admission he went learned earlier, formed acutely and then became home in order to be blessed by the priest of the the basis of their illness. All other symptoms can place, as a court preacher. Through diligent read- be considered as consequences or companion ing of the Bible, he had come to believe that he phenomena of this single main symptom. This was one of the two witnesses that appear in the includes phonemes, whose internal connection Revelation of John. The patient had told us all with the autochthonous ideas stand out particu- this in the clinical presentation a few days after larly clearly in these cases; and likewise the his admission, with full insight into the abnor- explanatory delusions, which depend on the con- mality of the experiences he described. The sec- tent. Ideas of happiness observed in the fi rst ond, short-duration attack was also preceded by patient, stand in strange contrast with the Affect fear and anxious ideas, the anxiety again being of anxiety, which, albeit mild, was dominant at localized in his heart—and the content of the the same time. The ‘hypochondriacal feeling of fearful ideas was that he would not come out of happiness’ [Ed], which is peculiar to the second here, that he would die here, and his body would case, has been mentioned already (p. 107); it is a be handed over for anatomy, etc. He impetuously quite rare phenomenon. We shall characterize the demanded his discharge, but could be appeased. illness as an independent form of autopsychosis, Over the next few days he showed only a haughty, recognized by acute onset of autochthonous ideas demanding manner; he sought to instruct the doc- with prominent participation of the vasomotor tor, but yet remained open to encouragement. He nervous system, through a course in short bursts wrote a guide for the physician to examine men- that follow one another in rapid succession, and tally ill people; spoke of his ‘great abundance of then through to the surprisingly favourable out- ideas’ [W], his ‘death-defying courage’ [W], and come within several months. The spotlight there- his ability to excel. He retained a certain degree fore falls on the independent signifi cance of the of insight into his sickness and of the vast multi- autochthonous ideas. Provisionally, I would like tude of thoughts that came to him, even though to propose the name of acute expansive autopsy- he did not regard their content as being abnormal. chosis mediated by autochthonous ideas [W]. 29 Lecture 29 199

In addition to these two cases, whose diagno- Gentlemen! We have concerned ourselves ses are suffi ciently secure, I know of another one earlier with overvalued ideas, but if we consider that I would like to refer to as ‘abortive’ [Ed], and just the time course to be the decisive factor, we not really belonging amongst the psychoses, often have to attribute new stages of these to because the elementary symptom of an autoch- acute autopsychoses, occurring during a chronic thonous idea remained isolated, without leading course of illness. even to any relatively fi xed delusional explana- Here it might also be the place to discuss tory ideas. I have seen casual mention of this case briefl y the not infrequent cases of psychoses by once before (p. 69, note). This was a 52-year- old obsessions [W]. In no other area is it more diffi - lady, the wife of a high-ranking military offi cer, cult to separate psychosis from neurosis: Thus, to who had suffered from diarrhoea for years, and identify both the degenerative aetiology as well was quite ‘run down’ [Ed], forever telling of all as elementary symptoms as lying within the nor- manner of hypochondriacal complaints, particu- mal mental range, it might be fi tting to speak larly during the last few months. Quite suddenly, solely of obsessional neurosis [ 1 ] . [W] This term she showed a striking urge to communicate, as a might be the more suitable, since the analogous result of thoughts that were ‘talking’ [Ed] within name of ‘anxiety neurosis’ [Ed] has already long her, but which were expressly not described as become familiar. In general we can propose that voices. ‘These can only be my own thoughts or obsessions fall within the neuroses, as long as inspirations.’ At times she showed a feeling of they remain isolated, and are not followed or anxiety, which, severely disturbed her sleep accompanied by other psychotic symptoms. (For because of her thoughts. Attempts to provide an these cases Westphal has proposed the name explanatory delusion were linked to a personage ‘abortive insanity’ [W] for these cases. However, who the patient had met shortly before, a dealer it is inadvisable in any direction.). However, an in magnetic cures; their content being the possi- exception to this criterion should be expressly bility of her being affected by this person. By stated, namely for mild anxiety, which often improving her diet, bed rest, care with sleeping, accompanies obsessions which are otherwise iso- complete restitution within 8 weeks. lated. A criterion that is reliable in most cases While autochthonous ideas all too often con- might be found in the oft-stated question of how stitute a separate clinical picture as just described, far a patient’s irresistible obsessions might affect this is not the case with the opposite elementary their treatment: The content and richness of the symptom. (I touch here, on a point that could obsessions undoubtedly have an infl uence, in that already have been mentioned in the context of in individual cases, the limits of neurosis are paranoid states, since only the combined explan- exceeded. This seems to be a very rare instance, atory delusion is obvious.) Just as emergence where, with great richness and abundant change [Ed] of thoughts by local abnormal irritation is of obsessions, it is not so much the content of usually attributed to an external infl uence, so can thoughts, but the compulsion to be continually momentary disappearance [Ed] of thoughts thinking, which is perceived to be so distressing. occur as a symptom of illness, to be interpreted in In general, this falls amongst the type of brooding- a similar way by a sick person. The complaint by addiction described by O. Berger [2 ]. If you certain patients, often heard in mental institu- remember the schema presented in the introduc- tions, that thoughts were ‘drawn out of’ [W] tion to these lectures, you will tend to class such them, usually seems to refer to this symptom. A brooding addictions amongst ideas registered as further explanatory delusion is often linked with a result of abnormal stimulation. That compul- this, that medical measures are to blame, and that sion is transferred by the patient to vivid registra- the thoughts in question are known to the physi- tion, which then impels achievement of goals. cian. I have quite recently received secure infor- The maladie du doute avec délire de toucher [W] mation, which excludes any doubt as to the described by the French [ 3 ] is likely to be only a meaning of the symptom. special case of the brooding-addiction. However, 200 29 Lecture 29

I do not doubt that in some cases, the state of arranged her whole life differently; and that she general brooding addiction can be so agonizing could no longer live. It was only fear of shame that it leads to psychotic acts, including suicide. that had held her back from ‘going into the water’ Those cases of limited but repetitious, and thus [Ed]. Her obsessions came in bouts, connected markedly Affect-laden content often reach psy- with a lively fear ‘inside’ [W], in the heart. After chotic proportions. Sometimes the content is each bout, she felt generally weak, particularly motor in nature, where patients complain of their with trembling in her legs, feet, and hands. It was being compelled to carry out certain actions that as if her eyes were dim; she feels unable to read they know to be unreasonable or unjust. An or to perform any work. Depressed mood con- accompaniment of anxious feelings tends only to tinually; also a sense of subjective ineffi ciency. soften the action carried out. Cases of arson by Admission into the institution resulted immedi- young epileptics, and the irresistible desire to ately in signifi cant improvement; the attacks steal—the so-called kleptomania—at the time of became less frequent and less severe; insight into menstruation are best known here. the illness gradually prevailed; and there was In our clinic we most commonly observe complete healing, with steady weight gain (4 kg) obsessions whose content is limited to religion, up to the time of her discharge on 15 November leading to delusions of belittlement. I want to of this year. A hint of autopsychic delusions of outline briefl y a typical example of this. A reference should also be mentioned, in which, 43-year-old single woman, well endowed, with- during the initial stage of her stay, a triple murder out hereditary affl iction but always very reli- was reported in the newspaper, for which she felt gious, was admitted as a voluntary patient on 31 a sense of self-blame. Furthermore, she had fre- August 1891, because she was afraid of commit- quent complaints about her head, about tinnitus, ting suicide. She had already been treated for 3 and a feeling that her head would spring off, etc. months in 1881 for ‘religious mania’ [Ed], had Objectively, she experienced no disturbance of made a suicide attempt at the time, and had been intelligence, memory, or attentiveness, etc. The discharged completely recovered. She dated her same patient was again admitted with a relapse of current illness from the spring, but it had been a much lesser severity, although similar in con- especially bad over the last 14 days, along with tent, in 1898, and, after a short period, she was insomnia and periods of despair. She knows that again discharged. I have seen a similar favourable she is mentally ill and had appealed to a clergy- course in a 20-year-old hereditarily affl icted jour- man for comfort, who has however encouraged neyman. In him too the feeling of unhappiness, her in her delusions. When she prays, the worst the suicidal tendency, and the inability to work, blasphemies come into her head; that she must were so pronounced, in spite of insight into his curse the risen God, Jesus Christ, and the Virgin illness, that the only place of refuge for him was Mary, belabour them with the worst epithets, and the mental asylum. Moreover, there were a num- utter indecent phrases against them. She cannot ber of accompanying physical symptoms, such as help these thoughts: They come against her will, palpitations, headaches, and hypochondriacal but they are her own thoughts. How bad must she sensations. Outbreak rather sudden, after a shock. be that she, hitherto always pious, should have Content: blasphemies when praying; recovered such thoughts! The clergyman also said that to within 9 months. Years ago, during the evening her. Thus, she knew that she was mentally ill; and meal, similar obsessions had surfaced quite tem- she had also previously turned to the panel doc- porarily [4 ]. tor, who had sent her here. Her explanatory delu- Gentlemen! The strange phenomena that, in sion, that she was wholly and eternally lost, was themselves, are personal thoughts totally free maintained at fi rst, despite partial insight into her from Affect, are transformed into phonemes illness. Linked to this was the idea that she had through which explanatory delusions arise. The brought the illness on herself; that she had lived thoughts then become known to others, and can too much on her own; that she should have similarly be seen as the main component of a 29 Lecture 29 201

particular, worsening form of acute autopsycho- add an internal relationship between these two sis. As you will recall, we reserved the term elementary symptoms, which will seem much thought echo [W] used by Cramer [ 5 ] (notes to more plausible to you, if you remember my pages 69 and 88) expressly for cases of this sort. remarks on the importance of the left temporal Patients fi rst notice that what they read and write, lobe in my twentieth lecture (p. 129). In this sense and later also what they speak, is repeated as we should regard thought echo as a special form of voices. Soon, every intention to do anything is functional disturbance of the left temporal lobe. heard as a voice. The resulting disturbance in Moreover, the relationship with obsessions is itself thought, when established, is experienced as made clinically valid, in that, in the one case, at the painful, and attention is forcibly drawn towards time when the voices had already become inde- it. The anxiety that accompanies it is localized to pendent, for a brief period there was also a com- the head, and is stated explicitly to be its conse- pulsion to repeat the voice content, and, if the quence. Hypochondriacal sensations of a minor voices are questioning, to give an answer. nature, such as general lassitude, headache, dys- It seems almost as if thought echo, in the nar- pnoea, paraesthesia of the limbs, in the mouth, row sense that we can understand, could lay and in the abdomen etc., are initially disregarded claim to a particularly serious and fatal import. In in the delusion, but nevertheless create the exter- addition, more complicated cases of illness in nal impression of a depressed, melancholic state. which it has occurred are striking in their severity I recall two cases of this kind, involving a and rapidly progressing course. 22-year-old maid and a 30-year-old woman Gentlemen! In the above, I have paid consid- telegraphist, with acute onset; and, within a year, erable attention to cases of special theoretical or rapid development to the point of persecutory practical signifi cance. However, with this, we are and consequent grandiose delusions, and pervad- far from having exhausted the topic of acute ing falsifi cation of content. In one case the autopsychoses. Rather, it seems to be a particu- thought echo occurred only during seizures, ini- larly rich fi eld, and some differentiation is needed tially only for hours, but then lasting for days. if we are to include a great number of cases of With gradual habituation to the echo, the depres- illness. Thus you recently became familiar with a sive impact faded and attentiveness became freer. case of acute traumatic autopsychosis [ 6 ], which Only in the depressive phase of the illness was besides showing severe autopsychic disarray and the elementary symptom present in isolation, but disorientation, also presented an autopsychic def- later the voices occurred independently. Not only icit of retroactive amnesia extending back to that, but the voices also commented on what the childhood. In terms of disarray and disorientation patient was thinking, and initially did so in a hos- this case was quite reminiscent of Miss v. F. tile manner, so that the voices were ascribed to described in the last lecture. Furthermore, we certain persecutors; yet later they commented in have seen [7 ] that, in a chronic residual case, a a joyful way, so that, for example, voices are delusional system existed that could be attributed interpreted as a royal court. In addition, every- almost exclusively to the elementary symptom of thing that people in the neighbourhood say or do a generalized autopsychic delusion of reference. is assessed as if those people know the patient’s All events in the environment seemed to the thoughts; and so it reaches the point, symptom- patient to be related to her thoughts, or to depend atically, of generalized autopsychic delusions of on them. Moreover, she assumed that her thoughts reference, with corresponding reinterpretation of were known to everybody else, although she the outside world. Allopsychic orientation will never experienced thought echo. Rather, these then also be impaired. were autochthonous ideas which could be identi- ‘Thought echo’ [Ed] is the fact that the voices fi ed here as the source of her generalized auto- are explicitly described as loudly resonant per- psychic delusion of reference. sonal thoughts, this being adequately distinguished We will learn about still other cases of acute from autochthonous ideas. However, we need to autopsychoses in the next few lectures. 202 29 Lecture 29

4. Wernicke C. Krankenvorstellungen aus der psychia- References trischen Klinik in Breslau. Breslau: Schletter; 1899. vol. 2 Case 27 is a case of autopsychosis due to obsessions. 1. Westphal CFO. Über Zwangsvorstellungen. Arch 5. Cramer A. Die Hallucinationen im Muskelsinn bei Psychiatr Nervenkr. 1878;8:734–50. Geisteskranken und ihre klinische Bedeutung, ein 2. Berger O. Die Grübelsucht, ein pathologisches symp- Beitrag zur Kenntniss der Paranoia. Freiburg im tom. Arch Psychiatr Nervenkr. 1876;6:217–48. Breisgau: P. Siebeck; 1889. 3. Le Grand du Saulle H. La folie du doute (avec délire 6. Wernicke C. Krankenvorstellungen vol. 1, Case 22. de toucher). Paris: V. Adrien Delahaye; 1875. 7. Wernicke C. Krankenvorstellungen vol. 1, Case 13. Lecture 30 30

• Presentation of two opposite types of illness diffi cult for her and slower than normal, whilst • Digression on volition her answers are otherwise prompt. What job did • Clinical picture of Affective melancholia she do? She helped with housework in her par- • Risk of suicide due to this ents’ inn; something that was hitherto not diffi - • Fantastic delusions of belittlement cult for her. Once she became ill, she could do • Phonemes and visions this no longer, could not settle down to anything. • Course, frequency of the illness Even getting up in the morning was an effort for • Diagnosis her. Everything that she had to do seemed terribly • Treatment diffi cult; and she was terrifi ed of the coming • Prognosis days. Thoughts of the future frightened her, and brought her to thoughts of suicide. By what method? She wanted to go into the nearby pond, but Lecture was thwarted, because she was not allowed to be left alone. Gentlemen! Was she afraid of anything else? In the 43-year-old patient, Mrs H. [1 ], who I No, just the thought of the future. present to you today, you will notice, from her Where was anxiety located? posture and facial expression, the deeply In her breast and head. depressed mood. When she notices me speaking Returning to the question of which word she of her bad mood, she bursts into tears. When I ask had been given to remember, it turns out that she the reason, she replies that she feels unhappy. had forgotten it after a few minutes, and knows ‘Why unhappy?’ only that it began with ‘A’ [Ed]. However, she ‘You cannot do anything more; you are physi- recognized it again amongst a number of words cally tired and always prefer just to sleep.’ spoken to her. Does she have any other reason to ‘What about thinking?’ take her own life, such as a physical ailment? Thinking strains her. No, she was in good standing with her loved How about memory? ones, but everything was indifferent to her, even This too has become worse. To test her mem- as far as her parents and siblings. Whether her ory retention, she is given the unfamiliar word siblings came to visit her in the clinic or not, even ‘Antananarivo’ [Ed] to remember. It turns out were war to be declared, or the Kaiser should die, that comprehension of a foreign word is more this would not affect her. She could feel neither

© Springer International Publishing Switzerland 2015 203 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_30 204 30 Lecture 30 joy nor grief; her heart was turned to stone. In visual fi eld examination in the healthy state shows fact she was constantly confi ned to bed, taking no itself normal.) part in the events around her; takes no notice of Presentation of our second patient, the visits by her relatives; and never expresses any 24-year-old shop assistant Bertha Pr. [2 ], as wishes. This even includes care of her body, sat- expected, takes the form of a dialogue. isfaction of her needs, making beds, and the like. The patient enters the auditorium convulsed She shows no initiative at all for chores under- with laughter, and greets those present in a loud, taken at certain times by all patients on the ward, somewhat imperious voice (imitating a lieutenant). and generally does not speak about herself except ‘Good morning, gentlemen, good morning when asked—yet this, as has been noted, is Storch, good morning Liepmann, how’s the little always prompt, provided the question makes no woman doing? Ah, good morning Professor, I am hard demands. When asked whether she thinks of very pleased to see you. How are you? Better anything at all, she replies that she goes over and every day? Right? I’m always a bit funny, but that over an agonizing thought, namely that, after the doesn’t hurt, right? Why shouldn’t I be funny?’ death of her husband (a year before), she has felt Me: ‘Now, just quieten down a bit; and sit so alone and abandoned. down; I want to say something to the gentlemen She is fully orientated as to her situation, feels and then you can talk again.’ sick, and has total confi dence in what the doctors The patient sits down quite unabashed, legs have arranged; and she came to the clinic volun- outstretched, supporting her face in her hands, tarily, to protect herself from suicide. Her spirits turned towards the audience. are brightened by encouragement, but she can ‘Of course, I will be very quiet. Only you will never overcome her doubts of ever being healthy speak. I won’t say a word. Ah, what is that?’ again. She is physically healthy and reasonably (upon seeing the water pipe with a basin). ‘You well fed. However, her appetite is very poor; she have a nice closet,’ goes closer, ‘Ah, a basin, a eats enough only at the behest of others. Despite fi ne basin, and soap, and such a clean towel.’ her need for sleep, it occurs only with the aid of ‘I think you want to be quiet?’ sleeping pills. Fifteen years ago she suffered an ‘Yes, I am too, but ugh, this is dirty’ (runs her attack of melancholia, from which she recovered. fi nger over the basin, shakes it in disgust and then For many years she was then one of the best sticks her fi nger in her mouth). female warders at hospital X. She was married for ‘Now, just sit down again. Are you Bertha 6 years and, since the death of her husband, just a Przytek?’ year ago, she has several times suffered bouts of ‘Yes, but we have known each other for such a an illness similar to that she presents with today; long time, Professor. Oh, what a fi ne frock coat their duration is usually about 4 weeks, with inter- you have; you are a very handsome man, vals of similar length in between. She describes Professor.’ Grabbing me by the hand and posing healthy times as feeling totally comfortable, herself with me after the style of song-and-dance sleeping well, eating well, and enjoying hard people, in a pas de deux [W], she sings as off-key work. The abnormal state always comes on fairly as possible in a loud, harsh voice: quickly, within 1 or 2 days, its arrival being preceded by cessation of her usual copious armpit Wir sind zwei Wunderkinder perspiration. Such dryness in her armpits remains Wie so Kinder sind, throughout the period of illness. Perimetric exam- Das sieht sogar ein Blinder, ination produced results of great interest for the Und wäre er ganz blind. concept of this illness state. This revealed concentric narrowing of the visual fi elds in both eyes, [We are two Wunderkinder] which, in the horizontal meridian, went laterally [Like such children] up to 50°, and medially up to 40°, and, in fatigue [That even a blind man can see] tests could be increased by a further 8–10°. (The [Even though he is totally blind.] 30 Lecture 30 205

Then in another corresponding theatrical and their equally contrasting conduct. I shall soon position: point out that I consider them to be relatively pure examples of those alterations derived from our ‘The wedding will be within a year.’ She then says scheme which I have designated as ‘intrapsychic with a comical, languishing glance: ‘Finally alone.’ loss of function’ [Ed] (or ‘hypofunction’) [Ed], Me: ‘Now be reasonable for once, Bertha, and and ‘intrapsychic hyperfunction’ [Ed], that is, let me say something.’ expressing abnormally reduced and, by contrast, ‘Indeed, I am always reasonable, that is my abnormally increased activity of intrapsychic strong point! You too, what? Now I am perfectly pathways. However, our experience so far is that quiet.’ disturbances of conscious activity, derived from Nevertheless, she continues to talk, taking up our scheme sAZm , always lead to changes in con- everything she sees and hears and using it in her tent of consciousness, mainly in one of the three stream of words. As she hears the word hyper- areas of consciousness we have differentiated; metamorphosis, she says, for example, ‘Yes, and this is also confi rmed here. We will fi nd that Meta, who has given me too much morphine.’ autopsychic orientation is disturbed in both cases, Catching the word Wesen, she says: ‘I have been and accordingly intrapsychic loss of function is on the Weser.’ shifted towards belittlement, and in hyperfunc- ‘How old are you?’ tion towards grandiosity. Functions of conscious- ‘I am now exactly 16 years 2 min old.’ ness also include that act, which constitutes ‘But how can that be?’ self-awareness of the mental condition, which, ‘Believe me, I am 16 years 2 min.’ momentarily, we are in. This fact led Griesinger ‘Where are you now?’ [3 ] to speak of a ‘psychic tonus’ [W], and to clar- ‘In the insane asylum on Göpperstraße.’ ify the abnormally exalted mood from a release ‘How are you treated?’ of—and the depressed mood from an inhibition ‘Oh, let bygones be bygones.’ of—movements occurring in the ‘psychic refl ex ‘Good or bad?’ arc’ [W]. However, changed mental states, as ‘Bad? There’s no word for it.’ the fundamental deviation of intrapsychic func- ‘Then you aren’t pleased to be here?’ tion, are, to an equal extent, essential qualities ‘I will go away. Why should I be here among of personality or individuality. Therefore it is thieves, whores, pickpockets and murderers?’ hardly surprising that an active consciousness ‘Whores? How do you come to be among notices such changes in personality and reacts whores?’ to it. This results in an autopsychic disturbance ‘How did you fi nd me [Ed], Professor?’ of identifi cation in the sense of my introductory ‘What are the gentlemen here for, Bertha?’ comments in Lecture 28 (p. 185). In transfer- ‘Ugh, they are old gentlemen, last time they ring such a disorder of identifi cation, assumed were handsome young men.’ to occur in psychosensory areas, to conscious- ‘You once said that you were a daughter of the ness of personality, it should be seen as a ‘par- Empress. How is that?’ aesthesia’ [Ed], according to our schema. Since ‘Oh, nonsense. I have never been an Empress, we learn from experience that there are numer- I am a Bofel.’ ous relatively pure cases in which the totality of ‘Adieu, Bertha, you may go now.’ symptoms are to be derived from hypothetical states, such as we assume, for intrapsychic loss Nodding familiarly to everyone, she departs, of function and hyperfunction, we therefore have laughing loudly, as she came. ‘Adieu, Liepmann, a way to defi ne two sharply differentiated forms remember me to the little woman. Adieu, of autopsychosis, which we can call ‘melancho- gentlemen.’ lia’ [Ed] and ‘mania’ [Ed]. Gentlemen! The main point in presenting these Let us fi rst consider melancholia [W], for two patients is their entirely opposite mental state, which Mrs H. gives us a good example. 206 30 Lecture 30

We cannot avoid here some brief detail about If we assume that, over a long period, ideas have what we understand by will [W] from our stand- come to possess a certain ‘value’ [Ed], which is point. For anyone to ‘will’ [Ed] a certain action then lost or greatly reduced, a more severe presumes making a decision, unquestionably an dementia occurs, for example in a paralytic action of pure thought (even if not totally pure: patient. Then this habitual relation will be vali- the reduction in memory retentiveness and the dated; and for the simplest of all reasons, he concentric narrowing of the visual fi eld are decides to stay in bed. However, under certain admixtures, which are not present in the majority circumstances, inaction [Ed], the refraining from of cases and possibly belong to a particular, very action, requires a greater effort of will. Think, for rare, recurrent form.). In content, this implies that example, of a conscientious mother, accustomed two or more, possibilities have been weighed to getting up at a certain time to care for her child: against each other. It is only natural that in nor- In the case of severe physical illness, she will mal situations, one [W] possibility easily wins a need all her self-control to obey the physician, victory, having gained its advantage through and refrain from her accustomed activity. habit and usage. Making a decision is then a nor- We can now defi ne as ‘will’ [Ed] that more or mal process, through evaluation of ideas and less complex idea which has proceeded from a trains of thought. Let us take a simple example. I resolution; and in turn ‘resolution’ [Ed] can be wake up in the morning and have to get up and defi ned as the ‘weighing-up’ [Ed] (‘contest’ [Ed] dress, which requires a decision. The two possi- would be more accurate) of two or more ideas, or bilities are to get up and to stay in bed; nothing is series of ideas, of which at least one fulfi lls the more natural than to get up promptly if one has condition that it has a motor content, and can done this all one’s life. But then—getting up may therefore at the same time form the point for ini- depend on other factors. For instance the time: a tiating motor processes. ‘Freedom of will’ [Ed] glance at the clock makes you decide to stay in presupposes freedom of determination, in other bed; or, I have spent a restless night, or believe I words, the normal value of all ideas which have have a fever and feel sick, and so decide to stay in cooperated in reaching the resolution. We do no bed. Clearly the decision is only correct and violence to language if the act of determination is rational when a large number of cooperating included in ‘will’ [Ed], which term may then be ideas have their normal value; and it becomes defi ned thus: Will is the result of the competition abnormal when the value of these ideas changes of different groups of ideas, of which at least one as a result of a mental illness. Thus a hypochon- is the idea of a motor goal, and has access to the driacal patient does not get up, perhaps because point for initiating activity in the centrifugal proof the abnormal physical sensations arising from jection system. From such a conceptualization, the mental illness make him feel physically ill we can understand that the ‘will’ [Ed] represents, and too weak to rise. to some extent, an index of the intrapsychic func- If, as in this example, only two possibilities tion connected to the AZ path of our scheme. are to be weighed up, either to do or not do some- Our consciousness must have a rough knowl- thing, it would be thought that only the fi rst case edge of the resistances in this centrifugal tract concludes an action, and that therefore the condi- Zm , and of the necessary expenditure of energy to tions for its [Ed] occurrence are always harder overcome these resistances, since we learn by than for the second case. That would in itself experience that it is harder to resolve to do some- probably be correct, as we shall see soon. thing, the more diffi cult is the task. Things that However, for this partially ‘prepared’ [Ed] state are new, unknown, and hitherto untried, always of consciousness in an awake person, the ‘value’ seem the hardest, even when the diffi culty is only [Ed] a certain idea has attained by usage, training an apparent one, based on our misjudgement of and habit becomes decisive; and in comparison our own ability. Thus, for an inexperienced per- to this, it is fairly irrelevant whether ‘to do’ [Ed] son, a strong ‘will’ [Ed], or an unaccustomed or ‘not to do’ [Ed], forms the essence of the idea. ‘effort of will’ [Ed] as people say, is necessary to 30 Lecture 30 207 jump on to a snow-bridge in crossing a crevasse, Consequently it is hard for a patient to make even when the leap is quite easy, and presents no decisions about necessary actions of everyday real danger. If this example seems too compli- life, and eventually, about any action at all. In this cated, it is much the same when one pronounces phase of illness we often hear the complaint that a diffi cult word in a foreign language: A timid a patient cannot get up and leave his beds without scholar gives up pronouncing the word right overcoming his very self. away, and makes no attempt. The effect of this condition is manifested in Many actions have mutual dependence on one different ways according to the personality of the another, in such a cogent manner that one of individual affl icted. In personalities who are them, once begun, forms the initial link in a more highly esteemed socially, who consider that whole chain of subsequent actions. Likewise, our carrying out necessary actions of daily life to be consciousness is aware that much greater effort is a duty, the feeling of failure, exacerbated carry- required under these circumstances, and there- ing out those duties, leads to the idea of ‘neglect fore requires especially strong motivation to of duty’ [Ed], wickedness, or accordingly, iniq- reach a resolution in our will for such an under- uity; that is, it becomes the source of delusions of taking. These undertakings, in contrast to the guilt, or of belittlement. At the very least, devel- simple actions just described, are rare ones which oping from this is a fear of the future [W], which require a person to climb a mountain, learn a for- always seems to impose new tasks on perfor- eign language, or take an examination. mance of duty; and this fear of the future is often These few considerations suffi ce to help us synonymous with a dread of living longer. Any understand symptoms which are based on reduc- incidental factor which complicates such tasks, tion of ‘will power’ [Ed] by loss of function [Ed] even if it falls within the range of habitual duties, at intrapsychic levels. The onset of Affective mel- readily leads to a feeling of catastrophe in consci- ancholia [W] is often manifested by inability to entious persons. In this regard, 1 can never forget carry out some very easy tasks. The tradesman the case of a colleague at Charité who, on return for whom a new project is required every day, from leave of absence after an attack of Affective fails in his tasks; the student refuses to enter an melancholia, was given charge of the ward for examination, although earlier he had been quite syphilitic women, and who could not get over the sure of his success; and for another, it becomes painful impressions of this service. He shot him- quite impossible to make a decision on some self on the day he was to begin the service, and matter, etc. Here we can see the mildest form of left a note bearing the signifi cant words: ‘I am intrapsychic akinesia. (Many suicides among absolutely unable to live any longer.’ Prior to this young men can be traced back to their inability to he had left no stone unturned, to get transferred to decide to sit an examination). another ward. There are numerous suicides At fi rst, individual actions which run along the which, in origin, take this form, and in most cases familiar tracks of daily life can continue with few the motives come to be understood only after problems; yet gradually the diffi culty of thought they have happened; for the conditions surround- processes increases, and then even a simple action ing these acts are such that the individuals con- appears to be a major undertaking. The patient cerned tend not to express their feelings, and it is himself notices that, for him, any resolution to act only later, usually when half-automatic utter- creates major diffi culties. The diffi culty increases ances are seen in their proper light, that any con- with the complexity of the task: Initially it is man- clusion can be reached about the mental state of ifest on every occasion which falls outside the the suicide victim. scope of routine activities of life, such as when a The self-knowledge that there are obstructions judicial matter has to be attended to, a journey has to ‘acts of will’ [Ed], the subjective feeling of to be made, or a person has to act in support, or in inadequacy [W], is perhaps the most signifi cant the interests of other people. Chiefl y these are all and characteristic symptom of Affective melan- the more important decisions. cholia. It is often described by patients in very 208 30 Lecture 30 practical terms, and forms the very core of their scholastics, that a person can control his thoughts intense feeling of misery. and feelings, whereas actually the thoughts con- A blunting of psychic feelings goes hand in trol the person, there arises the idea of neglect of hand with the diffi culty in decision-making. duty, wickedness, and unworthiness, which itself When I speak of ‘psychic feelings’ [Ed] I refer to can become the starting point for the idea of sui- another sort of feeling about which you already cide: ‘I no longer deserve to live, I no longer know: the ‘organ feelings’ [Ed], which I have deserve the love of relatives’ [Ed], etc., are expres- contrasted with the ‘quality of sensations’ [Ed], sions often heard from these patients. All in all, endowing the latter with the so-called ‘tone of the mental state of these patients may be described feeling’ [Ed]. These psychic feelings have noth- most accurately as a feeling of misery. However, ing in common with such sensations; rather, they this feeling of misery, as just analysed, has a very show themselves to depend on prolifi c intrapsy- different origin from that mentioned earlier, chic activity, encompassing a plethora of associa- which has its source in hypochondria. It is based tive connections. We understand by them some of on awareness of an aberrant change in personal- the following ideas: love, hate, like, dislike, ity, and may thus be regarded as a special type of friendship, sorrow, worry, etc., all of which are autopsychic disarray. verbal expressions for certain internal experi- Gentlemen! As you see, these are essentially ences which, with some justifi cation, are assumed subjective [Ed] troubles which defi ne Affective to be the same in all persons. While the psychic melancholia. Objective [Ed] symptoms are fi rst feelings mentioned usually refer to relations with noticeable when the illness reaches a certain persons [Ed],we understand by the term ‘interest’ level of intensity, but may easily be overlooked [Ed] a similar Affective state in relation to things or misinterpreted. These are the signs of intra- [Ed] and conditions [Ed], and so we can speak of psychic akinesia, which are thus essentially neg- an interest in art, science, in politics, in following ative symptoms: Patients gradually cease to talk some occupation, especially business, etc. As is about themselves, or to do anything. That was seen, ‘interest’ [Ed] really belongs amongst the also seen in our patient, Mrs. H. However, a psychic feelings, and it is only in practice that it noticeable retardation and severe limitation in is split off from them, as an oversight. Both are her reaction to external promptings exceeds the states of the individual, derived exclusively from narrower perspective on our illness. The reason intrapsychic activity. When they are compro- lies in the following condition: The absence mised and distorted, the patient notices a blunting of reactions—reactive akinesia—always corre- and a cooling of his feelings, for instance in his sponds to a relatively severe attenuation of intra- closeness to his nearest relatives, with lessening psychic function, which will likewise inhibit of interest, for example in business, public affairs, occurrence of the fundamental symptom of sub- and his usual diversions. The consequence of jective insuffi ciency. We have seen such severe self-knowledge of this is a state of abnormal loss of intrapsychic function and akinesia— indifference and inner emptiness, whose proto- characterized mainly by objective symptoms of type is the blasé attitude, the renowned ‘spleen’ defi cit—often enough, that it can be separated [W] of the English. For more refi ned individuals totally from Affective melancholia—a condition who are not satisfi ed by gross sensual pleasures, which we shall call depressive melancholia [W]. the charm of life then ceases, and thoughts of sui- We will have much more to say on this later. cide, at fi rst indefi nite, gradually take on a more Here I merely raise the question whether depres- tangible form. This thought becomes a real dan- sive melancholia can be regarded as a special ger when the patients have resolved upon a way mental illness. For Affective melancholia, in our to carry it out. limited perspective, no such doubts exist. The other consequence is delusions of belittle- For completion of our clinical picture, a few ment, or ‘self-accusatory delirium’ [Ed]. As a more symptoms are still to be mentioned. These consequence of the error, promulgated by the are so frequent that we must conclude that there 30 Lecture 30 209 is some internal connection between the symp- in that they could have been saved had different toms. Most of these patients complain of anxiety; approaches to care, or other measures been taken; and this has the hallmark of a physical anxiety, and each person’s occupation provides the con- localized by far most frequently in the thoracic tent for more-or-less fanciful self-accusations: a region, followed by the head. ‘Sad thoughts’ [W], merchant says he is a swindler; an offi cer, that a frequent expression of suicidal ideas, are mani- he is dishonourable, and so on. Secret sins of fest especially as seizures or as an increase in youth and sexual excesses are very common anxiety. Such anxiety can only be seen as a direct self-accusations. consequence of inhibition of intrapsychic func- Affective melancholia can develop progres- tion. It is the same with a further symptom, the sively so that the intensity of symptoms depicted monotonous persistence of certain nagging, reaches particularly severe levels. In this situa- obtruding ideas which the patient cannot dispel. tion a patient’s complaints, which heretofore In content, these ideas are of two kinds, referring have not exceeded the bounds of possibility, take either to experiences in the past going along with on a fanciful, and manifestly unlikely direction, the notions of the self-accusations, or of a hypo- resulting in fanciful delusions of belittlement chondriacal nature: Slight muscular pains lead to [W]. The patient accuses himself of being to ideas of being permanently paralyzed; a globus blame for the fact that there are so many sick sensation in the neck is interpreted as a cancerous people, that people must starve, that the world is growth; Molimina uterina [W] or Molimina alvi coming to an end. The fanciful element appears [W] as degrading sexual diseases. Patients’ feel- also in assertions which reveal, in content, a fail- ings of misery and hopelessness are thus ure of processes of association, for example, ‘I increased. Emergence of such ‘overvalued’ [W] am no longer a person,’ ‘I can never die,’ ‘Evening ideas seems to be a plausible secondary effect of will never come again,’ and fi nally ‘Nothing the same process, by which the illness is aggra- exists anymore.’ Such assertions can only be vated, and associative activity is reduced. Finally, interpreted as the patient’s becoming consciously certain general symptoms need to be sought. aware of the failure of association pathways to Many patients have a coated tongue, or more render possible an image of the world, of their obvious symptoms of gastritis, and all have poor own personhood, and of their body. appetites, which may reach the level of a pro- From the same belittling delusional idea, nounced aversion to eating. The majority have namely of unworthiness to live—and especially cold—often even cyanotic—extremities. to eat—a persistent refusal of food may arise, Affective melancholia usually develops quite with violent resistance to all attempts to feed. slowly, over the course of weeks or months, from Ideas of belittlement may also take on the almost imperceptible beginnings. It therefore guise of voices. Patients hear themselves being fi rst becomes evident to patients themselves and charged with most hideous misdeeds; they hear to their relatives when the above symptoms have words like: ‘murderer, adultress, whore’ and, as already become clear, and the diagnosis is then expressions of hopelessness, words like: ‘eter- made easily, on the basis of suitable leading ques- nally damned’ or ‘eternally lost.’ However, such tions. The clinical picture may itself be coloured phonemes are always isolated and sporadic, in individual ways, depending on whether self- remaining confi ned in their content to ideas of accusation, feelings of misery, or the blasé atti- autopsychic anxiety, even when anxiety is severe. tude are more prominent. Self-accusation is Visual hallucinations of more-or-less confused occasionally limited to the idea of being to blame form occur in milder forms of melancholia. These for the illness, by having incorrectly understood generally appear under favourable conditions—at or neglected some activities. Otherwise, its con- twilight or at night—and relate to the sad thought tent varies according to the patient’s personality. content which preoccupies the patient. Patients The delusion of being to blame for the death of see coffi ns, corpses, or an entire funeral, people in some deceased relative is particularly common, mourning, or deceased relatives. They usually 210 30 Lecture 30 expressly state that these are ‘images’ [Ed] or Affective coloration corresponds more to milder ‘shadows’ [Ed]. grades of Affective melancholia. More severe forms of such illness may arise Gentlemen! The clinical picture that I have from milder ones, as a worsening; but they may outlined for you is not identical with the melan- also develop independently, and then usually cholia of some other authors, nor with the illness much more acutely than the mild forms. designated as ‘melancholia’ [Ed] by Meynert [4 ], The course [W] of Affective melancholia may which he identifi es with ‘micromania’ [Ed]. We be represented purely in the form of an ‘intensity’ have already seen, and will be even more con- [Ed] curve, that is, the grouping of symptoms vinced later, that this form of belittlement has an summarizing the clinical picture, which itself entirely different aetiology, and therefore must be remains the same throughout the duration of the regarded differently. I have no reason to go into illness; and it is only their intensity which shows greater detail about the clinical pictures set forth some variation. As already stated, the illness gen- as ‘melancholia’ [Ed] by other authors, and I say erally develops slowly to its full intensity over a no more than that they usually include far too few weeks, then remains at this level, usually much. Nevertheless, an old tenet deserves men- only for weeks, occasionally for months, and tion here, the more so as it appears perfectly com- then, just as gradually or even more slowly than it prehensible to us from the little clinical developed, moves towards convalescence, and knowledge that we have so far acquired. At the fi nally, to recovery. Slight variations in intensity time when a prevailing unpleasant, painful men- may be manifested at the time of the height of the tal state, so diverse in its coloration in cases of illness, but, overall the course is continuous. illnesses, was called ‘melancholia’ [Ed]—a time After the illness has ended, a phase of mild which, for many authors, has not yet passed—the manic exaltation is seen quite regularly, lasting proposition was advanced, and always fought for only a few days or weeks; and it is always ill- since then, that all mental illnesses should begin advised to discharge the patient before this. The with melancholia. An exception has been recog- curve of body weight is an exact mirror image of nized only in certain cases of chronic mental ill- the illness curve, and impending return to health ness, the so-called ‘primary paranoia’ [Ed]. On is revealed by the fact that no further weight the other hand, if we consider that the painful increase occurs. Gaining insight into the illness, mental state of disarray, in its various colorations, the criterion generally required for every recov- forms the necessary attendant symptom of most ery, is therefore harder to evaluate in the present acute psychoses, we can understand the meaning illness, because, for Affective melancholia, liter- of this old maxim, and fi nd in it the expression of ally by defi nition, insight must be present to a cer- a clinical observation that is correct in itself, even tain degree through the whole duration of illness; if very vague in content. at least a certain ‘feeling of being ill’ [Ed] always Gentlemen! If we want to understand by exists, or else real insight into being ill is lost only Affective melancholia [Ed] simply the clinical occasionally, and then at the height of the illness, picture that I have outlined and traced back to the when infl uenced by ideas of belittlement. hypothetical state of loss of intrapsychic func- Prognosis [W] of the illness is generally tion, so setting the greatest possible limitation on favourable, provided the ever-present danger of the number of cases, you will still discover that it suicide can be excluded, or is known to have been is one of the most common mental illnesses. averted. However, there are rare cases where Understandably, this opinion can depend on esti- Affective melancholia becomes chronic, and mates which are only approximate, and on purely only some years later does a slow decline emerge personal experiences; yet I do not doubt that all in intensity of symptoms, without it ever merging experienced alienists will agree with me, once into either recovery or actual dementia. In their they go beyond the statistics of actual institu- clinical picture, such cases show some relation- tions, to consider the experiences in private ship to depressive melancholia, while the consultations. 30 Lecture 30 211

In fact the vast majority of such patients go to differentiated from one another by very defi nite a doctor’s consulting room, and only a small ‘pluses’ [Ed] or ‘minuses’ [Ed] of symptoms. number reach any mental institution, which, as This must be the main principal to guide us. Of the sad outcome often reveals, is greatly to be no less signifi cance practically, is the fact that regretted. This fact cannot be taken as accidental: most patients with anxiety psychosis experience A natural explanation can be found in the feeling numerous phonemes, with contents correspond- of illness that has often given rise to real insight. ing to both groups of ideas just mentioned; Much as such patients are willing to concede that whereas the melancholic has no sensory decep- their mind is affected, their ‘irresolution’ [Ed] tions of any kind, at least, when he seeks medical stands in the way of any decision, when they are advice. A further reference point in diagnosis is advised to go to an enclosed institution. Relatives given by the internal relationship between are rarely so understanding that they see how Affective melancholia and depressive melancho- much this measure is needed, for the general lia, namely signs of retarded thought and speech, view is that only the insane belong in institutions. and the inactivity, occasionally seen in patients— Hence every alienist will have cases where his symptoms all totally foreign to anxiety psycho- warnings have been all in vain, and he must limit ses. And so in most cases it is easy to exclude himself to prophesying suicide. On the other anxiety psychoses, and thus to confi rm the posi- hand, 1 will soon explain how, under favourable tive symptoms of Affective melancholia. conditions, real treatment in an institution can It is often much more diffi cult to differentiate actually be avoided. anxiety neuroses—whether hysterical or neuras- Gentlemen! It is the facts just mentioned, thenic—from anxiety melancholia. The diffi culty namely the frequency of the illness, the danger is obvious, and factually substantiated, in that such patients always face, and the almost guaran- subjective feelings of inadequacy may be promi- teed benefi ts of appropriate medical measures, nent in anxiety neurosis, and can actually arise which will keep you constantly aware of the from attacks of anxiety; and further, on examin- importance of an accurate diagnosis [W] of this ing a patient—a process essentially aiming to illness. In this respect there is only one serious elicit their subjective symptoms—has, in neurot- diffi culty, differentiating it from the large group ics, a mildly suggestive effect, which brings to of anxiety psychoses in general, and specifi cally light troubles which, in reality, do not exist, and from anxiety neurosis with hysterical or neuras- which are affi rmed only momentarily by the thenic bases. The differential diagnosis between patient, under the infl uence of the examination; Affective melancholia and anxiety psychoses and fi nally, the feeling of misery, and the fact that depends essentially on the following criteria: A formal thought activity is intact, and may occur group of ideas is common to both illnesses, if the in both illnesses in the same way. In such cases, latter occur to a marked degree: those of autopsy- the chief consideration is that Affective melan- chic anxiety and especially those of belittlement. cholia is a continuous [Ed] illness from the out- In both conditions there are complaints of anxi- set, the anxiety being only an accompanying ety, even though in melancholia these do not have symptom not one which determines the essence such a primary status, and lack fl uctuations char- of the illness as it does in anxiety neuroses. In acteristic of most anxiety psychoses. In contrast, contrast, anxiety neuroses always occur as subjective feeling of inadequacy the fundamental isolated attacks, in which anxiety is the principal symptom of our illness, is missing in the anxiety symptom; belittlement and ideas of actual anxi- psychoses, or is revealed only as an easily recog- ety, even autopsychic anxiety, are usually absent, nizable variant of belittlement, and thus takes on the and if suicidal ideas occasionally emerge, they form of autopsychic anxiety. On the other hand, are driven by motives entirely different from Affective melancholia totally lacks ideas of allo- those in melancholia. If an opportunity is pre- psychic anxiety so typical of most cases of anxi- sented to observe an actual attack of anxiety, ety psychosis. Thus, the two illnesses are dyspnoea and the symptom of phrenic nerve 212 30 Lecture 30 insuffi ciency [5 ] will usually be encountered. case (p. 200), of compulsive ideas of blasphe- Finally, careful history-taking will, in most cases, mous content which appeared especially while disclose previous hysterical or neurasthenic praying, feelings of misery were very prominent, problems of other kinds. There are always bor- interest in other people and objects blunted, and derline cases in which the differential diagnosis belittling delusions of depravity, and often also between Affective melancholia and anxiety neu- anxiety, were present. Nevertheless, the origin of roses remains unresolved, especially when the trouble, and especially the exact description impulsive suicidal tendencies are prominent. which the patient gave of her compulsive ideas, These are usually cases with the strongest heredi- seem to exclude any confusion with Affective tary affl iction and neurotic degeneration, which melancholia. are otherwise inaccessible to any kind of medical Gentlemen! Treatment [W] of Affective mel- treatment. I know of a case where a patient, the ancholia is one of the most gratifying tasks of young wife of a lawyer, after treatment in institu- our calling, for this condition almost always has tions with no benefi t, and then being discharged a good outcome, the dangers well-known, and home on a trial basis, locked herself in the closet therefore relatively easy to avoid. In many cases for a moment, drenched her hair and clothing in the regime of a well-run institution is essential, petrol, and set it alight. Her maid, who had looked and you should keep uppermost in your mind the after her as best she could, but at the moment of transfer of a patient to a suitable institution as that act was preoccupied with the children, was soon as you have made the diagnosis. Only an admitted to the clinic about a year later with the experienced specialist should make the defi nite overvalued idea that she must take her own life, decision that institutional treatment is un neces- after she had actually jumped into the river. sary [Ed]. In the latter case, arrangements must Gentlemen! As mentioned above, an overval- be set in place which are otherwise provided ued idea is usually a component of the symptom only in an institution; and these can be readily complex of Affective melancholia. Its content is defi ned. They consist of provision of total physi- generally derived from what Meynert [ 4 ] called cal and mental quiet, good food, sleep and com- self-accusatory delirium; and I have already said pletely reliable supervision. It is easily seen that that it may have been based on actual experiences. these conditions are hard to secure in a private Therefore, under certain conditions, cases of lim- home, while relatively easily met in any hospi- ited autopsychosis arising from an overvalued tal. If then a patient’s family—for the patient’s idea may show outward similarity to Affective wishes cannot be the determining factor—does melancholia, in that the overvalued idea, through not consent to institutional treatment, whatever its content, may approximate those of Affective your advice, you must at least make sure that the melancholia. I mentioned cases earlier where aforementioned requirements are complied with, another person’s suicide, the accidental death of and bed-rest and isolation for the patient imple- relatives, or the memory of some wrong commit- mented. You must be ever conscious of the great ted, has led to the development of an overvalued responsibility that you shoulder with such an idea, with which, naturally, there may be com- approach. bined feelings of intense misery, feelings of anxi- The principle of treatment is, moreover, rela- ety, and suicidal tendencies. Absence of other tively simple and consists of sparing the patient symptoms characteristic of Affective melancho- everything requiring a decision, which arouses lia, and presence of a circumscribed delusion of psychic feelings, or makes a demand on their reference in such cases, prevent an incorrect diag- interest. Everything must be presented to the nosis. Similarly, autopsychoses arising, through patient as self-evident and related to the treat- their content, from compulsive ideas, commonly ment, and no independent action of any kind result in self- accusatory delirium and delusions of must be expected of them. They must be washed, belittlement. For example, in the briefl y reported combed, kept clean; food and drink must be 30 Lecture 30 213 brought to them, all these measures to be contin- he deals with melancholia according to his ued until the patients themselves regard them as mainly aetiological principle of classifi cation in purely mechanical, habitual actions, and partici- two entirely different places: fi rst, as a specifi c pate in them of their own initiative. An attendant psychosis of ‘age-related degeneration,’ in other must, of course, always be present, but speaking words senile involution, which has a generally to patients or exciting them in any way is to be poor prognosis. In fact, you will learn that, in avoided. Under such treatment, feelings of mis- most cases, there can be recovery from Affective ery rapidly decline in intensity; patients soon melancholia in old age, even though, on average, sense it to be extremely benefi cial. Nevertheless, it seems to last longer, and the risk of relapse is it often occurs that, quite soon, patients show higher than in melancholia of adolescence and signs of impatience, and long for their occupation middle age. In addition, according to Kräpelin, or return to their family, whether from years of there is a form of melancholia which is more habit, or from anxiety about the relatives. This restricted and nearer to our clinical picture, but desire must not be made possible: The phase of which he places amongst illnesses arising as con- such premature requests ceases of its own accord, stitutional traits; these are not regarded an inde- and then gives place to the insight that judgment pendent illness, but rather as a component of a of the proper time be left to the physician. Food, periodic mental illness conceived as ‘manic- must, of course, be abundant and easily digest- depressive’ [Ed], or more recently as ‘circular ible; as soon as possible the patient is to become psychosis’ [Ed]. From my own experiences, I accustomed to overfeeding, by frequently taking must totally contradict this concept, according to small quantities of milk between meals. Any gas- which we should always expect recurrence, at tric troubles and disorders of digestion naturally least of the same disease. Affective melancholia require careful consideration. When convalesc- does show a tendency to recur, but this is not an ing, complaints of boredom and the need to be essential feature, and is, at any rate, a much less occupied are best allayed by such measures that pronounced tendency than for many other mental require only the patient’s passive cooperation, illnesses. If circular mental illness is disregarded, like wet packs, friction rubs, massage, and luke- and is not extended at will to include isolated warm baths. Thereby premature activity can be attacks of melancholia or mania, as Kräpelin prevented. does, then his claim, advanced with so much cer- Gentlemen! 1 have repeatedly stated that tainty, can be explained only by the fact that he prognosis [W] of this illness is generally had in mind the cases of ‘vicarious melancholia’ extremely favourable. However, naturally, this [Ed]—which I will mention later—that is cases applies only to the sharply defi ned clinical pic- in which an attack of recurrent mania is replaced ture we understand by the term ‘Affective melan- by one of Affective melancholia. Recurrent cholia’ [Ed]; and I must emphasize this all the Affective melancholia, which occurs in a rapid more, because in the majority of textbooks, and succession of attacks, as does recurrent mania, in those most widely used in our discipline, you admittedly does exist, but is one of the greatest will come across quite different opinions. This rarities. Mrs H. is an example. These cases, by comes about mainly because essentially different their rapid onset and decline, all seem to have a cases, for example ones of anxiety psychoses or distinct status, compared with the great majority. even ones of a more complex nature, are thrown With respect to the aetiology [W] of the ill- together with the Affective melancholia as we ness, most cases occurring during adolescence know it. Even in the clinical lectures of Meynert, and most commonly among women are to be dif- to whom we owe so much, you will fi nd this clin- ferentiated from the others; the former group of ical picture defi ned far too broadly. The teachings cases occurs almost exclusively in individuals of Kräpelin [6 ], are particularly widespread; and who have severe hereditary loading. 214 30 Lecture 30

4. Meynert T. Melancholie, Kleinheitswahn, References Selbstanklagewahn. Wien klin Wochenschr. 1889;11(39–42):745–47. 767–70, 783–86, 803–7. 1. Wernicke C. Krankenvorstellungen aus der psychia- 5. Wernicke C. Die Insufﬁ zienz der Nervi phrenici und trischen Klinik in Breslau. Breslau: Schletter; 1899. ihre Behandlung. Monatsschr Psychiat Neurol. vol 1, Case 7. 1897;2:200–4. 2. Wernicke C. Krankenvorstellungen vol 1 Case 5. 6. Kraepelin E. Die klinische Stellung der Melancholie. 3. Griesinger W. Die Pathologie und Therapie der psy- Monatsschr Psychiatr Neurol. 1899;6:325–35. chischen Krankheiten für Ärzte und Studierende. Stuttgart: A Krabbe; 1845. Lecture 31 31

• Clinical picture of pure mania not seem to us aberrant and would indicate, rather, • Levelling of ideas a desirable increase of psychic ability. The pre- • Course interruption through clear intervals rogative of mental giftedness or of genius depends • Tendency to recurrence essentially on the unusually rapid and more exten- • Diagnosis sive thoughts within the same timespace than is • Paralytic mania available to mediocrity. We describe wit, speed of • Paralytic grandiose delusions without mania repartee, presence of mind, versatility of interests, • Kahlbaum’s Progressiva divergens [W] and other valued attributes of prominent people in • Combinations with melancholia this way. In contrast aberrant facilitation of ‘acts of • Circular mental illness association’ [Ed] produces the inconvenience that • Chronic mania the train of thought is no longer strictly closed, as it is in the normal state, as represented by the well- worn path AZ , but that each link of the association chain extending from A to Z may afford the start- Lecture ing point for trains of thought, which correspond to secondary associations, which are normally Gentlemen! suppressed. In my introduction, I developed the Just as the clinical picture of Affective melan- idea that a strictly terminated train of thought is the cholia—which we derived from experience—is result of practice and training, that is, of functional fully explained by assuming an intrapsychic loss acquisition. In general, however, where more [Ed] of function, so we also encounter, albeit less complicated trains of thought are being modifi ed, frequently, an acute mental illness that, in all its a degree of self-control or collectedness is needed symptoms, may be derived from an opposite to suppress all secondary associations which might state—of intrapsychic hyper function [Ed]. We disturb the main one. As long as this ‘circumspect call it mania, and have an example in the recently collectedness’ [Ed] is not lost, secondary associa- presented patient Pr. Let us now consider its indi- tions may be noticed to an intensifi ed degree, and vidual symptoms more closely. yet the main association is retained. This possibil- Aberrant facilitation and acceleration of ide- ity exists particularly in highly trained minds. This ation, corresponding to the concept of intrapsychic results in a greater abundance of thoughts, a state hyperfunction, is manifested chiefl y as fl ights of of increased productivity, and eventually actual ideas [W]. It is not merely a more rapid fl ow of the improved ability, as can occasionally be seen in chain of thought between A and Z ; for such would initial stages of the abnormal state to be described

© Springer International Publishing Switzerland 2015 215 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_31 216 31 Lecture 31 here. Particularly in Homo tardus [W], a mentally without progressing to the point of incoherence; sluggish, and unproductive individual, a benefi cial and in what follows I will always have in mind change in the whole personality may be produced just this, when I speak simply of ‘mania’ [Ed]. in this way for a short time. We could then speak ‘Confused mania’ [Ed] will be given separate of a ‘coordinated fl ight of ideas’ [Ed]. consideration. Usually, however, the fl ight of ideas reduces Certain other symptoms are closely connected an individual’s ability, in that it robs him, or lim- with abnormal euphoria: These include increased its his ability to retain the main association. The self-assurance, manifest in a pretentious appear- fl ight of ideas then becomes uncoordinated. Thus ance, a domineering manner, or a sense of supe- rational judgment of actual ability is lost, and a rior knowledge and understanding. A degree of feeling of increased capacity arises, the counter- intrapsychic hyperkinesia is the counterpart of part of the subjective feelings of inadequacy in akinesia in Affective melancholia. In fact every- melancholia. While the latter leads to feelings of thing seems just as easy for a person who is misery, here it induces feelings of happiness, to manic as it is hard for one who is melancholic. the point of abnormal euphoria; but here too, Autopsychic disorientation takes the form of assuming that some degree of psychic ability pre- grandiose delusions, and a patient claims for vails, self-awareness of the change in personality himself attributes, property, offi ces, and func- may be enabled—an autopsychic paraesthesia in tions which do not match reality. Nevertheless, the above sense. Consequently, the Affective such manifestations of grandiosity usually remain state of abnormal euphoria which determines the within limits not far removed from what is pos- clinical picture often shows up as transitions to sible, or which are manifest only conditionally, as autopsychic disarray. If the patient can be stabi- opinions and expectations, or which are expressed lized, at least for a moment, it may be possible for ironically, as though the patient were joking, and closed trains of thought to occur, perhaps by dint indulging in ‘make-believe’ [Ed]. Not uncom- of strong efforts on attentiveness, and when monly however, grandiosity reaches excessive requirements are not too diffi cult. If the distur- proportions, and even fantastically grandiose bance exceeds such limits, the fl ight of ideas ideas, arise sporadically, yet never fi xed, chang- becomes not only uncoordinated, but incoherent. ing from day to day. The result is a disconnected jumble, so that any Abnormal euphoria is sometimes permanently possibility of intense Affective states is abol- combined with a tendency to irascibility. At other ished. Flight of ideas in severe degree—the coun- times it may be interrupted by irascible Affects. terpart of depressive melancholia—leads to a Both of these are understandable, in that the state of confusion, without a defi nite, controlling exacting, obstinate, and domineering characteris- Affective state, the ‘fl ight-of-ideas confusion’ tics of this illness naturally arouse people’s oppo- [W] according to some authors, to be met again sition, which enhances anger. If the irascible under the heading of ‘confused mania’ [W]. It is Affect does become permanent, it seems to be an intensifi ed mania, a clinical picture that due either to physical maladies, or to long- exceeds ‘Affective mania’ [W]. The justifi cation continued, improper treatment by other people. for making this distinction, as much as any prac- Increased activity in the process of association tical requirements, meets the needs of our theo- brings two other sequelae [W] to the fore, which retical derivation, demonstrably so, in that, in show plainly the contrast with melancholia. A mania, we often observe transition of one state patient’s interest in all events they witness, and into the other. The connection is much more cer- their readiness to follow up on any outside sug- tain here than in melancholia, where I suggest gestion is increased. Growing out of the increased that the depressive form, as a symptom complex, thought activity, is to some extent the need to sus- may be independent of the Affective form, and tain stimulation. This mental disposition may be needs to be considered separately. However, confused with hypermetamorphosis, but is mania is often limited just to the milder form, entirely different, as we will see later. Similarly 31 Lecture 31 217 with the second sequela , the increased ease in the boisterous, exalted mood of such patients! taking decisions, and the tendency to transform Only when an irascible tone prevails may this be decisions rapidly into action. The consequences missing, and probably then with comprehensible of this are enterprise, drive, and interference in psychological motives. The verbal content of that affairs of others. On the ward, these two attri- loquacity always betrays increased mental pro- butes in combination are enough to produce the ductiveness, even if this is of highly varied qual- greatest uproar. ity, each according to his individual style. As the Patients are no less disturbing as a result of Affect tends towards an elevation of mood, it is two other symptoms, which fall wholly within readily understood how irritating and annoying the range of intrapsychic hyperkinesia—the ‘urge such patients, with all their loquacity, can be. to be active’ [Ed], and the ‘urge to speak’ [Ed]. Gentlemen! I should now speak of an impor- The phrase ‘urge to be active’ expresses the idea tant symptom, whose derivation from general that hyperkinesia, defi ned elsewhere as ‘motor intrapsychic hyperfunction is not immediately impulse’, has a special content here, namely a comprehensible, but which is constantly found in drive to activity, or, better perhaps the need [Ed] mania, and is of special interest to us, in that an for activity; in other words, a compulsion to act opposite symptom occurs in melancholia. It is rather than merely to move. Hyperkinesia thus based on the levelling of groups of normally involves those types of initiative movement overvalued ideas. Manic patients all seem to which are more complex. The impulse depends undergo damage to their character. It never occurs on the increased rapidity and readiness to make to any such patient to express sympathy for other decisions, and increased interest in things, which patients, when the latter arouse so many feelings lead patients to get up to all sorts of mischief: to of compassion. On the contrary, he only com- throw furniture about, spill food, throw bed- plains of the disturbance that he thereby some- clothes around, take over the ward staff’s duties, times experiences, and hits back at every and to make suggestions correcting patients and interference. Thus, a certain brutality, or incon- staff, whether on proper or improper occasions, siderate egotism, is manifest. The manic lies, or even to attack them. In all severe cases, this cheats, and steals without compunction. He urge deteriorates still further: Patients demolish claims everything he is allowed, while criticizing everything which is not screwed or nailed down, this trait in others. Similarly, displays of sexual destroy linen and bedding, paint the walls with desire, which is usually increased, appear incon- improvised colours, not hesitating to use their siderate and shameless. No manic woman, who own urine and faeces, or, each according to his might previously have been the most innocent own style, to write, compose poetry, draw, and in and modest of girls, holds back with her opinions this way consume huge quantities of paper. and knowledge. Similarly, I have never seen a Besides this, patients’ movements usually man- manic woman who would have considered it at age to convey their exalted, happy, boisterous, or all out of the ordinary to be in the bath when the occasionally irascible mood: They dance, hop, physician came, and the tendency of these jump, laugh, make faces, make teasing gestures, patients to undress and to use obscene language and—quite seriously—threatening and menacing is well known. At a clinical presentation, despite ones etc. Many observations lead us to the view its powerful effect encouraging a patient to exer- that motor strength and shrewdness of such cise self-control, her free, uninhibited behav- patients may actually be increased; at least their iour—quite uncalled-for in a girl—and the way performances are often surprising in their strength she expresses herself, attract attention as being and shrewdness. abnormal, without further comment. No offi cer Loquacity seems to be an ever-present symp- who is manic takes the decent course, but breaks tom of intrapsychic hyperfunction, matching our his word of honour not once, but ten times. All experience that mental activity is always accom- opinions on matters which had previously panied by communication. How much more so in included the most sacred of feelings, are utterly 218 31 Lecture 31 transformed into cynicism. There are abundant objectively visible loss of vigour, and more extensive examples, by which patients show severe decline of nutritional status. In part, we adherence to their convictions, disregarding all must trace this symptom back to the favourable consideration for family, religion, honour, coun- infl uence that elevated mood normally has on try, etc. We take this quite regular change in char- food intake. The single deleterious effect which acter as being due to the normal value of ideas opposes it, is insomnia or, at least the reduced having suffered. However, whereas in melancho- desire for sleep in these patients; for appetite lia the way this happens is of a defi nite, narrow tends to be increased, and infl uence on metabo- circle of ideas becoming overvalued and domi- lism and circulation is always benefi cial. Here we nant by themselves, in mania we observe a sup- fi nd the diametrical opposite of Affective melan- pression and levelling of the normal range of cholia, in which gastric and digestive disorders, overvalued ideas that are decisive in attitude and as well as depressed circulation, are familiar and action, and which also determine every person’s frequent symptoms. This contrast is shown most character. It must be expected, and is confi rmed strikingly in cases of circular psychoses, where by clinical observation, that such a levelling of the transformation of the one clinical picture into ideas in persons whose character already left the other may occur in days, occasionally even much to be desired, must be especially ugly, and within hours. imprints on them the stamp of vulgarity even Mania is usually an illness with acute-onset more sharply than in other patients. and rapid progression. It is then stable for a few We can understand this levelling of ideas [W], weeks, occasionally months, at a certain intensity which is one of the most important symptoms of of illness, and then subsides, usually more slowly mania, when we take intrapsychic hyperfunction than it rose. It is the most curable of all mental to be a general [Ed] increase in excitability of illnesses, but not without danger. Mention should intrapsychic paths. On the other hand, the normal be made here of a tendency to suicide, which is overvaluation of ideas is to be explained by the not rare, its motive lying in overpowering physiological (functionally acquired) increase in moments of autopsychic disarray, which may excitability of specifi c [Ed], chosen paths. A gen- also be accompanied by anxiety; and the ease of eral increase in excitability can then easily elimi- execution made possible by the rapidity of nate the difference in excitability that leads to decision- making and unrestrained energy. In overvaluation of specifi c pathways, a concept manic individuals I have often come across that also accounts for fl ight of ideas and failure to severe self-infl icted stab wounds in the region of bring thought processes to an end-point. the heart. Gentlemen! The clinical picture of pure mania In its course mania is often interrupted by the is thus fully outlined. There is only one subsid- so-called lucid intervals which, for a short time, iary point to be made, namely the occasional may simulate the onset of recovery. Usually, a occurrence of phonemes, which then seem to be quick shift into what appears to be health is strik- the only way in which grandiose ideas can be ing, but should always arouse suspicion of early experienced. They are usually only isolated ones, relapse. Lucid intervals may last only hours, present at the height of the illness, consisting of sometimes several days, and may recur fre- words like ‘prophet’ [W], ‘Hohenzoller’ [W], or quently during the course of the illness. They are even ‘God’ [W]. Numerous hallucinations of usually accompanied by fatigue and exhaustion, various senses occur only in confused mania, but the consequence of the restlessness which pre- of this, more later. ceded them. Alternatively, a state of profound It is very striking, and different from all other moral depression may take place instead, espe- acute mental illnesses, that, in most new cases of cially in the rare cases where there is full insight mania, general health is relatively unaffected. into the illness during such intervals. Shame over The longer the duration of illness, and with it the their conduct during times of illness may even loss of muscular strength, the more it leads to lead to suicide. 31 Lecture 31 219

Gentlemen! Diagnosis [W] of mania in the totally insignifi cant change in the set-up used narrowly confi ned sense that I have given it here, everywhere. He further expressed his conviction is made with ease. Where you fi nd the above- that, without diffi culty, he could marry another mentioned symptoms all together, corresponding wife in addition to his current one. Here, fl ight of to intrapsychic hyperfunction, a manic condition ideas and loquacity only rarely go outside a can be diagnosed. If these symptoms are found degree of well-ordering. Eight weeks of bed exclusively, and no others, it is certainly a case of treatment in a hospital, and subsequent travel pure mania. As you can see, the disorder is were enough to restore him to good health. Two mainly one of form. You can speak of delusion years later, after the patient had been steadily formation only in so far as subjective feelings of engaged in a responsible position, a relapse increased capability are related from the outset to occurred, with far more fantastic grandiose delu- grandiosity, which, in the course of the illness, sions, and rapid progression to confused mania, occasionally leads to actual grandiose delusions. and only at this stage did we notice symptoms In new cases, where your advice and opinion are related to the projection system. I need not say sought, you will hardly ever encounter actual that reduced attentiveness and other symptoms of grandiose delusions. However, there is an excep- dementia were carefully sought, without fi nding tion here, which I want to go into more fully, anything. Only the placid, less-animated facial relating to the question of aetiology. In general, expression gave any reason for doubt in this pure mania, like Affective melancholia—but pos- regard. The further course unquestionably con- sibly to a greater degree—is included among fi rmed the diagnosis. I have come across many those psychoses often arising from a background instances with a similar course [1 ]. of hereditary affl iction and neurotic degenera- I might emphasize at this point, that there are tion. This is especially true of mania in adoles- also cases of this type of fantastic grandiose delu- cence, but occasionally also in later decades. sion starting acutely, but without mania—cases However, in the latter case another aetiology— that may initially be free from any symptoms of namely paralytic—must always be considered defi cit, or ones implicating the projection system, fi rst. Paralytic mania [W] is a relatively common and which later prove to be paralytic, a so-called illness, usually presenting with features that paranoid form of progressive paralysis, probably ensure diagnosis at the outset. These characteris- already recognized by most specialists [2 ]. In our tics are so familiar to you, that I need only briefl y sense we claim them as an acute, expansive auto- recapitulate them: They are symptoms related to psychosis of specifi c paralytic aetiology. Since the projection system, recognizable as early there is no evidence of real mania, there is no dementia, but chiefl y as impairment of attentive- diagnostic diffi culty. On the other hand I recall ness. However, there are also cases—none too the form of Progressiva divergens [W] instituted rare—where there is no sign of such symptoms, by Kahlbaum [3 ]—divergence here is in the fi gu- yet which should still be viewed as paralytic rative sense of progressive disorientation or mania. These cases otherwise correspond to the alienation from reality—which in its entire picture of pure mania just described, but where course, in addition to the rapidly expanding, fan- grandiose delusions are quite clear from the tastic grandiose delusions, may present symp- beginning. This grandiose delusional state has its toms of pure mania, albeit never leading to special signature, for it belongs to the category of paralysis or mental deterioration. Yet these cases ‘fantastic or demented state of grandiosity’ [Ed], are very rare, and in my entire experience, which which is specifi c to progressive paralysis. Thus is quite extensive I have seen only a few. an expert member of railway management Gentlemen! From these remarks you may get believed he had made an epoch-making discov- the idea that, for practical purposes, it is always a ery regarding the problem of central arrange- collection of manifestations which determines ments for points-switching. After his recovery he whether or not a case is pure mania. It requires no conceded that it represented no more than a special mention that any additional disorders of 220 31 Lecture 31 content exclude a diagnosis of mania. Real motor this illness has long been known by the name symptoms, that is, hyperkinetic in the narrow of circular mental illness [ 6] [W], or folie à sense (see our schema) have a similar signifi - double forme [W], noted for its poor progno- cance. In addition, the symptom of hypermeta- sis. In fact, prominent cases seem to be quite morphosis needs special mention. It likewise incurable. excludes pure mania, but is often encountered in confused mania, as we shall see. Despite this, we must take note that a single Gentlemen! I have already said that besides episode of the sort occurs quite often, without pure mania, manic states of many other sorts implying a bad prognosis. It is probably a variant occur, and are to be evaluated in an entirely dif- of the relationship described under 1. It is to be ferent way. They are either manic phases of com- further noted, that this often applies to the mild- posite psychoses occurring episodically, or est grade of both illnesses, which occasionally do combinations of two or more fundamental forms. not impair an individual’s social ability at all, or, Of the latter type, the so-called irascible form of more often, do so only temporarily. I know of mania will be discussed shortly. I will come back instances of the kind, which have never interfered to all the combinations later. with responsible business activity, while others The relationship of pure mania to melancholia needed to go into an institution only at times of is remarkable. Both illnesses reveal an internal greatest loquacity. With regard to prognosis, it relationship, in that they are combined in the fol- should also be stated that dementia never arises lowing three ways: from the circular form of mental disturbance, in the narrow sense, where it consists of alternating 1. A mild form of one illness generally tends to phases of Affective melancholia and pure mania. appear during convalescence from the others The attacks always tend to occur in the same way, and signals its termination. The duration of whether the illness has existed for 2 or 20 years. this switch, which often appears after the These cases are, however, relatively rare. (In the patient’s condition has become apparently broader sense, circular mental illness includes all normal, sometimes amounts to a few days, psychoses that present a regular alternation of sometimes a few weeks. manic and melancholic conditions [3 ].) Duration 2. Mania is the one illness which, of all psycho- of individual attacks varies, amounting on aver- ses, is most likely to recur. Between individual age to a few months. A special peculiarity of cir- attacks, at fi rst a period of years usually elapses. cular psychoses might be, that their individual Later, the interval is shortened, so that fi nally, phases develop more rapidly and especially the periods of illness may exceed those of decline much more rapidly than in the case of health. Something similar, but only very rarely, melancholia or mania alone. Duration of manic is seen in melancholia. Clinical experience or melancholic phase need not always be the teaches us that, now and then, recurrence of same. I shall return later to changes in body mania is replaced by a period of melancholia, weight in this illness, which L. Meyer regarded which is then a blessed portent of a better prog- as characteristic features [7 ]. nosis for the mania; and the same relation may While circular mental disorder in the narrower also occur inversely. This is the substitutional sense always develops the same pure forms of melancholia [W] mentioned above (p. 213). melancholia and mania, this does not apply to 3. Finally, a combination of the two illnesses recurrent mania. Rather—and the experience is occurs quite often, in the way that one super- very general—it is transformed progressively sedes the other. They are separated by an into the more severe clinical picture of confused interval of apparent health which may amount mania, with new foreign elements occasionally to days or even weeks, or sometimes is only being added. very brief, and may even escape observation. It should also be said that mania rarely remains Since Falret [4 ] and Baillarger [5 ] in 1854, pure over a long period, but that at the height of References 221 the illness a condition of confusion is readily sions, by disregarding all the norms and consid- established, which, in most favourable cases is erations imposed by law and custom. They make based purely on fl ight of ideas, while in more no allowances, yet demand greatest forebear- severe cases other elements are added. ance. Suggestions of formal thought disorder Treatment [W] of mania is generally only pos- need not be present in this condition. One case of sible inside a mental institution. this kind was preceded by severe psychosis of Apart from acute mania, there is a special many years standing, for which no fuller reports form of illness which deserves the name of were obtainable, but which was certainly not chronic mania [W]. I can say nothing defi nite as pure mania. The patient lacked any insight into to its origin, and only one thing seems to me to be his illness, and it was probably justifi able to established: that acute, pure mania never turns regard his condition just as ‘recovery with defi cit’ into chronic mania. When attacks of recurrent [Ed], or, if one takes objection to that, as a defi cit mania fi nally outweigh in duration the lucid state acquired through a psychosis. intervals, they do not turn into a chronic mania, at least not in the strict meaning of the term, a point that I alone can defend. Chronic mania has all References essential attributes of acute mania, modifi ed only in that it brings with it prerequisites of any 1. Wernicke C. Krankenvorstellungen aus der psychia- chronic, stable condition. Accordingly, the fl ight trischen Klinik in Breslau. Breslau: Schletter; 1899. of ideas continues within moderate limits, still vol 2, Case 8 is an example of paralytic mania. 2. Wernicke C. Krankenvorstellungen. vol 2, Case 12. limited by a degree of discretion and self-control. 3. Kahlbaum KL. Die Gruppierung der psychischen Consequently the exaltation is less pronounced, Krankheiten und die Eintheilung der Seelenstörungen. but still occasionally breaks out. On the other Danzig: AW Kafemann; 1863. hand, inevitable ‘collisions’ [Ed] in society tend 4. Falret JP. De la folie circulaire ou forme de maladie mentale caracterisée par alternative régulière de la to sustain irascible mental states. Elevated ego- manie et de la melancholie. Bull Acad Med. tism, which does not reach a level of frank gran- 1851;19:382–400. diose delusions, is still very noticeable, giving 5. Baillarger JGF. Folie à double forme. Ann Med the individuals concerned a prominence which, Psychol (Paris). 1854;18:369–91. 6. Wernicke C. Krankenvorstellungen. vol 1, Case 5, and in combination with their undeniable mental pro- vol 2, Case 15. ductivity, enables them to advance. Thus they 7. Meyer L. Über circuläre Geisteskrankheiten. Arch constantly create various diffi culties and colli- Psychiatr Nervenkr. 1874;4:139–58. Lecture 32 32

• Clinical presentations of a puerperally- way she carried out her singing was certainly induced and a menstrually-induced hyperki- surprising: It was accompanied by a ﬁ ne tremor of netic motility psychosis her lower lip and the whole of her lower jaw, a • Pseudospontaneous movements movement akin to that of chattering teeth, but • Idiosyncrasy of the movement without the teeth ever occluding. Her voice thus • Absence of compulsive speech in this attained a regular, tremulous character, reminis- • Psychomotor compulsive speech cent of many barrel organ performances, the more • Description of a case of jacktatoid compulsive so as she sung only the notes, without accompa- movement nying words—evidently a wholly invented, sus- • Verbigeration in compulsive speech tained hymn, almost always at very high pitch— • Choreatic compulsive movement with steady, quiet ‘conducting’ [Ed] movements. • Impulsive actions This singing, which, along with the patient’s • Disarrayed restless movement troubled, perplexed and unhappy facial expres- • Hypermetamorphotic compulsive movement sion, gave her a ‘constrained’ [Ed] look, hindered • Periodic recurrent course of the illness her eating food; and it ceased only in the evening, • Prognosis and treatment when, after of an injection of hyoscine and morphine, sleep ensued for several hours. Firstly, convince yourselves of the extreme exhaustion and frailty of this patient. When she is Lecture raised to her feet, she sways and needs support; seated on a chair, she occasionally lets her head Gentlemen! fall back, apparently in extreme fatigue; and she The patient who you see looks feeble, pale, appears distracted when enquiries are made, or and exhausted. In fact, for 4 weeks she has been in begins to answer, but soon loses the thought and a severe state of arousal, in which she has pro- stares into space. Evidently, she is able to follow duced an excess of movements, which probably only with effort, and I could not ask more of her, explains why all her energy has been quite used because she really is very much in need of rest up. To our great surprise, a turn-around occurred and protection. Yet her perverse facial expression from yesterday, after she had been in constant is remarkable to us: Firstly, she opens her eyes so motion the day before, mostly with histrionic- wide that the whites can be seen above the cor- melodramatic expressive movements, and had nea; then she wrinkles her forehead as if in anger, been singing virtually without ever stopping. The and again protrudes her lower lip and lower jaw.

Further, at times, we see marked impediments in Gentlemen! As I soon concluded, our patient her speech: she forces out a single word like a has suffered a pronounced hyperkinetic motility stutterer, labouring a long time over initial conso- psychosis over 4 weeks, and we see the subse- nants; or occasionally, she utters gurgling, inar- quent state of exhaustion clearly showing signs ticulate sounds; and she is unable to show her of this illness, which are largely motor in charac- tongue when requested, but only opens her mouth ter. Her facial expression conveys no psychologi- in an awkward manner. Words are often toneless, cal motivation; and the occasional protrusion of and therefore unintelligible. Yet at other times the lower jaw and lips, the peculiar impediment she speaks with no trouble, and in this way tells of speech, the fl uctuating inability to protrude her us how her illness started. She is able to give her tongue, the pseudofl exibility, unmotivated histri- name correctly, her age, and the date of a previ- onic gestures, and equally motiveless singing are ous confi nement; she also expresses her feeling all distinct remnants of the preceding motility of being ill, that she feels dizzy, and cannot psychosis, to be interpreted partly as parakinetic, breathe properly. She also admits that the clinical partly as akinetic symptoms. examination took its toll on her. Now and then With regard to the aetiology of our case, we she turns her head and listens, evidently attracted know only that the illness developed acutely over by phonemes. She often turns to the female the course of a few days, after the patient, a attendant beside her, as if for help, and it can be 27-year-old potter’s wife, married for 9 months, seen how hard it is for her to stay attentive. Yet had experienced her fi rst- and normal-delivery at familiar things, like the Lord’s Prayer, seem to the women’s clinic, and had remained psychi- give her no trouble; she repeats it in a devout cally normal for 10 days. She had breastfed tone, with folded hands. She then voluntarily another child besides her own, and was thus repeats Luther’s exposition on one of the Ten somewhat debilitated. At home she was greatly Commandments, and begins to sing a chorale, worried about her child, listening to every breath, with faultless words and melody. I then raise her expressed fear that he might die; and on the sec- right arm to a horizontal position; she permits ond night after that, she began to sing, to dance this without resisting, and holds the position for a around the room and to talk about angels, who short time, before letting her arm sink. Bending she could hear singing. The next day she mistook her head forwards produces pain, and is met with her husband for a physician she knew. The hyper- mild resistance. When she stands to leave the kinetic motility psychosis has developed, as it auditorium, she spreads her arms sideways, often does at the end of the puerperium, which, as palms supine, and makes a theatrical gesture, but we learn, is perfectly normal; and the patient is then follows the attendant in the normal way. therefore an example of the falsely named ‘puer- Gentlemen! As you have seen the patient’s peral mania’ [Ed], which in reality covers all mental state was not normal. First of all, apathy manner of acute psychoses, pure mania being the equating to exhaustion seemed to prevail, then least common. moods of euphoria or irritation appeared, all Gentlemen! Chance has favoured us, in that I within moderate limits, and always combined can present another patient, in whom you will see with expressions of helplessness and disarray. the fl orid stage of a hyperkinetic motility psycho- She was not visibly, or not adequately orientated sis. You witness the patient entering, dancing a to her surroundings and situation, and made the waltz step and singing a waltz melody. She then strangest statements about her own body: Last taps the crown of her head with the fl at of her night she had a ‘hump’ [Ed], which has gone hand and says ‘Holy water’, bows, and repeats away again, and her ‘eyes have been slashed’ the word and the same gesture fi ve more times. [Ed]. Any explanations we could obtain about the She correctly interprets the gesture I make with cause of her movements were quite incomplete; a my hand, inviting her to take a seat, and suddenly few isolated statements seemed to show that she sits down in the chair. However, she soon stands had been ‘compelled’ [Ed] to sing and dance. up again, bends forward, and throws her head 32 Lecture 32 225

forward so that her loosened hair falls over her fi nger with the gesture of the gourmet, and says face. She repeats this rhythmically about 20 ‘Roast pork’; or she extends her arms and hands times. Then she walks round, her body bending and says ‘I still have ten healthy fi ngers’; or, and swaying, busily gesticulating and talking while she has her arms outstretched and sways incessantly, with regularly accentuated steps, her torso: ‘How can the tailoress balance?’ reminiscent of the enforced exaggeration in the Evidently these movements completely divert her expressive movements of a minuet. The rhythm attention, so that only momentarily can it become of such dancing, hopping, and jumping whole- focused. Moreover, you have seen that incidental body movements is remarkably exact, when sensory impressions divert her, and lead to move- pushed to the limit and, in their execution may ments, although mainly she ignores my questions indicate great expenditure of energy. They are and requests. Nonetheless, when she has been accompanied by movements of the arms, expres- enticed to sit down, limiting herself, in silence, to sive and correspondingly energetic. Her face theatrical hand movements, and I say to her ‘she also displays an exaggerated countenance; she can go now’ [Ed], she at once comprehends this rolls her eyes, makes an angry face, and then a correctly, and stands up. haughtily repellant, or comical one. She makes Gentlemen! This patient, a 36-year-old unmar- threatening movements, attempting to strike— ried tailoress, also looks pale, emaciated and but not in earnest—these being defl ected imme- worn out, quite a natural consequence of the diately by herself. At the same time she makes effort she has expended in almost-continual, several interconnected assertions, at one point: unchosen movements. She has been in this same ‘They (or you? not decided) must be chopped up state for 5 weeks, varying now and then only in at the stake’. On the whole, her mental state, like intensity. Sleep can be induced only by hypnot- her movements, seems to be very unstable, ics, of which hyoscine seems especially effective; sometimes extremely happy, then haughty or food intake is inadequate, and is disrupted by her irritable. In general she cannot remain in one motor restlessness. place, or can do so only for a moment; at one With regard to this patient’s clinical history point, when asked “Why do you dance? Are you we have learned the following. Psychoses or happy?” she promptly answers in the affi rma- severe neuroses have not occurred before in her tive. Then, when asked ‘Do you know who these family; her father died of consumption at age 52. gentlemen are?’ she begins to sing, ‘So might She had been a poor student at school, but was Heaven forgive you’. industrious, very honest, and had led an orderly The connection between her spontaneous, life. She carried on a tailoring business with her almost-continuous speech movements and her sister, and has probably overworked; and over other movements is most extraordinary. It is recent years she also suffered from menstruatio shown in that her voice is often raised, matching nimia [W]. Eight years ago, she had been the rhythm of her general movements; and, this depressed for 3 months, probably with melancho- happens to a greatly exaggerated degree, as are lia; at any rate, she conveyed feelings of unhappi- her movements. Thus, much of what she says is ness, spoke with self-reproach, and at the time incomprehensible, or she gives voice to no more her relatives had noticed peculiar ‘knotting’ [W] than fragmentary sentences or isolated words or movements of her hands. Afterwards she had syllables. Furthermore, the content of these iso- been healthy, except at the times of her menses, lated fragments of speech is often connected con- when she always became markedly irritable and spicuously with the movements. Thus, she adopts sensitive. Eight weeks prior to admission she had a military bearing, makes the movement of strok- a 2-day premenstrual attack of ‘frenzy’ [Ed], in ing a moustache with her right hand, and says in which she talked and sang constantly, always in a gutteral tone ‘Lieutenant of the guard’. On motion, throwing furniture about, and had another occasion she raises her arm, bent at a terrifying visual and auditory hallucinations, right angle, opposes the tips of thumb and index with verbigeration, occasionally mistaking 226 32 Lecture 32 people and her surroundings. From the family’s the same pattern of movement, perhaps increas- description, she had very prominent hypermeta- ing to rhythmical repetition, will be especially morphosis at this time. With onset of menstrua- striking to you. It is manifest also in verbal per- tion she quickly became quiet, and slept formance, and has repeatedly led to verbigera- spontaneously. Four weeks later, menstruation tion in our patient. Second, you will not have passed without disturbance. Two days before missed the exaggerated, violent, and to some the next menstruation, which was exactly 4 extent affected character of these movements, weeks later, admission to the clinic became nec- along with the unusual muscular effort with essary because of a fresh attack of frenzy, after which they are connected, giving some of the having spent 2 days at home in this state. This movements a grotesquely graceful appearance. time, appearance of her period had no infl uence In our patients this is also noticeable in their on the illness. To-day, at this demonstration, she speech movements; and this is not always lim- should have menstruated again, for it is 5 days ited to pseudospontaneous movements, being over the 4 weeks since her last period, but this occasionally incorporated into expressive ones, time, menstruation seems delayed or not to be like laughing, crying, and singing. You will happening at all. probably remember the patient (p. 75) who apol- Gentlemen! These data are of special value, ogized for her song, irreproachable in itself, that because they show us a defi nite, though rather she had to sing, a production in itself perfectly imprecise, infl uence of menstruation upon the proper; but she had to sing it, even though she origin and decline of psychoses, and—I must did not want to. Finally the evident aimless- note here—that this is not an isolated experience, ness—and absurdity—in the form of her move- but recurs so often in hyperkinetic motility psy- ments, must be emphasized, for instance, when choses that we need to recognize it as, by far, the the patient repeatedly placed the fl at of her hand most common type of menstrual psychosis. In on the crown of her head, or spread her fi ngers, particular, hyperkinetic motility psychosis is or rhythmically bent her body forward, or bal- more often of menstrual than of puerperal origin. anced on one leg, etc. This aimlessness differen- I return to these aetiological circumstances later. tiates pseudospontaneous movements from the Gentlemen! Strange and outlandish as are the so-called ‘occupational deliria’ [Ed], usually movements that you have seen in our patient, connected with compound hallucinations, repeti- they might leave you suspecting that they are— tive to the point of perfection, and also from a in part at least—voluntary productions of a psychosensory component of conditioned reac- hysterical- histrionic personality. Admittedly, tive movements (as in alcoholic delirium) driven there are no hysterical antecedents, and the fact especially by cutaneous hallucinations. However, that being left alone has no infl uence also contra- when the movements resemble gymnastic exer- dicts this, for it is not clear why a hysteric should cises, as we often saw in the past semester, you continue such performances when there are no fi nd them here, in our clinical demonstration, witnesses. Finally, there are patients’ own state- totally out of place and evidently aimless. ments made after they have recovered—or when Gentlemen! Closer analysis of the pseudos- they become calm just for a while—that these pontaneous movements brings anecdotal evi- movements are independent of their volition, the dence to our notice, namely that the movements result of some incomprehensible kind of coer- are not psychologically motivated, but are a con- cion interpreted in various ways. However, you sequence of disordered identifi cation between Z will reasonably ask for positive signs, to allow and m , that is, on a psychomotor pathway. Items such pseudospontaneous movements [W] to be of clinical evidence, which are only occasionally differentiated from deliberate productions. There prominent in our case, lead to the same conclu- actually are such signs, as you have seen in our sion, in so far as the patient spoke a lot—although patients. A certain uniformity and monotony of in many cases of hyperkinetic motility psychoses, these movements, their tendency to recur with this will confi rm the diagnosis almost at fi rst 32 Lecture 32 227 sight. The evidence is that the motor impulse of Diffi culties in diagnosis are created only by hyperkinetic motility psychosis is accompanied milder or mildest grades of such pseudosponta- not by corresponding loquacity, but often by the neous psychomotor loquacity [W]. Any intention opposite symptom in the speech domain, namely to continue with a coordinated form of speech mutism. A striking contrast always exists, a lack then opposes the psychomotor impulse, with of proportionality between the mild degree of results which are very characteristic for special- loquacity and the severely affected motor ists. Falsely placed pathos, singing, or declaim- impulse. As you can see, this is the direct oppo- ing, or an unctuous tone of speech with frequent site of mania, where loquacity predominates elevation and lowering of pitch, and an increased and the motor impulse retreats in proportion, or rhythmic tendency, might lead one to ascribe is manifest more as a ‘desire’ [Ed] for activity. such productions to a ‘pulpit orator’ [Ed] with But if pronounced loquacity exists, which is their marked impact—even as far as the content. commonly the case, the changed form of speech However, the content also shows itself to be infl u- shows that it originates from a psychomotor dis- enced, apparently by the altered form of speech, order of identifi cation. Its undifferentiated form just as the form of the motor impulse in our leads to verbigeration, or at least to conspicuous patients shows an infl uence on its ideation; for it repetition of the same words or common is pre-eminently biblical, or at least is connected phrases; excessive expenditure of effort leads to to passages from the Bible, verses of hymns, unmotivated crying or howling; the aimlessness explanations of catechisms, remembered ser- in gratifying the vocal motor impulse leads to mons, etc. A patient of this type found that her senseless stringing together of words, and of talk ‘dripped from her lips like honey’ [W]. For words or syllables not even related by sound. In the sake of completeness I should mention that general the signs of psychomotor loquacity— the monotony of content, the tendency to repeat unlike those of an intrapsychic disorder—are the same words or phrases, also hold true. You monotony and incoherence rather than fl ight of see, gentlemen, that psychomotor loquacity in ideas. A further sign referring to content is pro- each case presents signs enough for it to be read- vided by the hypermetamorphosis which is ily identifi ed as such. hardly ever absent in hyperkinetic motility psy- Gentlemen! The importance of this subject chosis. The following reproduction of the spon- requires us to examine in greater depth the sort of taneous utterances of a patient may illustrate movement executed in hyperkinetic motility psy- what has been said: choses. In general, movements range between Scullion or bubble, then it begins to bubble or to two extremes, at one time appearing totally delib- burn, or with others, ah, Jesus, says my Mutho, erate, yet in contrast, also totally involuntary, evi- always from the beginning, if she was so small, ah dently occurring as an imposition on the patient’s so, ah, Anna, a, n, a, in the height, or so much intention. As an example of the former type, drops from above, ah, Jesus, I fi ndest thou, ah, Jesus and hence because she scullion, getel or gat- I remind you of the acutely ill young man, who I tel or Philadelphia or America or in Tyrol or the or presented in the previous semester, mute, with a doubles, ah, pocket pistol with and without a bang, congested face, who, with visible effort, per- since the matter is so, oh, Jesus, Jesus, it goes once, formed regular gymnastic movements of arms 2, 4 therefore so much even as one once goes to me so, so straight out, then 2, 3, ah, Jesus, ah indeed, and trunk for 10 min. These movements were so that is very fi ne, that is called counting, the fi rst, precise and apparently purposeful that you might the fi rst little song, oh Jesus, consequently one says doubt that they were involuntary performances work or destroying angel [strangling movements!] by the patient. After a few weeks in this hyperki- [to the attendant:] I might take away the cushions, for so many things, ah, Jesus, little star, her little netic state, which was sometimes replaced by child, come oh, come, oh not yet, just the same. akinetic phases of apparent exhaustion, he Stop, what is it, what is it that comes from my became calm, but at the same time with rapid home, ah, Jesus, ah, ah, ah, or from my school increase of feeble-mindedness, while his greatly- friend from the beginning either from Hanke, Anke, kekeke… reduced nutritional status gave way to a rapid 228 32 Lecture 32 increase in body weight. At present, you would from every attempt. “Ah no. It doesn’t work like scarcely recognize this ruddy, apparently pro- this. You must help me differently. You are doing it wrong. If you would hold me like this”, are charac- foundly demented patient, instantly refusing— teristic comments. If you ask the patient how you and unbiddable towards—any demand to think. should help her, she replies, “That’s just it, I can’t The contrast is provided by evidently un inten- fi nd out”. The presence of the doctor or attendant tional [Ed] movements, reminiscent of the famil- always has a somewhat calming effect. Patient begs that someone should always be there, then it iar jactation of unconscious states. Common to would be better for her. It is noticeable that the both is only the monotonous recurrence of the patient very often makes a movement entirely con- same form of movement. I was able to present a trary to her stated intention. Thus for example, she remarkably pure case of the latter in the winter decides that she should be laid down, and then always raises herself on the arm of the person who semester of 1891. This moderately well- would help her. Or she wants to stand up, and nourished, perfectly self-possessed, and thor- makes no effort to rise. Her corresponding asser- oughly attentive and oriented 79-year-old patient, tions leave us in no doubt about this: “Ah, that is Mrs. W., claimed that her illness was constituted not what I wanted at all; it should have been something totally different. I would gladly lie down so entirely by a peculiar motor restlessness. On that I can sleep, but I do not know how to begin to awakening each morning this was only slight, but go about it. For God’s sake, what should I do to sit it increased slowly during the day, reaching its down?” She sometimes struggles directly against high-point in the evening, so that the patient could the very help for which she has asked. To a spir- ited, earnest request to desist from her movements, not rest for half the night—until fi nally she fell she is quiet for a time and feels visibly relieved. asleep from sheer exhaustion. My Assistent [W] Likewise, it is seen that she can voluntarily per- at the time, Dr. Kemmler, left me with a splendid form all movements on request. However, a few description of the style of her motor impulse. minutes later her old movements begin. At the height of her motor restlessness she is entirely I want to convey only the essentials here: absorbed in her movements, and it is hard to fi xate Patient sits in bed, but constantly changes her posi- her attention. She then repeats the question instead tion; fi rst she tries to move to the upper edge of the of answering it, or uses rambling speech and thus bed, then to the lower, or tries a position on the loses the sentence construction, or leaves the sen- side, or raises herself up as if she would try to tence unfi nished. In between times assertions like: stand, then tries to get out of bed. These move- “I will tell you afterwards what I cannot think of at ments follow one another in extreme haste, usually the moment”, etc. On one occasion the patient was one movement is not completed before the next even unable to give her name; on such occasions begins, often a movement entirely contradictory in she shows her annoyance: “I know it perfectly nature. Pauses for rest hardly ever happen. In her well, but because of my restlessness I cannot speak haste she always and incessantly makes the same it now”. A portion of the patient’s movements futile efforts and the same movements. The resemble a familiar example of so-called occupa- patient’s assertions, which accompany her restless tion delirium [Lecture 26]. Thus for example she impulses, confi rm our assumption that she can fi nd occupies herself constantly with the bedding, no position or posture in which she feels comfort- pushes the covers off, pulls them up, covers her- able, as though every attempt to take a certain posi- self, then uncovers herself. She also busies herself tion evokes an unpleasant feeling, of which she with her items of clothing; she puts it all on, or puts would pay any price to rid herself. She is forever some of it on, and takes it off again, often with the trying all possible means. Assertions such as: “I do wholly unplanned result, so that she sits there not lie right like this, I cannot remain so; I must lie naked, and then complains, because it was so quite differently; I cannot remain sitting like this; improper. While she utters a certain intention, she I can’t abide this; I must get some rest; if I could quite often does the opposite. One night she was only stand up; if I could only lie down; but it very restless, constantly pushed the covers off and doesn’t do, perhaps it would if I don’t lie down at then expressed the desire to be covered, because it all”, etc. In her helplessness, she appeals to every- was so cold. When she was assisted and covered, one for help, and fi nally moans like a person in she suddenly became perfectly quiet and soon despair. If anyone approaches her, she immediately went to sleep. Evidently she was unable to start the claims their assistance. For example, she grasps sequence of actions—sit up, grasp the covers, lie the doctor’s hands, lets go of them, immediately down, and draw the covers up—in order to unite grabs them again, supports herself on his arm, them into a single action. Given a pencil and paper clings fi rmly to his sleeve, and promptly ceases to write, she was able to accomplish just as little. 32 Lecture 32 229

As already mentioned, restlessness ceases when exhausted patient presented fever and symptoms she is earnestly admonished; similarly, when she of pneumonia, and died 22 November. An infl u- performs some complicated movement on com- enza epidemic prevailed at that time. The relapse mand—in which she is always successful—or then began, repeated assertions that the patient her- when she is keyed-up to be attentive and impart self did not know what she really wanted, and that certain information. Patient shows that she is talk- this might be just as remarkable. Soon again great ative, in part garrulous, but without real loquacity. helplessness in the choice of motor means. Now and then an expression fails her, especially in Transitory and half-corrected negative-impact fi nding the word for verbs and abstract ideas, her ideas: She was being jeered at, laughed at, tor- prolixity then often serving to circumscribe or seek mented, also mistrustful of those around, fretful, out the correct expression. When she is asked the irritable in mood. Initially, only the impulse to get reason for her aimless movements, she showed a out of bed; later, motor impulse of the hands; and certain insight: “That must lie in the nature in such loquacity only after increase of the motor impulse a way that is just a misfortune. I do not know what from 1 November. This time, modifi cation of res- it is for”. Patient denied many movements after she piration, which was of a gasping character as in had performed them. For example, she speedily extreme anxiety. Yet anxiety itself was always pulls off her jacket and then claims that she could denied. Paraphasia in loquacity this time more pro- not have done it at all; another time, “that can only nounced; nutrition more impaired; the whole have been an accident”. She puts a stocking around attack more severe and increased to temporary fear her neck and says that it is not a proper necktie. of approach. Never hallucinations; hypermetamor- She turns the second stocking inside out and sud- phosis never marked. Allopsychic orientation only denly pulls it over her head like a cap; she is herself temporarily disordered during extreme restless- astonished at this moment, and pulls it on properly, ness. In the last days before the rapid decline of the over her foot. On request, she protrudes her tongue illness, fl inging, twitching of the arms, which dis- hesitatingly and spasmodically. Frequent verbiger- turbed even voluntary movements. Otherwise, ating repetition of the same phrases, e.g. “Oh God, forcible attraction of her attention had a quietening pity me. Please help me do right”. Never hypo- infl uence similar to that in the fi rst attack. The fol- chondriacal sensations, always perfect orientation, lowing sample of her loquacity, from 4 November, good memory and ability to be attentive. shows that ideas of anxiety did exist: “My dear After becoming quiet, a good disclosure: An doctor, I am entirely wrong; oh, God in Heaven uncomfortable feeling might have caused the pity me; Father in Heaven, pity me. Good doctor, movements, they could not have been voluntary. help me. Let me out. Heavenly Father, do not for- The uncomfortable feeling was located in the chest sake me. I am not able. I am perfectly right. You and gradually affected the whole body. At the time are compassionate. I cannot do differently, oh, dear when the motor restlessness abated, indications of God. No, no, no, I must go, be merciful. Doctor, delusions of relatedness: Another female patient you are merciful. Ah, Jesus Christ, pity me. I fail in had behaved so peculiarly, that one could not get everything. I have a false judgement. Further on any rest—she must probably have lain on the bed, nothing is important. Be merciful to me a sinner. so that she could get no rest. In the morning she Oh, doctor, forgive me. 1 will gladly follow, here I begged for a hypnotic, but immediately said she am damned. You do me great wrong, pity me. Now did not want it at all. Claimed that she was cold; at I stay. Yes, oh, my God and Father, do not forsake once asserted the opposite. Once said, quite aim- me. Doctor, I am unable to save myself. I earnestly lessly: “Can I sit up now, or can I eat something pray, do what you will. I am entirely innocent. fi rst?” Thou all good God, pity me. Heavenly Father, pity Female patient, previously healthy, had been in me. Dear, good doctor, listen to me. Good God, the public hospital. The last four weeks before her stand by me; pity and be gracious to me. I am a admission (on 12 September, 1891) often sleepless sinful person. Oh pity me, Lord, pity me”, etc. and complaints of headache and increasing weakness; a few days before admission the ‘twitching’ [W] began, as she called it. That she therefore had This case is so instructive in many ways that been considered mentally ill and brought to the we must linger with it awhile. First of all, it is lunatic asylum displeased her greatly. Motor rest- extremely rare, that a hyperkinetic disorder of lessness soon attained the severity just described, and continued, except for a slight remission identifi cation in the psychomotor tracts is so between 21–25 September, until the beginning of pure, and uncomplicated by other symptoms. October, to be replaced in a few days by complete I remember a similar case of a clerk K., 21 years quiescence until 6 October. A relapse began 27 old, who was admitted 27 December, 1894, and October, and increased in range and intensity until 17 November. On 18 November the severely- released to a provincial mental institution on 230 32 Lecture 32

21 March, 1895. He had previously manifested a initiative and expressive motor impulses, just as hyperkinetic state for several days, after a spree in gymnastics. The movements in patient W. of excessive drinking, with explanatory delusions probably resulted reactively from uncomfortable of being a gymnast; and he was therefore treated muscular sensations; this was also largely the by us for 17 days in November, 1894. It was case in patient K., although, according to his noticeable that, in this patient, there was no recur- assertions, there were additional abnormal physi- rence of rhythmical movements; he was perfectly cal sensations, including a ‘tingling’ [Ed] oriented and no explanatory ideas accompanied throughout the body and pressure in his throat. with his movements; and he was so conscious of Transitory panting, blowing and emitting of inar- the fact that his attention had been engaged coer- ticulate sounds can probably be traced to that cively by the movements, that he often answered statement. In any case, these are aberrant organ questions: ‘At once’, or ‘wait’, or ‘I must fi rst…’ feelings, which are the basis of the reactive move- In this patient we deal with the same sort of ments. The similarity to occupational deliria, an movements to be described in greater detail later. intrinsic part of the movements seen, can be eas- However, this condition intensifi ed further, to a ily understood from this point of view, because peak of complete confusion, during which he was occupational deliria also arise as reactive move- incapable of remaining fi xed in any one place. ments. However, we will not go wrong, if, in our This was also always accompanied by very severe cases (in contrast to Delirium tremens [W]) we hypermetamorphosis, unlike the patient previ- interpret the patients’ manipulation with ran- ously described. Here the course was not contin- domly presented objects as not actually being uous, but the patient had a perfectly lucid interval, induced by these objects, but rather, assume that with insight into his illness, and signs of exhaus- patients merely take the opportunity that they tion from 17 to 26 January, 1895, and a second offer, to discharge their motor impulses in rela- such spell, for just 1 day, with extreme exhaustion to these objects. tion on 6 February. We found out later that this The name jactatoid motor impulse [W] might patient, after staying for a year in the mental be applied in these cases. The similarity of the institution, was discharged home. I am indebted movements described to those of jactation in an to my colleagues for the following information: unconscious state is evidently based on the fact, His illness was recognized in the institution as that jactation also is produced by unpleasant remitting mania (naturally not mania in our organ sensations. sense); periods of manic, even stormy excitement The Affective state was much clearer in patient alternated with ones of calm, where he was still W. than in the other patients. It is that of ‘motor more-or-less confused. Later, the manic parox- disarray’ [Ed], admittedly increased transiently ysms became shorter and less intense; in periods to the point of actual anxiety and despair. Ideas of quiet his ‘presence of mind’ [Ed] gradually expressing anxiety dated from this time of maxi- increased; and insight into his illness developed; mum intensity. We should also regard the tempo- the patient improved physically, with a marked rary occurrence of random, uncoordinated increase in weight. From November, 1895 he movements as signs of increased intensity of the could be regarded as convalescent, but as a pre- disease process, while on the other hand, when caution, his being detained in the institution con- the illness was signifi cantly abating, an undoubted tinued during the winter months. contradiction was seen with the volitional inten- This is the same patient, moreover, from tions of patients, which were always soon able to whom the examples of motor loquacity, given correct the uncoordinated movements. earlier in this lecture (p. 227), were obtained. Gentlemen! It might not be superfl uous at As for the type of movements, the motor this time to mention that severe generalized cho- impulse in both the last two patients can be char- rea, which we usually place among the func- acterized as reactive, while the patients presented tional nervous diseases, is not so far removed fi rst were shown to be executing essentially from our topic. Of course, chorea can no longer 32 Lecture 32 231 be understood as a disorder of psychomotor post-epileptic and of short duration, lasting a few identifi cation, since it exceeds this by far, in that days at most. In paralytics it is seen in two oppos- it may exhibit random performance of individ- ing states, depending on whether it is the initial or ual movements, and thus impairment in innate terminal stage of the illness. In initial stages of muscular coordination. From the perspective of paralysis it corresponds to a mild degree of cho- differential diagnosis I should not omit brief reic motor restlessness, which may be largely mention of the signs otherwise linked to cases of unilateral, resembling Chorea minor. In terminal severe generalized chorea. Corresponding to such stages it is usually a matter of blind rage continu- discharge of muscular coordinations, patients ing for weeks; generally movements of the torso, with chorea also show symptoms of severe paral- usually performed mutely, apparently in a dazed ysis: during pauses in involuntary movement, the condition. head usually drops in a quite unrestrained man- Certain impulsive actions [W], evidently pro- ner; the trunk can show the same instability, so vide contrasts within these irritative states, and that standing, walking, and sitting become impos- encroach on the motor projection fi eld; their sible. If these patients are raised to their feet, they hyperkinetic mode of origin is beyond doubt, present a picture of most severe ataxia in their according to patients’ statements, but also derived every effort to move. Moreover, in such cases, from the context of the whole illness. I observed speech generally gives way to stammering and a disease in a 28-year-old, unmarried woman, becomes unintelligible, and swallowing may be who presented the same condition unchanged for impossible at times due to paralytic lack of coor- about 2 years, with certain remissions. During dination of the tongue. On the other hand, a cho- this period, she required constant supervision reic impulse to crying and uttering of stammering because, totally without provocation, she was sounds is occasionally manifest. It should be gen- inclined to violent acts—would strike out, throw erally known that such cases of severe chorea are knives and forks, or pull hair—usually against very commonly attended by certain manic symp- her female companions, towards whom she was, toms: loquacity, fl ight of ideas, notable lack of in fact, well intentioned. These impulsive acts embarrassment and thoughtlessness, for instance occurred repeatedly, without any external provo- on matters of seemliness, etc. On the other hand, cation and wholly unexpectedly, and were there- an abnormally irritable mood and irascibility may fore dangerous. Apart from that, in intervening prevail [1 ]. periods she was perfectly calm and rational, Gentlemen! Knowledge of descriptions of could always be kept in her home, and only occa- severe generalized chorea, known for example as sionally presented smacking movements of her a dangerous complication of pregnancy, is all the lips, and another symptom that was particularly more important in differential diagnosis between offensive to her and her relatives, the involuntary it and hyperkinetic motility psychoses, since utterance of obscene words (Coprolalia of other transitions between the two states occur quite authors). The patient was unable to suppress this, often, as our Case W. proves. We can then desig- but was able to utter them half-audibly, or her nate the form of hyperkinesia observed there, as a attention could be diverted. This patient suffered choreic motor impulse [W]. We can characterize an exacerbation of her condition over 8 days, in it as an increase in hyperkinesia or, in other which a severe choreic motor impulse, as we words, an overlap of the domains of primary defi ned it above, was continuously present. She identifi cation. The combined magnitude of motor usually muttered half-audibly and unintelligibly, manifestations (pp. 32, 33) shows itself to be a then suddenly and spontaneously would raise her threat to survival. Such a choreic motor impulse, voice to hurl some insult or obscene expression. which actually goes beyond the concept of hyper- Just as suddenly and impulsively, the motor kinesia, is seen particularly in epileptics and impulse was also interrupted by coordinated paralytics: In the former it is a component symp- actions, in which she suddenly struck, scratched, tom of profoundly dazed conditions, usually and pulled the hair of people round about. 232 32 Lecture 32

The state of exhaustion following this acute The jactatoid motor impulse of Mrs W. might attack led to an improvement, which gradually remind casual observers of cases of disease that passed into complete recovery. bear a superfi cial resemblance to hers, but are In this case the impulsive actions, like the totally different in character. Perhaps we can dif- speech movements, plainly showed their origin ferentiate a disarrayed motor impulse more cor- as purposive schemata arising during aberrant rectly by designating it as disarrayed motor irritation, and the patient herself stated later that restlessness [W]. In such cases an intense she had defi nitely never heard voices or com- Affective state of disarray leads to various move- mands. We would do well only to differentiate ments, such as changes of location, restless wan- this type of action, arising within psychomotor dering around, movements of embarrassment and functions. Actions brought on by hallucinations despondency, and to monotonous moaning, or other sensory drives, even if they also occur clinging to others, etc. These movements have all spontaneously, evidently do not belong here. the signs of psychological motivation, even Especially characteristic of these impulsive though they are mediated by an Affective state actions however, is their kinship with the course that may be foreign to normal mental life, as, for of a defi nite state of psychosis. They then read- example, in somatopsychic disorientation. ily become the source of complex explanatory Earlier (p. 157) we became acquainted with delusions. Thus the fi rst attack of patient K., motor discharges that bore the stamp of senseless mentioned above (p. 230), which lasted only 3 rage, as an expression of somatopsychic disarray. days, consisted essentially of his performing The life-threatening movements, motivated in gymnastic movements, which led him to imag- the strange ways of hypochondriacal patient N ine being a gymnast, and to develop a sort of (p. 159) belong here. grandiose delirium in respect to his personal This aimless motor impulse therefore has a capacity. Another patient, a 17-year-old baker’s basis totally different from that described above apprentice who had always been very pious, (p. 157). In the latter, movements are primary and suddenly felt the need to kneel down and pray, lead then to disarray. This relationship is also and he interpreted this as a direct infl uence from fully expressed in the type of movements. On the God. A sort of religious grandiosity developed other hand, in motor impulses with disarray, the from this, with the admixture of other motility relationship is the other way round: If disarray symptoms. He recovered completely. However, increases to the point of anxiety and despair, as it it became diffi cult for him to regain insight into does in acute psychoses with an entirely sensory his illness with respect to the fi rst events, and basis, resulting motor manifestations can be this was delayed, so that such occurrences were understood psychologically, presenting even still familiar to the patient at the time of com- fewer diffi culties. plete recovery. Finally I call to mind the doctor Gentlemen! For the sake of completeness, I of philosophy, who so drastically described to want fi nally to discuss a type of motor impulse, you the events that had taken place prior to his which is furthest removed from the motor admission. He had suddenly knocked the hat off domain, although it is often observed in hyperki- a totally unknown gentleman, with his cane. netic motility psychoses. We can indicate it as This gentleman, a perfect stranger, actually had hypermetamorphotic motor impulse [W]. The nothing to do with him, but Dr Sch. claimed that same process, which directs attention to immedi- the gentleman must have been a real blackguard, ate sensory impressions in an imperative way for the dear Lord had suddenly brought about an must, of course, often lead to movements match- unpremeditated movement by the patient, raising these sensory impressions. Thus for example ing his cane against him. This topic was on the sight of a washing jug and bowl, or a slate brings mind of one of the patients, who believed him- patients to wash themselves, or to write on the self to be continuously hypnotized in the institu- slate. In this way rapid alternation of different tion (p. 86). actions may be produced, giving the appearance 32 Lecture 32 233 of independent motor impulses. Hyperkinetic recovery. The course is, therefore, periodic and motility psychoses, which as already mentioned, intermittent, with a very rapid sequence and at are almost always accompanied by hypermeta- least short periods of remission. This periodicity morphosis, occur in rich combinations with such is not perfectly regular. One attack, usually the movements, but also with various states of delir- fi rst or the second, is more protracted than the ium, as for example in those of progressive paral- others, and may be brought about by coincidence ysis. If sources of hypermetamorphosis are of two attacks. Prodromes often precede the fi rst removed by seclusion of patients, such motor attack. These may consist of subjective troubles impulses subside quite predictably. of various sorts, such as headaches, disturbed Gentlemen! I might use this occasion to set sleep, periods of anxiety, and inner restlessness; before you the wide diversity of conditions which vasomotor troubles are especially common. The can induce excesses of movement amongst men- attack itself tends to begin quite suddenly, espe- tally ill people. You know that more-or-less fren- cially when periods of illness have preceded it. zied behaviour is very common among those who The duration of an individual attack is usually are acutely mentally ill, and may be due to most less than a month, except for protracted attacks, varied causes. Yet the term ‘frenzy’ [Ed] implies which usually correspond to the peak of the ill- no kind of diagnosis: It is merely the broadest, ness. Here I want particularly to emphasize that best-known, popular expression for a state of the so-called ‘periodic mania’ [Ed] of some restlessness. authors belongs, in most cases, amongst the Gentlemen! A review of all conditions that hyperkinetic motility psychoses. may lead to frenzied behaviour amongst mentally Aetiologically, the periodic event of menstru- ill people will have shown you that concise defi - ation bears the closest relationship to our illness. nition of hyperkinetic motility psychoses faces Next most often, it is found among postpartum some diffi culties. Therefore I have presented women, as the ‘puerperal mania’ [Ed] of other detailed examples of several cases of special authors. This corresponds to the fact that the ‘purity’ [Ed]. Always the primary fact, that the majority of persons so affected are women, and movements are not motivated psychologically, are young. If however the illness occurs in males, and that a manifest impulse to such movements it shows a similar periodic, intermittent character, exists, must provide us with the main criterion. which therefore cannot be exclusively of men- But it is in the nature of things, that illness, espe- strual aetiology. Common cases with paralytic cially if it is severe, greatly interferes with any aetiology provide an exception to the periodic closer analysis of how far falsifi cations of content course. of consciousness extend, and are not mere conse- For differential diagnosis [W], in essence, we quences of movements; and even the information need consider only ‘confused mania’ [Ed], which patients give us subsequently about their condi- usually is similarly periodic and recurrent; and tion is often insuffi cient, because memory defi - this is to be studied in more detail later. In favour cits may obscure part of the period of a patient’s of the latter, a decisive fact is when the hyperki- illness. It should then be expected that some netic clinical picture is merely an augmentation cases belonging here are more than pure hyperki- of pure mania and has demonstrably risen out of netic motility psychosis, although they are under- it. Moreover, mania is the only illness that pres- stood in this way, according to signs described ents an actual transition to hyperkinetic motility above. psychoses, and thus has an internal relationship If the purest cases possible are taken for guid- with the latter. As a consequence of this relation- ance, the following may be said about the course ship, differential diagnosis between the two [W] of the illness. The disease seems to be distin- diseases is sometimes impossible. We shall deal guished by the fact, that it recurs over a number with this further when discussing confused of periods—four, in patients previously men- mania. Later, we will get to know hyperkinetic tioned—and then exhausts itself and ends in full motility psychoses as a phase of cyclic motility 234 32 Lecture 32 psychosis, and of periodical hyperkinetic states corresponding to the boundary between our dis- in the course of a total motility psychosis. ease and confused mania. It was that of a 15-year- The prognosis [W] of the disease is generally old girl, who had not yet menstruated, but favourable, and, as I must state, at odds with most repeatedly presented vasomotor symptoms of a authors, since, with careful treatment, after a worrisome nature. Periodical recurrence of number of periods, most cases end in complete attacks about every 4 weeks and the added vaso- recovery. The hereditary or degenerative predis- motor symptoms in these attacks persuaded me position which is usually present does not alter to apply leeches to the inner surfaces of both this view. Corresponding to preceding ill-health, thighs during the third intermission, whereby the puerperal hyperkinetic motility psychoses are fi rst menstrual fl ow was actually established, and usually more severe than the menstrual ones. further attacks prevented. The girl has remained Bromide treatment, as recommended by Krafft- healthy since then (about 8 years ago). Use of Ebing [2 ], has never achieved anything substan- narcotics in the hyperkinetic motility psychoses tial in my experience, nor has it in cases of is generally contraindicated. Almost all sleeping menstrual psychoses. Moreover, the special aeti- pills fail. Hyoscine seems to have a specifi c ology is thoroughly decisive for the prognosis, so action on motor hyperkinesia, often in surpris- that the paralytic form here leads to dementia, as ingly small doses of ¼–½ mg. administered sub- it does in other paralytic psychoses. This is true cutaneously. Owing to this sedative action in cases of hyperkinetic motility psychoses, hyoscine is also the best hypnotic in these cases. which occur in the course of a real hebephrenia Apart from bed rest, in so far as it is practical— or other chronic, hebephrenic degenerative psy- use of warm baths, prolonged over several hours, choses. The dangers of hyperkinetic motility psy- and permanent under certain conditions, usually choses are chiefl y the loss of energy from the has a favourable effect. Hospital treatment can continued muscular exertion, and the ever- present only very rarely be dispensed with. insomnia; and the continuous motor impulse adds essential impairment to nutritional status. States of sudden collapse are therefore com- References monly seen. Furthermore, there are injuries that patients incur through their violent movements; 1. Wernicke C. Krankenvorstellungen aus der psychia- in particular, there is diffi culty in carrying out trischen Klinik in Breslau. Breslau: Schletter; 1899. vol 2, Case 13 is a typical example of severe chorea. aseptic treatment of these injuries. 2. von Krafft-Ebing R. Lehrbuch der Psychiatrie auf Only in rare cases can treatment [W] be based klinischer Grundlage für praktische Ärzte und on aetiology. I remember a case of this kind, Studierende. 4th ed. Stuttgart: Enke; 1890. p. 572–3. Lecture 33 33

• Confused mania or agitated confusion fl ight of ideas, loquacity, and motor impulse. The • Escalation of intrapsychic hyperfunction to foreign elements that are added range between confusion two extremes, sometimes in pure form, usually in • Different grades of fl ight of ideas combination, are either psychosensory or psy- • Admixture of sensory and motor excitatory chomotor disorders of identifi cation, dominated symptoms by symptoms of irritation. If confused mania is to • Clinical picture be regarded as an independent illness, as is often • Meynert’s Amentia in fact justifi ed, when the initial or end stages of • Asthenic confusion as a phase of confused pure mania are only very short in duration, it mania and as a stand-alone illness could be called agitated confusion [W], and its subdivisions could be differentiated as confusion with sensory or motor agitation. In the fi rst case agitation is based on an essentially reactive motor Lecture and speech impulse, that is, on those that can be traced back to sensory states of irritation; in the Gentlemen! second case it takes on the guise of a hyperkinetic By confused mania [W] we wish to identify a motility psychosis. In the vast majority of cases clinical picture that is manifest as an exaggera- these two contrasting sets of phenomena occur in tion, imposed at a peak of mania, and presenting combination. The rarer exceptions are mainly as its external signs a motor impulse and conspic- purely sensory cases; existence of purely hyper- uous loquacity with confused content; but, in kinetic ones must remain questionable. addition, as soon as we analyze its individual The preceding brief empirical principles may symptoms, it can certainly present with entirely indicate to you the range within which we can different components. Crucial to our approach is manoeuvre. Such defi ning of boundaries is essen- therefore the practical and clinical perspective, tial, because frequently you will fi nd ‘confusion’ that this is an acute psychosis, which can begin [Ed] described under the headings of ‘primary and end as mania, but in intervals between peaks confusion’ [Ed] or ‘dissociative confusion’ [Ed] of illness, which may predominate overwhelm- (according to Ziehen) [1 ], as an actual illness. ingly, it often loses some typical features of Usually all that is thus designated is the respec- mania and, in their place, acquires all manner of tive state of a patient, in whom we always still strange admixtures. In this complex clinical pic- have the task of determining the individual ele- ture, the chief signs derived from mania, are ments that lead to the state of confusion. In so

© Springer International Publishing Switzerland 2015 235 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_33 236 33 Lecture 33 doing we will at least have to raise the claim that Overvaluation of certain ideas—accepted by confusion, as a symptom of stimulation—that is, us—and the ‘closed train of thought’ [Ed], also one connected to fl ight of ideas and loquacity—is have a defi nite internal connection, according to separated in principal from the corresponding Meynert’s formulation [2 ]. The majority of asso- state of defi cit—that is simple incoherence by ciations, are located within ordered thought pro- sejunction (dissociation). Only the fi rst case cesses characterized by Meynert as ‘large, widely would call for special consideration, in the task branched, long, profoundly and strongly coordi- before us. nated’, [W] and fi nd their counterpart in simply You may thus conclude that, despite this dif- coordinated ‘narrow, brief, unbranched, weakly fi culty, I am motivated purely by empirical con- and shallowly ordered, aimless’ [W] associa- siderations, because generally, with a consensus tions. ‘The association intensity corresponds to all too rare in our discipline, the internal connec- the molecular tissue attraction as a source of tion between mania and confusion, and the fre- strength. The mass of arching fi bres, within quent transition of one into the other, has been which two sources of force, that of the idea of an accepted and is taught. I refer only to Meynert, “objective” and that of the initial idea, tend who earlier (that is before the appearance of his towards each other, as it were, in the act of think- clinical lectures) had even gone so far as to see ing, always attaining vital force for elevation every acute psychosis that we would call mania above the threshold of consciousness from two arising from a state of confusion, by way of ideally centralized cortical areas; but the second- weakened associations, leading to the clinical ary association arises from only one of these picture of Amentia, which he himself analyzed so areas: either that of the “objective” [Ed] or that of masterfully; while later he designated under the initial idea, according to whether for example mania cases of illness that differ not signifi cantly the rhyme fi ts its word picture. Functional attrac- from our ‘pure mania’ [Ed]. What Meynert has tion is the weaker here, and is inhibited by the expressed on this occasion about fl ight of ideas stronger.’ What is here called ‘tissue attraction’ and associative weaknesses belongs among the [Ed], we again designate as increased excitabil- most extreme views written by this thinker on ity. If we disregard such functional differences of psychological questions. Without being able to excitability in the functions of the organ of asso- follow him completely, I would still try to shell ciation, the primordial condition of the childlike out the kernel of this and make it useful for our brain—Meynert’s ‘genetic confusion’ [W]), in purpose. My comments about the fl ight of ideas which any given association is possible— in mania summarized above—all too briefl y— reappears to some extent, and may be retained for will thereby be complete. I disregard the fact that a while, because anatomically preformed combi- the basis will be vasomotor fl ux, or functional nations exist between any two given cortical hyperaemia, a consequence of nutritive attraction areas. Different gradations of ‘fl ight of ideas’ as Meynert expresses it, an action produced by [Ed] can then increase to the highest grade, association fi bres, corresponding to the ‘closed which, for us, represents disjointedness or inco- thought pathway’ between an idea being regis- herence, when, after uniform and general increase tered—Meynert’s ‘attack idea’ [W]—and the of excitability, individual differences between idea of its ‘objective’ [Ed]. For our purpose, we various association pathways are largely obliter- may disregard vasomotor infl uences and be satis- ated. It is such confusion, arising from an exag- fi ed that, also according to Meynert, the closed geration of mania that we have in mind when we train of thought is a functional acquisition point- recognize the clinical picture of confused mania. ing towards a most minute localization in defi nite A decisive criterion for this is the state of irrita- anatomical elements. We rely upon the fact of tion evidently present, seen as loquacity and pathways well-worn by use, which conse- motor impulse, and—in the absence of any actual quently have become more ready to respond defi cit—in the breakdown of associations. and more excitable, in comparison to the others. Therefore it remains possible for patients to 33 Lecture 33 237

fi xate their attention momentarily, when they are attention (by the infl uence of the process which given external stimulation, and likewise by their Meynert calls ‘partial wakefulness’ [Ed]). No being given increased motor force; and they may fi rmer view can therefore be gained from the fact even occasionally be amenable to more complex of incoherence in the fl ight of ideas, seen in the trains of thought. In other words, previously spontaneous loquacity of these patients; yet the acquired contents of consciousness remain essen- patients’ reactive statements can then themselves tially untouched. be judged correctly only when the fact of their We must thereby return to the difference constant diversion by internal irritation is taken between activity and content of consciousness. into account. Yet every ordering in contents of consciousness If we recapitulate our views about the fl ight of consists of gradations of excitability acquired by ideas as expressing intrapsychic hyperfunction, practice, in which total dissolution would have to we can differentiate three grades: The fi rst and occur of the contents of consciousness into their the second, the ordered and the disordered fl ight simplest elements, that is, into fragments. The of ideas, are both peculiar to mania and deter- immediate consequence of this must be total dis- mined more fully by accompanying abnormal orientation in all three domains of consciousness, euphoria. Moreover, the contained, closed train which should appear in the same way in the con- of thought—the ordered [Ed] fl ight of ideas—has tents of the loquacity, as it does in the way a the characteristic that it is organized essentially patient’s motor impulse becomes manifest. by its content, whereas the disordered fl ight is However, in confused mania we require that the determined more by similarity of word sound, levelling of ideas does not go beyond the auto- rhyme, assonances, sequences, etc. In the inco- psychic domain: No actual symptoms of defi cit herent form—or fl ight of ideas of the third should appear with regard to the external world grade—which characterizes confused mania, and to corporeality; yet even in the autopsychic word similarity and sequences likewise play a domain we will no longer include in confused large part, but this can also extend to every com- mania those states of the so-called confusion in prehensible connection of the sequence of words which real defi cits in contents of consciousness brought up during loquacity, or only fragments of are demonstrable as reactions, such as when time words, which are lost to us. An example of disor- is no longer correctly perceived, or when a per- dered fl ight of ideas is taken from a later demon- son fails to be able to make a tally of different stration [3 ] of one of our cases of mania, Miss coins, even when given suffi cient attention. These P. To my question: ‘Was your admission neces- must be classed amongst the more severe clinical sary?[ she replied literally: ‘Was it necessary pictures. Professor? Am I the girl from Wahrendorf ? Were In a word, we must try to confi ne the clinical you then in the village or in the city? Are you picture of confused mania to those cases which educated, reared, trained in the village? Or are do not actually show a close connection in their you a relic piece , or what are you really, or which course with mania, but also, according to the piece will you have? A rib, liver, a pair of feet or degree of confusion, which appear just as a fur- a couple of pickled ham hocks, brawn, ah, brawn ther increase of intrapsychic hyperfunction; that perhaps? A bit of jelly perhaps?’ In this example is, the incoherence, to whatever degree it reaches, the jump to the relic piece is confi ned to incoher- remains largely a formal disturbance, without ence, while we are well able to follow the mecha- resulting in more severe defi cit states for contents nism of the combination of ideas. of consciousness. Evidence that such defi cits do Gentlemen! Confused mania in our strict not exist can be gained from the fact that it is sense occurs in rare cases as the acme of a single sometimes possible to elicit reactive statements attack of pure mania and is then usually of shorter from patients, showing their retaining the possi- duration than the pure mania. It is encountered bility of ordered trains of thought, albeit only much more often in recurrent mania, and espe- exceptionally, and with special efforts to sustain cially in cases of periodical mania, that is those 238 33 Lecture 33 cases in which relapses follow one another with was fi lled with supernatural strength and a feel- actual periodicity. Most often, we encounter ing of happiness, which only occasionally gave menstrually related periodic mania, usually way to anxious ideas. The strength of all departed appearing pre-menstrually, which we may cer- souls was in her, and it was an abundance of tainly regard literally as a type of ‘periodic’ [Ed] thoughts which prompted her to talk. At fi rst the mania. As an example of an irregularly-recurrent situation seemed to her to be the time of resurrec- confused mania, I remind you of the case of Miss tion, then to be a religious war, in which she F., 37 years old, presented some time ago, who believed that, by her intercession, she was called passed through her 23rd attack since age 20, and upon to decide the fi ght between good and evil. is now held in a provincial secure unit, where she Her present experiences seemed to her to corre- is generally free from relapses. At the time of spond with certain prophecies in the Bible. presentation she appeared to be extremely buoy- Innumerable voices of relatives, former pupils ant in her mood, but still irritable: she could not and their mothers, who she recognized by the stop laughing; overwhelmed me with reproaches; sound of their voices, though unseen, were stand- uttered a stream of verbiage, which could hardly ing by her side to fi ght for her. She saw deceased be interrupted; and her loquacity, unintelligible persons as skeletons that moved, as well as dark as it was, seemed to be determined in part by forms whose likeness she had never seen before. similarities of its content. Her motor impulse was All these could not harm her. She knew quite well largely manifest as an excess of expressive move- where she was, yet she saw heaven and enlarged ments, used in part to express her dislike for me. stars, saw angels, and could reach the sky with With arms akimbo, body bent forward like a her hand. On the other hand, she often saw an scolding door-to-door saleswoman, she made entirely strange country in front of her, an various grimaces towards me, stuck out her unknown part of the earth, probably where evil tongue, fi rst approached, then stepped back; in spirits lived. She believed that she recognized short she enacted a sort of domestic scene with relatives in fellow patients. Physicians and atten- me, in which she did not spare her fi lthy remarks. dants, recognized as such, were representations She seemed to correctly recognize place and per- of evil; she believed that I was the incarnation of sons, although her conduct seemed to be con- evil; to fi ght against her I would kill her brothers. trolled by some grandiose ideas, without confused Also, gentlemen, she ascribed a hostile intent to loquacity providing any fuller explanation. you. She often believed that her food contained Usually isolated, she became inaccessible to poison. Occasionally, she was anxious and had to physical examination. She stripped off her cloth- sing. Her movements were such that she felt there ing and was usually found naked, untidy, smeared was a snake in her body; its head stuck into her. food about, refused it in part, and occasionally When she closed her eyes she saw the snake, showed a fear of being approached. Occasionally slender and glistening. She often put bread into it was noticed that she started singing when under her ears to feed the snake. She stripped off her evident stress, for she had become hoarse because clothes because they were poisoned by contact of her loquacity. Furthermore, there were many with the snake. One day, the snake was voided aimless movements, for example violent clap- with her stool, and then calm prevailed. She ping of her hands and peculiar twisting move- poured milk into the toilet bowl to feed the snake. ments of her torso. This condition had developed The snake was Eve’s serpent and signifi ed over the course of a few days from a form of pure Original Sin. By suggestive questions it was mania, continued for about 14 days and then ascertained that she believed that she was the gradually passed into a state of calm, but also of Virgin Mary, made pregnant by the Holy Ghost. exhaustion, after which the patient was able to At the time of these communications she had impart intelligent information to us. You will complete insight into her illness, and for a long remember the astonishing, unexpected content time, she was then free from recurrences. Apart she gave us of her experiences. She felt that she from recurrences, there had been representative 33 Lecture 33 239

‘vicarious melancholias’ [Ed]. The connection of of pure mania, while the fi rst attack, even more this clinical picture with mania is evident, even if than the second just described, bore an over- only the beginning, but not the end of the recur- whelming stamp of hyperkinetic motility psycho- rence corresponded to mania. Previous attacks of sis. Allopsychic orientation in this case was the illness, especially the fi rst, which appeared completely intact. The course of periodic puer- along with menstruation, were pure manias. peral mania in Mrs. Cz., who I presented to you Actual disorientation in the allopsychic area in her fi fth attack, was similar. The main features never occurred; in the autopsychic area it had of the clinical pictures consisted of incoherent characteristics of grandiose delirium, under- fl ight of ideas manifested in occasional repartee; standable in the context of mania—this having unrestrained, exalted mood, and correspondingly religious coloration, corresponding with the exaggerated expressive movements, desire for patient’s personality; and in the somatic domain, action expressed by tearing and smearing, unre- disorientation consisted essentially of abnormal strained conduct, with addition of motor hyperki- sensations, perhaps linked with menstruation, nesia, acting like a chansonette artist; and and an explanatory delusion for the pseudospon- hypermetamorphosis. Preceding attacks had a taneous movements, particularly of her trunk. form more akin to hyperkinetic motility psycho- That this delusional explanation took on the form ses, while the following sixth attack and last of a sensation and a vision, has numerous analo- attack was purely manic followed by permanent gies elsewhere. restitution, once a stage of exhaustion had passed. Another example of confused mania of which This patient always remained perfectly orientated I remind you, was the case of Miss B., a periodic in the allopsychic domain. menstrual psychosis, which recurred six times in Confused mania, in the sense we give to the all, but then declined, never to return over the name, does not by any means embrace all cases next 4 years. The regularity with which the manic of the so-called periodic mania. Quite often, attacks always heralded approaching menstrua- attacks of periodic mania do indeed correspond tion, and the prevailing opinion that such cases to the clinical picture outlined, yet allopsychic were incurable, led us to propose removing her disorientation is also present, manifested as fail- ovaries as a remedy, a procedure thwarted essen- ure to recognize—or mistaking—the place of a tially by opposition from her relatives. The situation or persons, often even objects. The three patient has now recovered without such an inter- cases just described teach us that such allopsy- vention, permanently I hope, for I have often had chic disorientation need not follow from marked the same experience, that periodic mania, as we incoherence in the fl ight of ideas. We will there- understand it, exhausts itself after three to eight fore proceed correctly, if we regard such cases recurrences, like the periodically-recurrent not as confused mania, but as periodic manic hyperkinetic motility psychoses. At the time she allopsychosis [W]—and they are often also presented during the second attack, she showed a totally sensory psychoses. largely manic picture: confused loquacity, arising Gentlemen! Permit me at this time to make a from incoherent fl ight of ideas, only a moderate few comments on the clinical picture of Amentia, motor impulse, but a very changeable mood, or acute confusion, outlined by Meynert. I have often suddenly transformed to dejection or anxi- repeatedly indicated how important I consider ety, and certainly with anxious phonemes. Meynert’s clinical lectures to be; in my opinion, Moreover, hyperkinetic symptoms were added they have provided the foundation for better more prominently than in the previous case, con- understanding of the symptomatology of acute sisting of expressive movements of anxiety and mental illnesses. However, it must be expressly despair, unmotivated raising of the voice, etc. In stated that Meynert also succumbed to the gen- addition, a very marked hypermetamorphosis eral fate of other authors, who have laboured hard existed. Recovery in this case was accomplished, in their monographs in certain provinces in our and in that the last attacks acquired a form more discipline: He has embraced, under the term 240 33 Lecture 33

‘amentia’ [Ed], a great number of acute psychoses general weakness of association, is always mani- that are fundamentally different. This is already fested fi rst in the autopsychic region, and second intimated in the title of the section, where we and third in allopsychic and somatopsychic fi nd, as synonyms of amentia, the terms: ‘acute domains. If the phenomenon of confusion alone is insanity, general insanity, mania, frenzy, melan- kept in mind, this idea would correspond in some cholia with excitement, melancholia with apathy measure to the facts. of other authors’. However, you will also fi nd Gentlemen! I can accept a clinical picture of transitory psychoses, the so-called twilight states primary confusion only to a limited degree, when and other conditions discussed in this chapter. confusion consists of a defi cit state shown as Apart from amentia, Meynert then differentiates actual incoherence. We should have to consider only melancholia and mania as specially acute as its signs the demonstrable exhaustibility of psychoses. Nevertheless, the chapter on amentia ideation either in absolute failure of fl ight of is of lasting value for all time, and indicates the ideas, or at times when failure of fl ight of ideas is greatest advance psychiatry has made clinically appearing. Doubtless there are those conditions, since Kahlbaum’s work on catatonia, since it in which patients can occasionally fi xate momen- contains the fi rst real theory of mental illnesses tarily, and can be motivated to produce reactive and especially of acute psychoses, founded on movements or expressions; but these are always hypotheses derived entirely from the condition those of the simplest kind or are responses to of the affected organ. You can judge how far intense impulses, by a sort of ‘whipping-up’ [Ed] Meynert approximates the standpoint that I have of attentiveness. Incoherence in spontaneous always advocated in these demonstrations, from expressions of these patients shows itself to be the fact that he always places in the foreground independent of loquacity and motor impulse. symptoms of functional defi cit, that is the differ- More complex questions and commands remain ent grades of weakening of associations, and he evidently not understood, without degradation of considers symptoms of irritation to be a conse- the sensorium being responsible. These patients quence of these. In just the same way, I have rep- always tend to be disorientated in allopsychic resented sejunction as the fundamental process, terms. Signifi cant Affective reactions are absent. and derived symptoms of irritation from this. If I In consequence of the evident failure of associa- have often differed in detail from Meynert in how tive activity—so that, apparently, the excitatory I carry out of this principle, the future will reveal stimulus could be conducted to the more remote how far this has been justifi ed, and was required, links of the association chain only with diffi culty unconditionally, in relation to clinical facts. or not at all; and—to express the contrast with I might emphasize specifi cally only that Meynert’s agitated confusion—these conditions might be amentia, according to his own description, may called asthenic confusion [W]. Actually, they are embrace all cases of illness that I described as usually accompanied by other symptoms of acute autopsychosis, allopsychosis, somatopsy- weakness, attention being captured only with dif- chosis, motility psychosis, and their combina- fi culty, with considerable degradation of memory tions; and that, from a clinical standpoint, it is retention, along with general physical weakness necessary to postulate corresponding degrees of and reduced state of nutrition. Such a picture of weakening of associations in Meynert’s sense. asthenic confusion, which can be accompanied The situation may arise, that the fi rmest associa- by all manner of symptoms of sensory irritation, tive links exist in the domain of consciousness of is often found to be a consequence of other acute the body, the next fi rmest in consciousness of the exhaustive psychoses, or phases of such, but environment, and the loosest—and likewise the could not be referred to as primary confusion. latest to be acquired, with the greatest individual Gentlemen! If, to do justice to clinical facts, differences—in consciousness of personhood. we must acknowledge confused mania as an Correspondingly, a similar measure of severity of independent clinical picture, and fi nd its illness, or, according to Meynert’s concept, of essential sign as an increase of the intrapsychic 33 Lecture 33 241 hyperfunction to the point of incoherent [Ed] relapse then occurred. In the menstrual psycho- fl ight of ideas, we cannot consider it accidental, sis of Miss B, described above, states of exhaus- that such conditions tend to occur especially tion after the fi rst and second relapse occurred after severe attacks of confused mania or agi- on two occasions in almost identical manner. tated confusion. I might assign such cases to the It is easy to interpret the allopsychic disorien- highest grade of weakened association described tation in such a case as a symptom of exhaustion, by Meynert, which he compares to genetic con- occurring in an area of content of consciousness fusion (see above). Two cases of this sort, for that had previously exhibited active irritation, which more precise data exist, presented with shown as hallucinations; so the disturbance of asthenically recognizable signs, and with physi- identifi cation, the psychosensory paraesthesia cal decline as well: That is, there was a com- and anaesthesia could be traced back to defective pletely quiet, affectless state of mind, and only excitability of allopsychic contents of conscious- occasional unmotivated grimacing, and absence ness. At any rate it would be justifi able for us to of spontaneous utterances or movements. Simple regard the demonstrable weakness of association commands, like raising the hand, poking out the as a state of exhaustion of the intrapsychic path- tongue, standing up, and so on, are understood ways, a transformation of heightened excitability and obeyed. Likewise, simple questions such as into a lowering of excitability. Thereby the weak- name, age and other personal details were ness of association postulated by Meynert (see answered promptly. On the other hand, going p. 236 above) would turn out to belong not to beyond this, some tasks requiring combination mania itself, but to be a consequence of mania could not be performed. For instance, numbers appearing only during an unusually severe abnor- to which the big and little hands of the clock mal process. point are given correctly, yet the time is not Gentlemen! You have seen the internal con- known. Coins are named correctly, accurately nection of such inter-dependent clinical pictures, counted, yet their value could not be computed. and I certainly believe that the stages of exhaus- A simple route, through different streets which tion substitute for confused mania. My views are are perfectly familiar to the patient, cannot be less certain in support of a primary asthenic con- described. However, enumeration of serial asso- fusion [W], which can occur as an independent ciations or simple, memorized material, like the illness for many months, and can then be fol- Lord’s Prayer, is carried out well. Attentiveness lowed by complete recovery. In one case of this is relatively good; memory retention badly kind, the principal characteristics of the state of impaired. Places and situations are not recog- exhaustion were found as previously described, nized, and neither are persons, who would have namely a certain defect in spontaneity; failure of been known before the illness. This goes so far ideation in more complex demands; attentive- that the physician, for instance, is claimed to be ness retained just through excitement; but very the mother, while later, when the state of weak- poor memory retention and simultaneous allo- ness has abated, other more subtle mistakes psychic disorientation, accompanied by symp- come to the fore. Hence, there is no subjective toms of motor and sensory irritation of moderate feeling of inadequacy, not even a suffi cient sense nature. In other words, pseudospontaneous of physical weakness, no insight into the illness movements occurred that were monotonous but in the preceding attack of mania. For the latter, not rhythmic, along with phonemes and hyper- mainly, there is amnesia. With respect to the metamorphosis. Signifi cant Affective reactions decline, over time, this state of weakness exists were absent. The course was remitting, com- at a severe degree only for a few days, followed bined with akinetic symptoms for a few days at then by gradual restoration, along with simulta- the height of the illness. The patient, a poorly neous increase in strength and weight. developed, 20-year-old youth, has not had a Admittedly, the condition of apparent recovery relapse for 4 years. I might confi ne myself to lasted for only a few days, because a very acute mentioning such cases here, emphasizing only 242 33 Lecture 33 that precisely the same symptom complex should autoallopsychoses’ [Ed]) in very acutely ill be called ‘acute primary asthenic confusion’ young girls; and furthermore, whose outcome is [Ed], and understood as such. always one of complete recovery, even if only Gentlemen! To demarcate such cases it would after a long-lasting paranoid state. However, be well to remember the old differentiation these cases had the peculiarity, that in contrast between habitual forms and actual illnesses to a relatively poor attentiveness, which was advocated especially by Kahlbaum [ 4 ]. The state hard to capture, memory retention was surpris- of exhaustion described above is evidently not to ingly good. be regarded as an actual illness, but shows us asthenic confusion as a habitual form or, as recently termed, a disorder. Cases of the last- References described kind are, on the other hand, examples of an independent and primary exhausting illness 1. Ziehen GT. Neurol Centralbl. 1891;10:644. [Ed], certainly in the state of asthenic confusion. 2. Meynert T. Klinische Vorlesungen über Psychiatrie auf wissenschaftlichen Grundlagen für Studierende The condition—or habitual form—of und Aerzte, Juristen und Psychologen. Vienna: asthenic confusion could also be further con- Braumüller; 1890. ceived, as it has been here. I have often seen 3. Wernicke C. Krankenvorstellungen aus der psychia- cases of weakened association, with autopsy- trischen Klinik in Breslau. Breslau: Schletter; 1899. vol 1, Case 5. chic and allopsychic defi cit symptoms, but no 4. Kahlbaum KL. Die Katatonie oder das motor excitatory symptoms (therefore: ‘asthenic Spannungsirresein. Berlin: A Hirschwald; 1874. Lecture 34 34

• Examples of akinetic motility psychosis case of akinetic motility psychosis from the • General impassivity clinic; or at least, we cannot be sure that the case • Negativism is pure, until the patient returns from a motion- • Flexibilitas cerea less state to give us information about his internal • Muscular rigidity processes. This awkward position is, of course, • Persistence in positions merely the result of our lack of knowledge, and • Parakinetic behaviour in standing and we must not despair of succeeding later on in rec- walking ognizing, from its own defi nite and specifi c signs, • Verbigeration a pure akinetic state. At the time of when immo- • Pseudo-fl exibilitas bility actually exists from its own defi nite and • Behaviour of the sensorium specifi c signs. However, at present I must limit • Catalepsy myself to singling out a few examples of akinetic • Melancholia attonita or cum stupore motility psychosis, as can best be used for teach- • Kahlbaum’s catatonia ing purposes. For this it might be most suitable to • Course of the illness report on Frau K. (p. 223 seq ), who I presented to • Outcomes you in a stage of remission from a hyperkinetic motility psychosis. This patient then progressed to a state of general immobility, interrupted by only brief periods of hyperkinesia; the immobil- Lecture ity has been presented as permanent, because a loss of basic strength indicated that an unfavour- Gentlemen! able outcome was likely, and yet, it was actually When any impairment in motility—in other transitory. She is therefore an example of the aki- words, any state of general immobility—is mani- netic phase of a ‘cyclical motility psychosis’ fest, we can learn nothing from this fact about the [Ed], in which both phases are involved, rather patient’s internal processes, his state of mind, and than the motility phase alone. The report of the current ideation. Facial expressions leaves us demonstration runs as follows: none the wiser, for akinesia often extends through this aspect of expressive movements, so that a The patient is brought in on a portable bed and simple ‘demented’ [Ed] expression may be the placed at the front of the auditorium. result of the absence [Ed] of any expression. As a The patient is left to her own devices: She lies on consequence, it is not possible to present a pure her back in bed, with head raised a little on her

pillow. Her eyes are rigid without fi xating on she does so, she wrinkles her eyebrows some- anything; blinking is rare. Facial features are what, and her face betrays the hint of a painful fl at, corresponding to a state of exhaustion, expression. somewhat distorted by a half-open mouth, On pricking her hands, very similar behaviour lowered at its corners. is seen. Initially they are turned back and forth, Behaviour on external stimulation: When the but are not withdrawn, although they are in no patient’s name is called repeatedly and loudly, way restrained, being allowed to rest freely on and even when she is grasped by the arm, the the open palms of the examiner. The right hand in sole reaction to be seen is an increased fre- particular is not withdrawn. quency of blinking. Her eyes remain unchang- On pricking her cheeks, nose, and lips with a ing, continuing to stare into space, and not needle, she contorts her face in a markedly pain- directed towards the examiner. ful way and starts to cry with suppressed sobs. Maintenance of imposed postures: When I ele- Thus, reactive akinesia can be interrupted by vate her right arm, there is very marked resis- painful irritation. tance, which gradually subsides to become The patient is requested to sit up, but remains more pliable (‘waxy fl exibility’ [Ed]). Her immobile, so she is raised up in bed. arms remain in any position given to them, Reaction of the patient to incentives for acti- even if these are uncomfortable, until they are vating movement: When requested to stand up, put in some other position. It is especially sur- she moves her legs a little as though attempting prising that this patient, despite her evident it, but falls backward with her trunk in a recum- weakness, holds her elbow fi xed at a right bent posture. She is then raised up again to a sit- angle and somewhat abducted at the shoulder, ting position, whereupon, in spite of a proven for a long time, totally without support. good intention, she crosses her legs in a totally Another behaviour can be seen in her lower inappropriate manner. On further encouragement limbs: As the lower leg is grasped and moved she attempts to get up, but succeeds only with back and forth, the entire pelvis moves as well considerable assistance. She is now taken by the (that is, muscular rigidity of the pelvis–thigh hand and led around the room, offering no resis- muscles, as in spastic spinal paralysis). In tance, although at each step she must be given a addition, her legs are perfectly fl accid, and, slight tug on the hand. Her gait is of a clockwork when elevated, fall immediately under gravity. character, individual steps being separated by Her head is also freely and easily moveable in marked pauses. In standing, her knees are slightly all directions. On the other hand, attempts to bent, feet together, and she sways back and forth, prise apart her mandible from her upper jaw but does not adopt a stable position on her feet. meets with very stiff resistance, and similarly, When she is requested over and over again to later on, it is impossible to separate her eye- walk, she begins to lean forward slowly; but, lids, when they are kept closed after her out- once her centre of gravity is outside her centre of break of crying. balance, suddenly, and unexpectedly, she begins Refl ex behaviour: Tendon refl exes in her legs are to run. This movement accelerates in a manner normal; those in her arms defi nitely exagger- similar to propulsion in Paralysis agitans [W], ated. Refl ex excitability of cutaneous capillar- and is clearly interpreted as preventing a forward ies is normal. fall, threatened by her initial inclination. In her path she reaches her bed, lets herself fall onto it, On pricking the soles of her feet with a needle, and lies, with proper decorum, on her side. the patient reacts promptly by dorsifl exion of the When once again, she is stood up, the patient, toes, then of the whole foot. On repeated [Ed] who has not stopped sobbing since being pricked pricking she turns and twists it back and forth, with the needle, sways markedly, yet is supported and fi nally withdraws it by fl exing her knees. As by a female attendant, and apart from blinking 34 Lecture 34 245 more often, does not react in any way to demands Condition on 8 May, 1899: Nutrition level made of her. She has to be put back to bed again, good, distorted features; organs and bodily func- and is carried out. tions in good order. Patient sits in a fi xed posi- It had been established in this patient, that dur- tion, left hand on the crown of her head, eyes ing the hyperkinetic phase and in transitional straight ahead, paper and pencil lying on the table periods between the opposite phases, in addition in front of her. Expression unhappy, perplexed; to motility, her orientation was affected by the outburst of tears on seeing her brother. Facial disease, in all three areas of consciousness. I expression not fi xed, changing in comprehensible therefore chose the next case chiefl y because she ways during the course of the examination. represents an unusually pure example of aki- Patient stands up spontaneously, seizes paper and netic—or rather parakinetic—symptoms by pencil in the right hand, indicates that she wants themselves, while orientation remains quite nor- to go to the next room, her usual abode, sits there mal; and not so much as a hint could be found in in her accustomed place, eyes directed to a fi xed this female patient - who readily provided us with place on the opposite wall. This gaze is main- any information we required - of any explanatory tained forcibly, so that she looks neither at the delusions. Apart from headaches, any abnormal questioner, nor down when she is writing. All sensations about which the patient complained answers are in writing, hastily written with the were probably exclusively aberrant ones from lead pencil in abbreviated form: For instance, to muscles, or ones of position, therefore to be the question, ‘why so excited?’ [Ed]:—‘Can’t classed amongst disorders of psychomotor iden- help it’. Complete mutism, yet, with urging, she tifi cation (see later). The case involved a 47-year- attempts to repeat, but with evident effort. Instead old spinster, sister of a physician, so that her of pronouncing the auditioned word ‘Anna’, pro- retrospective statements are unusually reliable. longed verbigeration took place of the syllable Until the beginning of her illness, she had been ‘ruh-ruh…’, fi nally to be lost in toneless, rhyth- a science teacher in a middle school, had no mic repetition of ‘r-r’. She denies that she can heredity taint, was formerly in good health, and poke out her tongue; but then, after several became ill in September, 1897, in connection with attempts, succeeds spasmodically for an instant. menstruation. Her diffi culties were thought ini- Instead of written answers, often makes intelli- tially to be hysterical, but increased over a few gent gestures, which she otherwise prefers to weeks to a state of general immobility. Tube feed- employ. However, both hands are usually occu- ing was needed for some weeks. Akinesia gradu- pied: one is always pressed to the back part of the ally remitted but stereotyped movements crown of her head, the other, with its index fi nger appeared. In place of mutism, there was verbig- extended, rhythmically taps some part of the eration, but no real hyperkinesia. Encouragement body, face, trunk, or thighs. and verbal suggestion led to improvement in her speech. There was then a cessation of all symp- Q: What is on the head? toms, giving us hope of full restitution. However, ‘Inside’; ‘now pricks many times’, ‘fi ne nerves’, a relapse occurred in October 1898, similar to the ‘sickness’, ‘worse every day’, ‘worse after present one, but worse, according to the patient’s eating’. own statement. Her left hand became constantly Q: Why is your hand held there? clenched into a fi st. After a few weeks, there was ‘Not let loose, otherwise falls back’, ‘as if it another remission, with progressive improvement breaks’. almost to the point of free mobility. According to Q: Can she otherwise move freely? her physician brother she was then apparently ‘Fingers held to a point’. normal for a few weeks. Three to four weeks ago, Q: What are your other complaints? another relapse took place, again coinciding with ‘Great restlessness when eating’, ‘nerve weak- onset of menstruation. According to the patient, it ness’, ‘restlessness during the day’, ‘must is now becoming worse, day by day. often pass water’, ‘no will power’, ‘no help’. 246 34 Lecture 34

Stress and many sleeping drugs were given as It is very rare that such good information can the cause of the illness. Had been worse in be obtained in akinetic motility psychosis during October. The following are excerpts from the its actual presence. Evidently it is possible only patient’s written statements: She must cry, is con- when the area of akinesia is as circumscribed as fused, complains of restlessness, but not of anxi- in this patient. However, this circumscribed con- ety, knows and understands everything, can write, dition is correspondingly rare amongst acutely ill but the examination strains her, it is hard for her cases. to keep her eyes open. The brain is sound, only Several more examples of akinetic motility the brain nerves are sick. Writes name, age; that psychoses provide us with further information she has menstruated every 3 weeks. She defi - about the quintessential symptoms belonging nitely denies external infl uences, electricity, here. The fi rst comes from my time in Berlin: secret forces, and voices. When she closes her This 33-year-old university Professor B. had eyes, she sees bright colours. She must be suffered severe articular rheumatism 3 years watched, when she closes her eyes. before, then remained healthy, and had no famil- She leans back as if exhausted, closes her ial tendency to nervous disorders. For 2 years he eyes, lets her right hand fall over the arm of the has laboured beyond his strength on a scientifi c sofa, the left remaining on her head. The right project. Three days prior to his mental illness he hand now makes rhythmical convulsive move- had an attack of dysentery with bloody stools, ments. On my remarking that this is involuntary, marked meteorism, and very intense pain. He is a fl eeting look of thanks, patient grasps my hand markedly run down physically, became delirious, with her right and carries it to her mouth to kiss mistook people’s identities, had visions, saw dev- it. On passive removal of the left hand from her ils, and heard voices. This condition worsened, head—but at times spontaneously also—the right and, simultaneously a general muscular rigidity hand replaces the left on her head. However, the set in, at fi rst in paroxysms, and then with longer right hand is always used for any activities, duration. After 2 days of being almost motion- although the left is freely movable. However, she less, he held a crucifi x in his hand, convulsively, is unable to offer me her right hand on leaving, for half a day; raved excitedly about the devil; making helpless gestures instead. Spontaneous uttered inarticulate sounds, especially at night. gestures are few, then hasty, most often changing Then these reactions to aberrant sensations location as a result of inner restlessness. No fl ex- ceased, and he remained in a perfectly motionless ibility. Patient must be waited upon, but is tidy, state for 8 days, usually accompanied by muscu- and willingly fed with a spoon. Sleep and nutri- lar rigidity, generally keeping his eyes tightly tion good. Full understanding of the situation, closed. He could swallow fl uids occasionally, becoming dependent on her ‘care-giver’, satis- while at other times he spat out everything, and factory interest and memory of daily events. voided excreta into his clothes. In this condition With some resistance the patient is brought to he was taken by carriage to a mental institution, sit in a chair by the window and to fi xate on a but because of his rigidity, could be transferred in fi nger held before her; and for a moment she and out of the carriage only with diffi culty, and seems able to move her eyes voluntarily, yet the sat leaning back, poorly supported, with arms haste with which she strives to return her gaze to and legs stiffl y extended. He could then be led their former direction prevents a defi nite state- into his room, or—actually—was slowly pushed. ment. As for the relationship that a certain spot Absolute mutism prevailed, interrupted only on the wall has with her eye movements, it is from the third day of his stay in the institution by impossible to learn anything positive despite all several hours of inarticulate outcries. Witless efforts. She tries to convey by various gestures facial expression. On the 11th day of illness mus- that such a relationship does indeed exist; but she cular rigidity ceased. On being addressed, lip defi nitely denies that it is a command, electricity, movements but no sound; however, occasionally magnetism, or some secret force. opens his eyes. Marked frailty during the 34 Lecture 34 247

following days, generally perfectly motionless, a tremulous voice, trembled all over, made but occasional outcries. Patient then began to nervous movements with his hands, began to cry. leave his bed occasionally; stood at the window He was pacifi ed by encouragement, later was in a for prolonged periods with raised, outstretched stable mood, only occasionally complains of arms, and cried out several times. Went into the pressure in the head as described above, or of a corridor in his night dress, once answered very pulsation in the head: a feeling as if the brain slowly and softly: ‘I do not know’. On the 14th were moving back and forth. These troubles day, the fi rst spontaneous utterance: Patient said gradually disappeared, and about 6 months after to his attendant: ‘Look, Carl, see how I am’. The the outbreak of his illness the patient was dis- following day it was learned that the patient had charged from the institution, fully recovered. pain over his entire body; does not know who he Since then 12 years have raced by, during which is, where he is, claims he has no head, and has time, the patient, an honoured professor, has been been quartered. Speech is slow and childlike. functioning perfectly well in his former position. Every request is felt to be arduous. On the 19th An even more acute type of illness is pre- day, with his hand grasping his head: ‘This is not sented by the 26-year-old Doctor of Laws, of my head, my head has been exchanged, I have a Jewish descent, who I was able to present to you strange head, I am perfectly hollow’. From the 22 a few days ago. He had become acutely ill with day on: marked improvement, better statements; anxious ideas and most profoundly disarrayed, patient is tidy. Feeling in his head as though it had refused food for several days and made four were sore—a confused feeling, patient feels that suicide attempts, all of which, fortunately, had he is very severely ill, and asks for reports. Then been averted. We found him sitting in bed with continued improvement, tries to orientate him- congested face, hot head, feverish appearance, self; provides information on his thoughts during his pulse was not accelerated, yet remarkably the severe illness. He sometimes felt that his weak. His facial expression was somewhat rigid brain consisted of many parts, which moved up and immobile. Patient did not answer any ques- and down; at other times as if he had no brain, but tions, but followed the questioner with his eyes. a piece of ice in his head. Patient remembers that He did not comply with any requests, did not he had considered himself to be a steamship (an show his tongue, or open his mouth. Our efforts explanatory delusion), that he did believe that he to prise apart his lips brought about rather the has been the undoing of navigation on the Rhine, opposite effect—involuntary closure; the grasped in that he has twisted all the rudders. He has hand was held as though it raised his hackles. believed the world would be separated and has Otherwise, the patient sat quite immovable, in a been able to bring it back together, has been in normal posture, except that, from time to time, the royal palace, destroyed the fl oor there, and slight shivering and trembling movements then tried to replace it with tile; Prince Bismarck occurred, as if a cold shiver were passing over his came and gave him a malicious look. Patient body. If the patient was taken out of bed—to wonders how such perverse ideas can arise in a which he offered no, or only slight resistance—it person. He knows no reason for the muscular was noticed that he tottered, and did not have full rigidity. Progressive increase in insight into the command of his movements. Finally he suc- illness, sleep and appetite good, appearance ceeded in standing alone, and then, it was striking improved. A few complaints of an uncomfortable that he held his right leg half-bent, resting only feeling of pressure at a certain place in the left the outer border of his foot on the fl oor, while the parietal region, which later occurred only inter- left leg gave support to his body. He remained mittently. Six weeks after onset of the illness, in unsupported in this position for several minutes, full convalescence. After a consultation and a bad with the same immobile facial expression. We night following this, a state of mild excitement now attempted to put his head into another posi- occurred, in which the patient accused himself of tion, by bending his neck. This was met with con- an indiscretion the day before, talked hurriedly in siderable resistance, which continued beyond 248 34 Lecture 34 the medium position, so that fi nally he stood with while, she rests on one leg and fl exes the other, so head and trunk bent forward. He never used his that she touches the fl oor only with her toes; hand to defend himself. Meanwhile, during these indeed, she also lifts it completely off the fl oor. imposed movements he could not regain his old All these peculiar expressions of movement position, and was swaying; in this new position are devoid of any purpose that we can see, lack he shifted from one leg to another, now standing any change in facial expression, and without on the right, with the left half-bent and resting it patients being able to provide any motive, when only slightly on the outer border of the foot. Next they are able to speak, as in this last case. When day we found him squatting in bed with his legs resting, whether in bed or sitting on a chair, some under him; the fl accid positioning of his legs was of these patients assume a fi xed abnormal posi- noticeable. Today, approach of a hand triggers tion [W], for instance, by fl exing the cervical ver- the withdrawal of the upper limb on approach, tebrae forward, so that in reclining, the head is and of the trunk on the same side, while touching always raised from the pillow, or a squatting the legs has no such effect. Not a trace of any real position is taken, like that of the male patient defensive movements can be seen. I now place described above. my right hand in the patient’s right palm; his A localized tonic muscle spasm may occur in hand then closes, while I begin to execute a slow the context of such generalized immobility, with tug with my hooked fi ngers. The more I pull, the a predilection for it affecting the muscles of more fi rmly he clamps his fi ngers against it, and speech. I remind you of the patient Kl, who so I could draw his upper body into a leaning became very acutely ill with turbulent symptoms, position over the edge of the bed. He remains in and the next day was admitted to the clinic. He this position as long as I pull, and gradually appeared to be conscious, and followed the exam- returns to his former position, once I stop pull- iner with his eyes. His tongue, maximally pro- ing. This patient is now taken out of bed, and truded, lay between fi rmly closed jaws; it was seems about to collapse, as though his lower greatly swollen, cyanotic, and gangrenous near extremities have failed him completely. But if the teeth which had sunk deep into it. He was one proceeds cautiously and supports him on unable to utter even a sound or to swallow fl uids, both sides, we see that he can use them well; and had to be fed via nasogastric tube. Pain sen- yet, owing to their abnormal position, an unusual sation and refl exes seemed generally to be mark- amount of force must be employed. He remains edly blunted. After I had waited the greater part in a squatting, almost sitting posture, with legs of a day for the muscle tension to abate, I decided crossed, and is thus able to move forward unsup- on ‘re-positioning’ [Ed] under chloroform anaes- ported, and to regain his balance when he loses thesia, and fi xed his jaw in a half-open position. it. It seems as if he might fall at any moment, yet There followed a semi-somnolent state, lasting he actually keeps himself securely on his legs. many days, and only very gradually was the pro- (The patient passes his excrement into his cloth- truded tongue withdrawn back into his mouth; ing, absolutely refuses food, and was tube-fed then he started to convalescence, and, within a several times during the narcosis. Death from short time, could be discharged, recovered. The pneumonia after a few days.) peculiarity of this case was that the patient, at a Another patient, who has also been taken ill time when he still controlled his other move- very recently, has lain in bed groaning, answering ments, had to keep his tongue in this forcibly requests very rarely, and usually seems preoccu- protruded position. The patient, a 32-year-old pied fi rst in pursing her mouth, and then in evert- draughtsman, gave defi nite information as soon ing it in snout-like fashion; she is taken out of bed as he could speak, that he had always remained and made to walk; then plants one foot before the well orientated, maintaining full consciousness other slowly and cautiously at defi nite distances throughout the period of general immobility. in a dancing manner, somewhat like a tightrope Gentlemen! These cases of illness, sometimes walker. When she is left to stand quietly for a presented to you directly, sometimes only 34 Lecture 34 249 reported to you, show that ‘akinetic motility evacuation become necessary. Swallowing is psychosis’ [Ed] encompasses some very different usually markedly disturbed, so that prolonged clinical pictures: They have in common as the artifi cial feeding may be needed. Nonetheless, it most striking symptom, only the akinetic state, is rare for accumulated saliva not to be spontane- which differs in degree and extent during a period ously swallowed, and real paralysis of the swal- of continuous illness, and also varies greatly in lowing refl ex is demonstrable. However, this duration. Later we shall be able to make a rather undoubtedly can occur in more-acute, short-lived sharper differentiation. For the time being, we states, often with increased secretion of saliva. Of focus particularly on the different motor course, this condition includes cessation of all symptoms. initiative movements, so including complete We call akinesia extending over most of the mutism. Remnants of reactions, such as tremor of musculature by the name immobility [W]. It var- the eyelids, are usually present. In the eyelids, ies, as our cases show, according to its severity, in one can almost always see noticeable reactions to that sometimes it is so marked that it leads to ces- passive movements, even when passive motility sation of almost all reactions, producing a condi- fully resembles that of a lifeless body, in which tion apparently similar to death. In fact, confusion case, they may not only be retained but aug- between such cases, with actual death must have mented. This is not the usual behaviour in persist- occurred repeatedly, and is to be explained by the ing immobility, but corresponds rather to the fact that respiration and the circulation in such more acute phases of akinesia. Reduction of pas- cases may be greatly reduced, and a condition sive motility is encountered more often, a symp- akin to syncope may sometimes exist. I shall tom that can similarly assume very different return to this. Apart from such cases, we are deal- levels of severity. Most commonly with this type ing with somnolent states, which cannot be con- of inert patient, only the excessive imposed fused with actual death—at least, not by movements meet with resistance, or only certain physicians—for the heart sounds, the respiratory groups of muscles present resistance. Muscles for murmur and pulse, albeit weakened, are plainly closing the eyes, mouth, and jaws are primarily detectable. Extremities are usually cool, occa- involved. Grouped with such localized resistance, sionally cyanotic, and body temperature may be there can also be those symptoms often called considerably lowered. These are cases which ‘negativity’ [Ed] or ‘negativism’ [Ed]. Negativism appear from time to time, sensationally, in the [W] is shown in the eyelids when an attempt to daily press, with great regularity, as the ‘sleeping open them is met by apparently active resistance, uhlan’ [W] or ‘apparent death of a prisoner for leading to even fi rmer eye closure; likewise, in weeks’ [W]. In fact, in a portion of these cases, the lips, attempts to separate them are met with every reaction to painful stimuli is lost, due either closure of the mouth; and in the jaws, by a resis- to stupefaction of the sensorium, actual analge- tance which becomes stronger the greater the sia, or real loss of refl ex action. Nevertheless, in attempt to force down the lower jaw. Masseters the majority of cases, a refl ex response to a nee- and temporal muscles are then hard and tight to dle prick can be demonstrated, if only as a twitch- the touch. Such fi rm clenching of the jaws usu- ing of the eyelids, or on applying the needle to ally hinders introduction of a feeding tube by the most sensitive parts of the face, or even to the mouth, so this method of nourishment is only eyes. Reduced tendon refl exes, especially the possible in exceptional cases; and hence a nasal patellar refl ex, can unquestionably occur some- tube is preferable. After the sites just described, times, but not in conditions of longer duration negativism is most commonly encountered in discussed here. On the other hand, more com- muscles of the neck, in such a way that passive monly, tendon refl exes are exaggerated, so that raising of the head from the pillow not only meets patellar clonus and even foot clonus may occur. with resistance, but is responded to by vigorous Faeces are usually voided in bed; at other times backward bending of the head—a state of neck bladder catheterization and attention to bowel rigidity which ceases as soon as the effort is 250 34 Lecture 34

discontinued. Altogether, the symptom of nega- to this is to be found only in the rare cases of tivism has the characteristic that it seems to fol- continued muscular rigidity. low passive muscle stretch in a refl ex manner, and Muscular rigidity [W] is a manifestation usu- is increased in proportion to the force imposed. In ally occurring only as paroxysms in the context the extremities, it therefore occasionally occurs of more general immobility. I have never seen it only when movement is performed rapidly and continue uninterrupted for days; but occasional with large excursions, whereas slow, less exten- attacks are seen in almost every case. They occur sive movements often meet with no resistance. If either spontaneously, or from trivial provoca- generalized immobility is not very severe, such tions, usually consisting of attempts to get the attempts can produce signs of pain, such as facial patient into an upright position, or to impose pas- distortion, or fl ow of tears; in such cases, painful sive movements. In the warder’s notes the state- stiffness of the joints may be assumed, owing to ment is often found that patients had held the maintained fi xation in one position. themselves rigid. Not uncommonly profuse per- Meanwhile, I must return to cases characterized spiration follows, or the face becomes congested. by a diffuse tenderness of the muscles. Such attacks usually last for only a few minutes, Very often tests of passive motility lead to the but for hours in severe cases. In these attacks, fi nding of waxy fl exibility [W], Flexibilitas cerea patients may be suspended, supported only at [W]: Every passive movement meets a moderate, head and foot, as in a hypnotic experiment, and and equal resistance in all joints involved. It may even also be weighed down. As in tetanus, it results in maintenance of imposed positions. is a matter of a tonic muscle spasm—and often Most pronounced is Flexibilitas cerea [W] no less powerful—with involvement of masseters always occurring in the extremities; in the neck and facial muscles, but remissions, and ever- region there is instead mainly a degree of nega- returning sudden paroxysms, characteristic of tivism. Positions that can be imposed on patients tetanus, are absent: The whole condition is with Flexibilitas cerea [Ed] can be very uncom- always a continuous one, and usually less-stormy fortable and yet are maintained for a long time. in character. We saw, in the case of one patient, Thus, lying in bed, all limbs may be raised nearly that these states of rigidity may interfere with the vertically, this position being maintained. When patient being transferred. You will remember that patients sit on a chair, the trunk may be bent to this patient, Mrs. K., presented with moderate one side, arms outstretched, one leg elevated, localized rigidity limited to pelvic–thigh mus- thereby putting the patients in a position that, for cles; yet this condition might have another sig- normal persons, could be maintained for a long nifi cance, to be regarded merely as a mechanical time only with great effort. If a patient is stood consequence of prolonged immobility, analogous upright, one leg may be fl exed at its joints in such to the muscular stiffness in paralyzed limbs. a way that only tips of the toes touch the fl oor, or If we encounter a patient with generalized the trunk is bent so that the arms touch the fl oor. immobility, it is always advisable to get him out Under these conditions, patients often seem to of bed and stand him on his feet. It is then usually have a special facility for preserving their bal- found that this person—appearing to be dead— ance, so that comparison with Goltz’s [1 ] can stand and walk, provided some care is taken, decapitated frogs springs to mind. In all these and the patient suffi ciently supported. I recall one experiments the patient takes no part; even in patient I presented, whose knees gave away, but moderate immobility there is no distortion of his was then in a position to walk and stand, albeit in features, no glance directed at the examiner. a strikingly changed way. Total failure of the Maintenance of uncomfortable positions may be legs, as found in fl accid paralysis, occurs only observed for 5, 10 min or longer, according to the temporarily, in more acute states. On the other degree of immobility; and in the end, and most hand, lack of spontaneity in these patients is often, limbs yield to gravity, and uncomfortable always very noticeable. They remain standing ad postures of the trunk are corrected. An exception infi nitum [W] wherever and however they are 34 Lecture 34 251 placed, and any shift in their position can be certain defi cit symptoms. You will remember, achieved only when they are pushed, or a change gentlemen, that I always explicitly emphasized in balance requires them to move. In this regard, that motility is represented along with conscious- the behaviour of Mrs. K. was characteristic. Lack ness of corporeality. You see how far I was justi- of spontaneity can be understood when we fi ed in this, from what I have just said. observe the conduct of patients, once a milder Certain parakinetic symptoms, in hyperkinetic grade of immobility prevails, so that somewhat motility psychosis, about which we have already more complex experiments can be set up. Under had a chance to learn, give us a better hope of certain conditions it is possible, under certain their being traced back to processes of irritation. conditions, to help such patients, for example, to In fact, it is impossible to draw a sharp boundary get up onto a chair, but they then show them- here between hyperkinesia and parakinesia. In selves to be quite incapable of getting down and, most cases of less severe, yet more extensive aki- if forced, may fi nally fall in an awkward way. nesia, as in our patient Miss M. (p. 245), this Similarly, patients plainly show that they have takes the form of verbigeration [W], that is, understood a request to get in or out of bed, yet monotonous repetition of words, interjections, or they make futile attempts to comply, for they parts of sentences, often with quite nonsensical cannot recruit the necessary muscular coordina- construction—and this may occur either tempo- tion. Evidently in such cases the motor system is rarily, only on certain occasions, or in certain not freely at their disposal as it is in normal per- phases of the illness. Thus a patient verbigerated sons, one consequence being akinesia for initia- for months on end the words: ‘Anna mia mara tive movements. Another symptom, which is Kochlunsky o Landleben’. It is simply a symp- often seen, is the Affective state of motor disar- tom, of activation, since this patient repeated this ray—I remind you of our patient, Mrs. W. phrase over and over, and was not signifi cantly Disturbance of the motor system is also sug- disturbed in this way even by eating. However, at gested by parakinetic symptoms, which appear the same time, speech was restricted to predeter- usually when a patient’s location is changed for mined motor tracts, since, when verbigeration external reasons. We can only assume that any ceased, she was not yet in a position to talk, change in position adopted by a patient must be despite clearly wanting to do so; in other words based on some abnormality of position sense, or she had a motor aphasia. I speak here of a patient some other constituent in the complex sum of already known to you (p. 6), who has remained motor concepts, despite general mechanisms of dumb for 5 years, and then, with great effort, had walking and standing remaining intact. Since bal- to learn to speak again. In other cases, a link of ance evidently cannot be maintained on the basis this sort between verbigeration and mutism may of a particular level of mental ability, the only be seen. Incidentally, I should point out here that possibility remaining is unconscious compensa- verbigeration can also occur in writing, obvi- tion, in other words, adjustment acting exclu- ously in those who are not totally motionless. sively within consciousness of corporeality. Shift Parakinetic phenomena analogous to verbig- of the form of movement [W] away from the norm eration are also to be seen when immobility may vary greatly from one case to another. Thus, ceases. These are the so-called movement stereo- one example is the peculiar gait of the tightrope types [W], that is, certain movements of the limbs walker who, cautiously balancing, places one that are repeated rhythmically in unchanging foot exactly in front of the other, or of one who manner, and are therefore designated as ‘pseudo- walks wholly on their heels, or on the edge of spontaneous movements’ [Ed] of a certain uni- their foot, and so on. It is improbable, as Cramer form type. Once again, in these situations, the [2 ] assumes, that this is a case of hallucination in clinical connection with absence [Ed] of move- muscle sense, because—apart from inappropriate ments—the state of immobility—is clearly rec- use of the term hallucination—the abnormal ognizable in many instances. We have become position must be viewed as a compensation for acquainted with examples of this in one of our 252 34 Lecture 34 cases, Miss M. You will have the chance to see joint resistance is lacking, may be grouped with other examples during clinical rounds. Thus one waxy fl exibility as Pseudo-Flexibilitas [W]. Easy patient makes constant movements with her acceptance of these movements by patients is usu- mouth, which she everts like a snout; another ally akin to actual fl exibility. The freest interpreta- utters at fairly regular intervals a half-groaning, tion of this symptom, which is usually found only half-grunting sound, without any other Affective in moderate levels of immobility, is that it is based signs. You have met another patient who, while on some sort of ‘suggestion’ [Ed] exerted on the eating, aimlessly dips his spoon, time and again patients. In some way, an examiner suggests to into the bowl, taking it out empty again. He the patient the execution of a movement, towards behaves like someone who, deep in thought, does which the patient is apathetic. It is easily under- something quite mechanically. We saw another stood that akinesia, the absence of spontaneous who made constant rocking movements of his impulses on muscles, provides the most favour- trunk, yet another making only nodding moveable basis for this. The pseudofl exibilitas [Ed] ments of his head. One patient performs a more then often appears only when real waxy fl exibility complex movement, in that he passes one hand abates, and the patient’s condition is seen to through his hair, then describes a circle around improve. It thereby shows itself as the mild degree his head and calmly returns to his former posi- of disturbance just mentioned. In keeping with tion. Occasionally, the evident aimlessness of our view that it is due to the effect of suggestion, such movements is concealed by the fact that an at this stage of the illness it is sometimes possible, object is manipulated in the proper manner, such through verbal suggestion, to exert a favourable as when a patient lifts her bed covers again and infl uence on other akinetic symptoms, such as again by one corner and smoothes them. Yet in mutism, food refusal, and lapses of personal these cases, the handling itself is clearly aimless. hygiene. However, it is also only in such cases Moreover, more-or-less forcible movements of that suggestion as a method of treatment can be the entire body may occur, as when female employed successfully. It is the general experi- patients frequently make coitus-like movements ence of all observers, including the most passion- of the trunk. Even very complicated coordinated ate devotees of hypnotism, that, for all other movements, which appear to be spontaneous, are psychoses, one struggles in vain. proved to be pseudo-spontaneous by their con- Maintenance of certain body positions is not nection with mutism and other akinetic symp- found in exclusive combination with symptoms toms, as well as by their rhythmic repetition. For of waxy fl exibility or pseudo-fl exibilitas; it also instance, a patient continuously marches to a cer- occurs independently of these, in that patients of tain corner of the room, then returns, and then their own accord, apparently spontaneously, goes back, like a pendulum. They are therefore adopt certain positions and maintain them with movements restricted in an unchanging manner abnormal persistence. Most often in this respect, to certain muscle groups, or to a defi nite coordi- we meet the remarkable manifestation that the nated movement. Similar movements, repeated head is held above the pillow with the neck in a rhythmically, can be grouped with other hyperki- fl exed position, an uncomfortable one relieved netic symptoms, but never in such a circum- usually only during sleep. Such a patient scribed and localized manner. explained why she held her head in this position: Besides negativity and waxy fl exibility, She had the feeling that her head might otherwise another disorder is encountered quite often, to be fall backward, it being totally slack (see also: differentiated in relation to passive motility of information from Patient M., p. 246). The next limbs, trunk, or head. Patients seem strikingly most commonly seen sign is adopting and main- willing to yield to passive movements; sometimes taining a particular squatting position, often quite it even appears as if they actually assist [Ed] uncomfortable, for instance with legs crossed or them. Any body position thus reached is then usu- trunk turned half to one side, or preservation of a ally maintained. This symptom, in which any position midway between sitting and reclining, 34 Lecture 34 253 while one arm is used as a support, etc. Totally disarray, which we can generally assume to be abnormal positions are less common, and tend present for disorders of motor identifi cation, not to be maintained for long, for instance, when described unmistakeably by a proportion of a female patient adopts the gynaecological knee- patients during or after their illness. The basis for elbow position, or a male patient stands on his this is just that a certain level of activity in the head, leaning against the wall. Any attempt to sensorium is retained. correct such fi xed positions, is met with varied Gentlemen! We thus come to the further ques- reactions. Some patients quietly accept what is tion as to how far akinetic behaviour allows us to indicated, but immediately turn round and resume make conclusions on the state of the sensorium their former position; others become resistant, [W]. In this respect, we propose with certainty and in some cases violent. The same goes for that the state of the sensorium shows clear depen- cases when it is desired to prevent pseudosponta- dence on the extent of akinetic symptoms, just as neous movements or series of movements located this might also be claimed for muscle rigidity. In in particular muscle groups. states of severe generalized immobility, clouding Gentlemen! The present attempt to describe of the sensorium is generally found, and this can the main akinetic symptoms must include a num- go so far that it is impervious even to painful ber of apparently heterogeneous phenomena. In stimuli. Accordingly, any memory of time spent the endeavour to describe only what fi ts together, in this state either does not exist at all, or does so I have been guided exclusively by experiences in only in that dream-like hallucinations, or actual the clinic. However, you will have noticed how dreams may appear, in fragments, and are consid- much it comes down to the greater or lesser extent ered to be real. When the aetiology is hysterical, of the akinetic symptoms. Some symptoms, such the state of the sensorium usually corresponds as waxy fl exibility and muscle rigidity belong more to one of so-called ‘ecstasy’ [Ed], and exclusively, or largely to severe levels of general- remaining memories are endowed with feeling ized immobility; others, which we fi nd to be tone of supernatural events. In such patients, you prominent only in partial akinesia, or in general- also encounter fi xed body positions, as are also ized akinesia of only moderate degree, prove to found as expressions of enraptured ecstasy. Those be symptoms indicating susceptibility [Ed]. In cases which have led to the special clinical pic- this group, we can include mutism, negativity of ture called catalepsy [W], are particularly well mouth, jaws, and neck, and also refusal of food. known. Ever since Kahlbaum introduced us to In akinesia of moderate severity, spread over the knowledge of motility psychoses, this alleged whole body, we can fi nd generalized pseudo- type of functional nervous disorder has increas- fl exibilitas, circumscribed pseudospontaneous ingly been disappearing from textbooks. Without movement, and mutism which is exclusively disputing that periods of an akinetic state may reactive. It is common to the great majority of occur in hysteria, which are of shorter duration cases, and by the very nature of akinetic symp- than elsewhere, and with specially favourable toms, no information can be obtained about inner outcome, I should say explicitly that these cases processes and probable motives for patients’ do belong amongst akinetic motility psychoses. motor behaviour. Most often, one can ascertain, We fi nd a contrast to these dream-like states in either during periods of remission or after the ill- cases like that of Miss M. (p. 242), when there is ness has passed, that alleged voices, commanding no doubt about clarity of consciousness. All cases or vetoing in their content, had infl uenced such lying in between show a more or less clear senso- behaviour; However, I need discuss no further rium, with either a lesser extent or a lower sever- that these phonemes explain nothing, after my ity of akinesia. When the sensorium is signifi cantly previous remarks on the signifi cance of halluci- clouded, despite only moderate extent or severity nations, and particularly of phonemes. Rather, of akinesia, features of delirium such as restless- they themselves need an explanation; and it is ness, or signs of occupational delirium are easy to fi nd in them the Affective state of motor often simultaneously present. In comparison, the 254 34 Lecture 34 deepest levels of unconsciousness are to be found described above are not confi ned at all to my in the rare, extremely acute cases, in which the so-called ‘motility psychoses’ [Ed]; they are to be muscular rigidity is intermingled to a degree akin found amongst a great number of other, far more to epilepsy, seen occasionally also in epileptic complex cases, and not merely those of acute ori- seizures, but of longer duration, and leading to gin. Only where they constitute the clinical pic- death in a few days. ture, solely or in greater part, as in the above Gentlemen! The state of severe generalized cases, are we justifi ed in accepting a special ill- immobility has always been known to alienists; it ness [Ed] whose essential symptoms are motor in was probably also called atonicity and consid- content. In particular, I would particularly ered the essential basis of a unique clinical pic- emphasize that ‘catatonic’ [W]—or, in our sense, ture: Melancholia attonita [W], or Melancholia specifi c motor—symptoms, tend to appear in the cum stupore [W]. I feel no need to deny that this majority of chronic progressive psychoses at illness has anything to do with Affective melan- some phase of the illness. We are thereby warned cholia in our sense; I recommend rather to drop to confi ne our clinical picture of akinetic motility this term and replace it with ‘akinetic motility psychosis within the narrowest possible limits. psychosis’ [Ed]. That a whole series of other Gentlemen! Much as we may want to debate motor symptoms besides atonicity belong this, the practical clinical perspective is suffi - together clinically was proved by Kahlbaum [3 ] cient: It allows us to claim that it is impossible to in his monograph on catatonia. He explained its recognize a single dimension according to its relationship with melancholia, and emphasized boundary; and that, in the background to akinetic the importance of the state of muscle rigidity motility psychosis more extensive disorientation amongst mentally ill people. In these respects, may be present, which may temporarily conceal Kahlbaum must be acknowledged as the real essential akinetic symptoms. Perhaps at some founder of the theory of motility psychoses. future time, we will acquire data which allows us Gentlemen! It is proper that I take this oppor- to differentiate in this dimension between pure tunity to do justice to Kahlbaum’s contributions. parakinetic motility psychosis and its combined After Meynert [4 ], we are indebted to this great forms; but at present, given the existing state of investigator and observer for the greatest knowledge, we would be forced, artifi cially, to advancements that clinical psychiatry has made split apart those cases where there is an essential in more recent times. You will readily grasp that coherence with respect to akinetic symptoms. I adopt the same view as Kahlbaum in validating Involvement of the sensorium, present in the the concept of catatonia, the more so as the most pronounced cases, undeniably signifi es that importance of his work is acknowledged more the disease process should be extended into the and more, and a few gifted younger ‘psychia- psychomotor realm. We are accustomed to con- trists’ have taken it up as well. Nevertheless, the trasting symptoms arising as part of the senso- value of Kahlbaum’s work must be perceived rium, as a general illness, with focal symptoms of essentially in the fact that he gathered a number brain diseases; yet we must not forget that they, of important stones for erection of his structure, like the indirect focal symptoms which I differen- while the structure itself is not durable. He has tiated, are based on summation of several defi - not escaped the fate of all authors who laboured on cits; and, like them, represent secondary effects monographs in a designated domain, and has out- of focal illness (‘long-range effects’ [Ed] of other lined much too broad a clinical picture, a step authors). On the other hand, we must recognize backward, in so far as the narrow concept of that more drastic clouding of the sensorium con- Melancholia attonita [W] or cum stupore [W] has stitutes defi nite disorientation in all three domains fallen by the wayside. One can thus also account of consciousness, and so we see that the greater for the diffi culty this clinical picture has met extent of the illness process cannot, by its very with in gaining general acceptance, as well as nature, be separated from its intensity. the still-lively opposition to it. Motility symptoms Corresponding with this, severe involvement of 34 Lecture 34 255 the sensorium is observed exclusively when there university professor is an example of this. A spe- is greater severity of generalized immobility. cial class can probably be made up, characterized There must therefore be other criteria by which by an initial stage of ‘delirium of relatedness’ we can try to differentiate within the clinical pic- [Ed] lasting for weeks. The duration of the aki- ture of akinetic motility psychosis; and we fi nd netic and parakinetic state usually amounts to a these chiefl y by studying the course of the illness. few weeks. Undoubtedly, the reciprocal relation- Accordingly, we want to include as akinetic ship is thus that akinesia represents a more motility psychoses those acute cases of illness intense symptom; and so, parakinetic symptoms which present, as a rapid development, that com- usually appear fi rst when remission in the akine- plex of akinetic and parakinetic symptoms sia is seen. In rarer cases with severe, more exten- described above, which are sustained in continu- sive akinesia but relatively intact sensorium, ity throughout a longer duration of illness. That parakinetic symptoms, such as verbigeration, ste- the further course can then be organized along reotypical movements, altered gait, etc., are espe- entirely different lines, is understood just as eas- cially likely to appear, if, along with pronounced ily as what we already know, that after an apo- akinesia for initiative movements, reactive move- plectic attack with marked loss of consciousness, ments can still be elicited. Following the akinetic complete restitution can sometimes occur, while and parakinetic stages, in which we will fi nd the at other times a series of focal symptoms remain. peak of the disease curve, there is usually a para- As is generally known, such focal symptoms, noid stage, in which parakinetic symptoms are occurring in the context of some major insult in intermingled to greater or lesser extent. Only in this restricted sense, gives us the prospect of this paranoid stage might it become apparent recovery, the signifi cance of this fact doubtless whether, and how far other disorders of identifi - lying in the fact that a focal symptom arising in cation, such as those in the psychomotor domain, this way is a secondary effect, often an indirect are included in the clinical picture. Those like our focal symptom; but, naturally the same apoplec- professor belong amongst the most favourable tic onset can also be direct, and therefore accom- cases, where the paranoid stage might be assumed pany incurable focal symptoms. Likewise, in to exist just as long as perfect insight into dream- akinetic motility psychoses, a proportion of such like events of the akinetic state had not yet been cases in which stupor and muscular rigidity acquired. In most cases with a favourable course, occur, show themselves capable of recovery, our as in this case, hypochondriacal symptoms stand university professor being the most convincing out in particular as signs of more widespread example. somatopsychic disorientation during the para- The start of an akinetic motility psychosis may noid stage. be very sudden, almost apoplectiform. The above Persistence of sporadic delusions, which cor- (p. 253), briefl y mentioned, very acute cases, with respond to dreamlike memories, indicates merely a rapidly worsening course, appear to have had an the suggestion of a paranoid state. Signs of men- apoplectiform onset. However, irrespective of tal weakness, like ‘emotional incontinence’ [Ed] these, a similar acute-onset sometimes occurs. For and mild exhaustibility, are also mingled with us, over the course of the year, it has happened other symptoms, in such favourably proceeding repeatedly that such patients had been found on cases. At other times, the akinetic/parakinetic the street, or on the fl oor, in a strange house, stage is soon followed by prominent dementia, motionless, and were brought into our clinic; and which can still end in recovery, although usually it was subsequently established that the patients after a quite long duration of 6 months to 1 year; had carried on their usual occupations right up or, at other times, this becomes the defi nitive out- until then. At other times, an initial stage of a few come of the illness. Not uncommonly, the stage days was reported, where disarray was present, of dementia follows an intervening paranoid not exclusively of a motor type, with outbursts of stage, and these cases seem largely to terminate anxiety and despair, dominating the picture. Our in a permanent state of dementia. If the paranoic 256 34 Lecture 34 stage is very marked, that is, if it has expanded by no means rare, and I have seen this after both into formal systematization, remediation can still slight—or after more pronounced indications of occur; and then an increasing level of insight into paranoic stages, and also after a stage of demen- the illness, growing slowly but steadily, can be tia; while in Kraepelin’s [5 ] textbook, dementia is seen. Finally, in about 1 year, there may be com- described as the regular outcome for such cases. plete recovery, without residual defi cits. In such a Here, as well as elsewhere, we come across little favourable course, elementary symptoms of pho- by way of thought, plus an ignorance of facts, nemes and delusions of relatedness soon disap- which features are arguably unsuited to a text- pear. In other cases, progressive systematization book. Moreover, the tendency to recurrence, occurs, when religious, grandiose, and persecu- emphasized by Kraepelin, is in no way greater tory ideas arise—so-called ‘prophetic delirium’ than in most other acute psychoses. [Ed]—which may build up from the most fully As for the aetiology [W], akinetic motility thought-out premises, evidence of great intellec- psychoses have a predilection to affect persons of tual productivity. Signifi cant memory defi cits young age, and of those, predominantly the may accompany this paranoid stage, as well as female sex. It is not unrelated to menstruation. the demented stage; these are related to the Relatively often, the post partum [W] state or akinetic stage. other exhausting infl uences are to be found as the Gentlemen! If we ask ourselves why it is that immediate precipitating factor. Emotional states the akinetic-parakinetic stage is followed at one have often preceded it, and hysteria, as men- time by a paranoid stage, at another by a demented tioned above, has occurred in a proportion of stage, naturally only by reviewing a large number cases. The percentage of cases that had earlier of cases can an answer be provided. It thus seems presented with a moderate grade of congenital that the state of the sensorium during the akinetic imbecility or at least of retarded mental develop- phase is an important matter for consideration. ment is quite high. The greater its involvement, and the more the Diagnosis [W] meets no diffi culties for the state approximates to sleep or unconsciousness, akinetic state, if one adheres to the above descrip- the more likely is it that a stage of dementia will tion. Beyond our narrowly-defi ned clinical pic- ensue, and this tends to follow especially in cases ture of acute akinetic motility psychosis, of so-called twilight states with attendant symp- diagnosis is possible only when the previous his- toms of accompanying delirium. If, on the other tory is known, when it can be established that hand, the sensorium is only slightly involved, akinetic symptoms have an independent signifi - pronounced states of paranoia usually occur, cance, and are not accessories to another type of although these can still be curable. Although this pre-existing illness. Therefore, a defi nite duration result is based on a statistical review of cases, it of continued akinesia is important for differential also confi rms what we might already have diagnosis between it and other motility psycho- expected. Delusion formation in the paranoid ses, a point to which I return later. Only a remit- stage is based here, as in other cases, chiefl y on ting pattern of akinetic behaviour should be explanatory delusions, and for their formation, a mentioned, which sometimes occurs, to be inter- prerequisite is a certain intactness of the senso- rupted by abatement of symptoms for a few days. rium. Indeed, the case of Miss M., which I We have already discussed sporadic interruptions reported to you, might be an example of this, yet of immobility by apparently spontaneous acts, explanatory delusions with perfectly clear senso- which are, in reality, reactions to hallucinations. rium, failed to appear. Nevertheless, it is noted I only touch on differential diagnosis in relation that this case is of relatively recent onset, and to melancholia here, owing to the still-prevailing according to all precedents, explanatory delu- confusion in nomenclature. Prominent cases of sions may be expected to occur later on. As for so-called Melancholia attonita [W] or cum stu- the outcome of our illness, I must state very pore [W] all belong here. Only akinesia of clearly that an outcome of complete recovery is dementia, with its intrapsychic hallmarks, and 34 Lecture 34 257 so-called depressive melancholia could be coughing have stopped, at least partially. If this mistaken for our illness. However, pronounced method fails, the attempt to feed should be given reactive akinesia is never found; as in akinetic up this time and repeated later. Should it not suc- motility psychosis, the contrast between the lack ceed even then, although the indication for of initiative and the well-retained reactivity to forced-feeding still exists, under some circum- external stimulus is therefore always most notice- stances you will have to resort to use of light able. Furthermore, both in dementia, and in anaesthesia. Ether rather than chloroform is rec- depressive melancholia, the specifi c motor symp- ommended, but narcosis should not be taken toms of muscle rigidity, negativity, Flexibilitas beyond the point where the swallowing refl ex is cerea [W], and pseudofl exibility are absent. abolished. At other times, it would be preferable Treatment [W] of akinetic motility psychosis to dispense entirely with introducing the tube, has as its objectives a series of most important and to be satisfi ed if sometimes only small tasks, connected to very defi nite symptoms. amounts of fl uid are swallowed spontaneously; Foremost amongst these is the struggle to over- also, nutritional enemas should be tried. However, come food refusal. Cases usually need artifi cial there are always certain exceptional cases where feeding, that is by means of a tube, for a long such diffi culties are encountered, perhaps when period. Much has been said for and against the you encounter a vigorous and energetic con- effectiveness of this measure, and there are still scious resistance, or when there is dreamlike, some authors who abhor it, on account of associ- impulsive resistance with total failure to grasp ated dangers. Far from denying these dangers, I the situation, or when a patient is overwhelmed prefer to emphasize that even with careful manip- by hypochondriacal and anxious ideas. On the ulation and much practice in this manoeuvre it other hand, in the vast majority of cases, artifi cial can occur that patients aspirate liquid food and feeding can be achieved without substantial resis- suffocate in this manner. This happened to me tance, and it would be an error not to employ it in once, and the tracheotomy, which was carried out these cases, because of the danger it presents in immediately, did not avert a fatal outcome. other cases. Often, patients quickly adjust to the However, this should serve only as a warning procedure and even assist, or otherwise give rec- against forced feeding at all costs, but rather to ognizable signs of gratitude. The widely pre- stop at once when any violent strangling or ferred material is a thick-walled Nélaton catheter coughing interferes with the fl ow of the feeding with lateral openings. Feeding through the nose mixture, and particularly if there is any sugges- is by far more practical and usually also more tion that the tube is located in the trachea. A easily achievable than by mouth. Most highly mechanical diffi culty is sometimes encountered, recommended as a nutritive fl uid is a mixture of consisting of paralytic depression of the larynx, a milk, sugar, and eggs, mixed according to Voit’s condition which can also occasionally interfere recipe. Any medications or wine may conve- greatly with introduction of the tube in acute bul- niently be poured in after the feeding. Feeding is bar paralysis. In other cases, this condition is not usually carried out twice every 24 h. present, but spasm of the pharynx, with the lar- The need for feeding is based in part on the ynx pressed against the pharyngeal wall posterior very severe nature of the illness. I mention the to it will produce the same hindrance. The oro- case of a young girl admitted to the clinic 8 days pharyngeal or intranasal tube then impinges on after acute onset of her disease and who died the upper border of the reclined epiglottis, and if within 3 weeks, with an anomalous fever and this obstruction can be successfully bypassed, rapid loss of strength. No diffi culties were comes against the open glottis. If it is necessary encountered in feeding, and took place quite reg- to battle against such diffi culties, it is advisable ularly; but weight loss had nevertheless amounted fi rst to pour in a small quantity of some indiffer- to 18 pounds at time of death, almost 1 pound/ ent test fl uid, such as clear water, through a fun- day. Autopsy revealed no organic illness of any nel. In every case, wait until choking and kind, but brain mass was abnormally low 258 34 Lecture 34

(1,100 g). A similar loss of body weight, despite admitted [6 ]. If a patient survives the akinetic suffi cient nourishment, is often seen in akinetic stage, there is generally no longer a threat to life motility psychosis, and shows how seriously the provided there are no special complications, of whole clinical picture should be regarded. which I mention only those of stomatitis and Next in importance after taking care of nutri- scorbutic-like haemorrhages into the tissue. On tion, is attention to defaecation and voiding of the other hand, at this stage it becomes relevant to urine. Quite commonly catheterization of the ask whether full restitution, or outcomes in bladder is needed, at least from time to time. dementia, or as a progressive chronic psychosis Moreover, by getting the patient out of bed and to are to be expected. In many cases, prognosis in the toilet at regular intervals, one aims to develop this respect may be judged from the curve of some sort of habit. If there is a very sluggish sen- body weight. Rapid increase in body weight with sorium or as a consequence of other conditions, corresponding improvement in mental symptoms and voiding takes place in bed, care has to be allows one to conclude with fair certainty that taken over most scrupulous cleanliness. However, there will be complete recovery. On the other the risk of bedsores is so slight that I have never hand, if a pronounced stage of dementia occurs, seen it in this illness. increase in body weight is of no guide to progno- Gentlemen! In my opinion the behaviour of sis; even after a longer duration of the demen- the musculature is a special and rewarding objec- tia—up to 6 months or more—patients can still tive for treatment, although I cannot claim exten- come belatedly to recovery. A rapid rise in the sive experience here, because conditions in the body weight curve, at the same time that a promi- clinic do not favour this. However, if we consider nent paranoid stage is developing, appears to be the great value provided by the state of the mus- an unfavourable sign for the fi nal outcome. cles, in part for overall metabolism, in part for subjective well-being of patients, systematic treatment of the muscles should be attempted in References all cases where it is allowed by external conditions. This treatment should consist of regular 1. Goltz FL. Beiträge zur Lehre von den Functionen der Nervencentren des Frosches. Berlin: A Hirschwald; passive movements, massage and local electrical 1869. stimulation of muscles. I need not call any special 2. Cramer A. Die Hallucinationen im Muskelsinn bei attention to a proper care of the skin by ablutions Geisteskranken und ihre klinische Bedeutung, ein and baths. Beitrag zur Kenntniss der Paranoia. Freiburg im Breisgau: P. Siebeck; 1889. The prognosis quo /ad vitam [W] of the illness 3. Kahlbaum KL. Die Katatonie oder das is always questionable, not only because of the Spannungsirresein. Berlin: A Hirschwald; 1874. dangers due to individual symptoms, such as 4. Meynert T. Klinische Vorlesungen über Psychiatrie refusal of food, but also from the whole character auf wissenschaftlichen Grundlagen für Studierende und Aerzte, Juristen und Psychologen. Vienna: of the illness, as I already emphasized. What is Braumüller; 1890. p. 17. more, the initial acute stage is particularly dan- 5. Kraepelin E. Psychiatrie: Ein kurzes Lehrbuch für gerous in many cases, in that physical disarray Studierende und Aerzte. 2, gänzlich umgearbeitete can promote suicide attempts. I have already Aufl age des Compendium. Leipzig: Abel; 1887. 6. Wernicke C. Krankenvorstellungen aus der psychia- quoted a case in which multiple attempts at sui- trischen Klinik in Breslau. Breslau: Schletter; 1899. cide had been thwarted before the patient was vol. 2, Case 2. Lecture 35 35

• Akinetic phases of hyperkinetic motility cases, it is evident that, as the disease process psychosis becomes augmented, defi cit symptoms appear in • Cyclic and complete motility psychosis place of symptoms of activation. Likewise, in the • Signifi cance of the paranoid phase clinical picture of agitated confusion, one can • Excursion into intrapsychic akinesia sometimes see such an increase from hyperki- • Indicators of psychomotor akinesia netic to akinetic symptoms. In two cases of this • Theoretical considerations for understanding kind, the acute onset of confused mania was motility psychoses made up of a 1- and a 2-day akinetic-parakinetic stage. The second [Ed] type of combination consists in mutual separation of the opposed states of hyperkinesia and akinesia, with each single phase Lecture producing pictures of hyperkinetic or akinetic motility psychosis, as described above. The main Gentlemen! difference from the fi rst type lies therefore in the To gain a fi rm standpoint, it was most oppor- more protracted continuous course of each phase. tune for us to see initially the two clinical pic- You see, gentlemen, that it is a parallel with the tures, of hyperkinetic and akinetic motility familiar circular psychosis, which in pure cases psychosis, conceived as narrowly as possible; shows just such an alternation between mania and from these it would seem possible to pene- and melancholia. In fact, just as in circular psy- trate the area in which we fi nd by far the majority choses, frequent changes from akinetic to hyper- of cases defi ned specifi cally by motor symptoms, kinetic phases may occur, even if not with the yet which in one way or another are more com- regularity of circular psychoses. These cases plicated than cases already considered. seem to stand out by their poor prognosis. Primarily we have to consider here the differ- Much more frequently, however, the combina- ences in course, and in the combinations between tion results in only a single cycle of this sort, in the opposing states of hyperkinesia and akinesia. which case I avoid the term ‘circular’ [W] and We fi nd such combinations represented by two speak of the special form of cyclic motility psy- main types. The fi r s t [Ed] type consists of a pic- chosis [W]. I have seen cases of this sort almost ture in which, either from its onset, or at some exclusively in young girls and women, and their time during the course of a hyperkinetic motility aetiology seems to be predominantly menstrual psychosis—within hours or a few days at most— and post-natal. The hyperkinetic stage always an akinetic motility psychosis occurs. In such occurs fi rst; and a distinct stage of exhaustion

© Springer International Publishing Switzerland 2015 259 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_35 260 35 Lecture 35 stupor is often inserted between it and the still possible to communicate with patients, akinetic stage, or after the latter; the fi nal out- reveals a difference with respect to disorienta- come is either recovery, death or profound tion. The sensorium is likewise only temporarily dementia. Mixed in with the hyperkinetic stage is clouded or remains perfectly clear. It may be often a stage of mania, whilst in the akinetic state, found in some cases that motility is almost exclu- a state of melancholia is often added; in other sively affected, and such cases seem to be charac- words, at one time intrapsychic hyperfunction, at terized by rapid development of explanatory another, loss [Ed] of intrapsychic function. At the delusions, therefore without unfavourable pro- same time, patients are usually completely disori- gression. It is from such patients that the best entated; and motor disarray is always very prom- information about purely motor symptoms can be inent. In these cases, one could speak of the obtained after their recovery. substitution of one clinical picture for the other. Gentlemen! Experiences in the clinic do not More often, however, here also the akinetic allow us to defi ne any exclusively parakinetic symptom is always an expression of increased form of motility psychoses. Where altered forms intensity. In such cases, of cyclic motility psy- of movement dominate for a long time, or chosis onset of the akinetic phase may appear throughout an entire illness (as you saw in one earlier in some subdomains of motility than in case [ 2 ]), it transpires that phases of akinesia and others. In particular, it is observed that motor hyperkinesia can be differentiated, so that the loquacity has already passed into mutism, while parakinesia, even when striking, does not exist the motor impulse lasts a few days more, before independently. The concept of parakinesia is evi- it passes on in similar fashion to immobility. In dently only an abstraction, just as we might ana- unfavourable cases, the hyperkinetic stage often lyze paraesthesia arising in peripheral nerves in has an anxious hypochondriacal content, with part as hyperaesthesia, in part as paraesthesia, corresponding phonemes [1 ]. without losing any essential part of the Having just seen that such opposite states as symptomatology. motor hyperkinesia and akinesia can occur in Gentlemen! As we have seen above, it is in the combination, it will not be strange that we quite nature of akinetic symptoms, that it is often often encounter cases whose main feature is a totally impossible to decide how far they are mixture of akinetic, hyperkinetic, and parakinetic intermingled with other identifi cation disorders, symptoms. These cases of mixed or, if you will, and at other times this is possible only after the complete motility psychosis [W] therefore do not akinetic stage is over. So we must then take into present particular phases belonging only to one account the possibility that the above clinical pic- category, but they occur in rapid alternation, at ture of akinetic motility psychosis, derived one time predominantly hyperkinesia, at another, entirely empirically, is too broad, and still con- akinesia or parakinesia, or—simultaneously— tains cases in which the motor symptom complex there may be akinetic, hyperkinetic or parakinetic is merely grafted onto another syndrome, which symptoms, but in different muscle regions. is just as signifi cant, and encompasses it. How Special mention must be made here of certain justifi ed this concept is, we see in some cases of recurrent cases lasting only hours or days, associ- ‘complete motility psychosis’ [Ed]. These reveal ated with the most severe Affective states and at the outset, apart from the ever-changing motor total disorientation, followed by a stage of symptoms, images of ‘fantastic menacing delir- exhaustion and amnesia. Such cases occur occa- ium’ [Ed] with severe disorientation in all three sionally as the so-called transitory psychoses; areas of consciousness, and which always seem and I have found that, in cases where they recur at to have an unfavourable outcome. Very similarly, short intervals, the course is always unfavour- the fantastic menacing delirium in the paranoid able. The easy assumption that epilepsy is stage of an akinetic motility psychosis is some- involved, has not been proven. The fact that in times the only expression of disorientation, that such cases of complete motility psychosis it is was previously concealed by the akinetic stage. 35 Lecture 35 261

These cases also have a largely unfavourable likewise ceases, and in place of that overvalued prognosis. At other times, the fantastic menacing idea, a lack [Ed] of thought prevails, perhaps delirium occurring within well-retained allopsy- even, at times, complete standstill of thinking. An chic orientation is to be seen in the same paranoid anxious Affective state might be possible once stage, combined only with hypochondriacal sen- we remember that failure of processes of associa- sations, mainly intestinal in nature. These cases tion represent, in a certain sense, a threat to the also follow a predominantly unfavourable course, body. On the other hand, specifi c motor symp- so that we are to some extent justifi ed in regard- toms such as fl exibility, pseudo-fl exibility, mus- ing the fantastic menacing delirium in motility cular rigidity and negativity are missing. psychoses as a generally unfavourable prognostic Patients fi tting this picture are not rare. feature. Affective melancholia may occasionally show Gentlemen! To understand other more com- some similarities, and I believe that in the past, plicated cases of motility psychoses, it may help I have observed transitions of one condition into to discuss together all those symptoms based on the others, in which the picture of depressive disorders of identifi cation within the psychomo- melancholia corresponded to more severe grades tor pathway Zm , as we always did hitherto in of the illness, cases which always showed a much analogous cases. However, it has been proved longer course than the vast majority of cases of necessary, above all, to clarify how intrapsychic Affective melancholia. In particular, a character- akinesia is to be differentiated from psychomotor istic of these cases, it seems to me, is strangely akinesia. A digression into intrapsychic akinesia intact reactivity in speech, a clearly diffi cult way [W] therefore cannot be avoided. of giving an answer, with just a soft fl at voice, or Gentlemen! Affective melancholia presented with much effort—just when I have turned away us with an example where symptoms derived from the patients. The same hesitancy, the same from a hypothetical scheme, and these alone, complication and retardation, apparently involv- make up a clinical picture which, in reality, is met ing overcoming some sort of inhibition can, in very often. The situation is not so simple for that such cases, also extend to all other reactive move- state of illness—a more severe grade of intrapsy- ments. I now think it likely that these transitions chic functional disorder—namely a defi ciency of from Affective to depressive melancholia do psychically induced movements, which is a strik- sometimes actually occur, and so I can no longer ing form of akinesia in objective terms. The inde- maintain that depressive melancholia is signifi - pendent signifi cance of such a condition, which cant as an independent illness. More detailed provisionally, I would like to call depressive examination of such cases during the last few melancholia [W], has become more and more years has always revealed to me additional symp- questionable over the years. To begin with, I want toms which are there to be found, but only when briefl y to present the hallmarks of this condition, you know what you are looking for. Without hav- as derived from our schema. Patients of this type, ing arrived at a conclusive judgment of this, of their own volition, stop speaking or doing any- I want briefl y to share my experiences. thing; they therefore present symptoms of mut- First [Ed], I have collected a series of state- ism and akinesia for initiative movements. ments, in part from the patients themselves, in Expressive movements are correspondingly part from their relatives, according to which a fewer, the face less animated, while reactive specifi c condition continued for hours, or occa- movements are also involved, but less severely sionally days, at the time of onset of motility psy- so. Insofar as reactive movements are [Ed] choses, corresponding most closely to what I affected, this depends on the patient’s intrapsy- have just described—the cessation of any kind of chic capacity, certainly not on changes in activa- ideation. Sometimes a defi nite body position was tion of muscle groups. With complete failure of maintained which, in itself was in no way abnor- processes of association, the Affective response mal or constrained. Information given later by that is linked to subjective feelings of inadequacy patients indicated a complete stand-still of 262 35 Lecture 35 thoughts, as occurs normally in the state of the the projection system, or by actual defi cits. When so-called bewilderment, but then only momen- combined with a mild degree of somnolence, a tarily. A female patient of this kind was found in special subgroup among such cases seems to be such a state on her admission, persistently defi ned, which, to judge by results of specifi c immovable, her clothes pulled up, and in a foot therapy, should be grouped among the luetic bath ordered for her. The motor character of this brain diseases. Of Heubner’s cases [3 ], a few disorder only became clear later on, because she might belong here. had had mutism already for a long time and could Gentlemen! As you see, in these cases, as in not protrude her tongue, while all other reactive pseudomelancholia, we are dealing with a defi - movements were carried out promptly. A second nite phase—usually the initial one—of a com- [Ed] series of cases consists not only of short- pound psychosis (see later). In the case of a lasting conditions, such as those just described, combination of severe loss of intrapsychic func- but correspond to a separate clinical picture of tion and hypochondriacal symptoms, it is differ- longer duration, always lasting over a year, for ent, and allows one to interpret the fi rst of these, which the name pseudomelancholia [W] might and the resulting akinesia representing as merely be appropriate. This ‘pseudomelancholia’ [Ed] the sequel, induced psychologically, of a severe usually forms the fi rst stage of a compound psy- feeling of physical illness. These cases, which are chosis, which in general has an unfavourable in large part curable, present the same combina- prognosis, although the possibility as an exception of symptoms throughout the entire illness, tion, of a favourable outcome always exists. This and thus form a uniform, albeit mixed, clinical clinical picture has been spoken of before picture. In contrast to hypochondriacal melan- (p. 103). Cases in this class usually present with cholia, mentioned earlier (p. 162), this is driven some signs of Affective melancholia, so that they throughout by disorders of psychosensory identi- might be identifi ed as borderline cases between fi cation of the patient’s own body, except that, by this and the above clinical picture, constructed on its very nature, this exercises special infl uence the basis of theory. However, sooner or later in over motility. The Affective reaction is psycho- their course, they produce further signs, in that sensory, and thus consists of hypochondriacal delusions of relatedness join in, this being feelings of misery and attendant anxiety. At times entirely foreign to melancholia. Cessation of of remission, or with a favourable response to a melancholia—which may last for a year or medication such as opium, you may hear from more—then usually gives way to a further, wors- patients that they feel too ill to think, or speak or ening stage of persecutory delusion, and soon to do anything. In brief, the akinetic reaction is also of grandiosity. therefore psychologically motivated and not The third [Ed] case, is the most important, refl exly induced as in the previously mentioned which, on its own would justify establishing a (p. 132) cases. Aberrant sensations can have vari- separate clinical entity of depressive melancho- ous locations, usually intestinal. lia. I have often seen cases of illness, which by Gentlemen! I must make special mention of any criterion, present primarily with a pure type the frequent cases of acquired dementia whose of intrapsychic akinesia, but which, later on, chief characteristic is intrapsychic akinesia. Here sometimes after 6 months, turn out to be cases of I give only bare essentials to differentiate this progressive paralysis. Paralytic symptoms, par- from depressive melancholia. It may be claimed ticularly ones arising from the projection path- that the intrapsychic akinesia of acquired demen- ways, fi rst emerge here when supposed depressive tia is the same as that in depressive melancholia: melancholia is starting to improve and a favour- A defi cit in objectively visible movements able turn of events is anticipated. Far more often, depending on reduction in intrapsychic function however, we meet cases of depressive melancho- is the indication of those symptoms of Affective lia in which hallmarks of paralysis are there right melancholia which are felt only subjectively, the from the outset, either through participation of inability to take decisions, the coldness of psychic 35 Lecture 35 263 feelings, and the blunting of interests. Therefore, by previously mentioned, specifi c motor the motivation for voluntary movements is defi - symptoms. cient; patients sit or lie around in an apathetic state, and do not present any trace of autopsychically- Gentlemen! Before I pass on to describing induced Affect. On the other hand, the obvious psychomotor akinesia in detail, I would like to sluggishness of thought often means that psychic mention a symptom which is encountered occa- capability is overburdened, and then leads to sionally in cases of total motility psychosis, or in expressions of discontent, and, of impoverish- those of compound motility psychosis, the so- ment of knowledge, judgments, and often even of called imperative speaking [W]. Patients in ques- ideas. That the latter ‘symptoms of defi cit’ [W], tion, during attacks which sometimes last only however prominent they may be, do not of them- minutes, at other times up to an hour, may utter, selves bring about intrapsychic akinesia, will be with evident effort and every sign of anxiety, evident to you from my remarks at the beginning either single words—often quite disconnected— of our clinical studies (p. 54). or a defi nite series of words, such as a series of From all these experiences, we can take the numbers, or sometimes whole sentences, usually following to be characteristics of intrapsychic in a fairly loud monotonous raised voice, approx- akinesia. imating the mechanical expressionless impression of recitation by a schoolboy. The 1. The disorder is always uniform and general, content—where it is coherent—may be derived corresponding to our assumption of diffuse from the current situation. One patient of this degradation of excitability extending over the type generally uttered punctuation aloud, which, entire organ of association. Distinction in his opinion, belonged with the sentences that amongst different muscle groups is never he was delivering, somewhat in the following seen. Most noticeably, speech reactions are manner: ‘When I speak, comma, it strains me, impeded and retarded in exactly the same way fullstop. I cannot do otherwise, semi-colon’. as are all other reactions. Complete failure of These patients state that what they say, has been speech reactions does not occur, or does so said to them or dictated, and they must repeat it. only when more complex psychic perfor- The compulsion which actually occurs is mani- mance is required, and to that extent. fest unmistakably in the mechanical way they 2. Initiative movements are in general affected repeat; in the evident effort employed, which more severely than are reactive ones. This is often radiates out to other areas of musculature; especially true for speech, which may cease and also fi nally in patients’ facial expressions, entirely unless there is some external infl u- sometimes more involuntary, sometimes anxious ence—‘initiative mutism’ [Ed]—although a and perplexed. As this continues, a patient may response is always given to simple questions, fi nally come to be bathed in perspiration, sinking albeit sometimes only very softly or tone- back in total exhaustion, then needing a long rest lessly, with very slight lip movements, slowly to recover from the effort. According to patients’ and sometimes at the very last moment. As for own testimonies, there is no doubt that they expe- expressive movements, they are indeed few, rience a compulsion to repeat voices they have yet not absent; and when conveying Affects, heard. such as the above-mentioned hypochondriacal In these cases, patients themselves state—and feeling of misery, they occasionally appear as also demonstrate by their conduct—that they are expressive movements. A part of this is the subject to a compulsion; while at other times we habit of looking at the questioner during oral may observe directly that their ‘will to speak’ conversation. In intrapsychic akinesia this [Ed] encounters certain resistance. An irradiation special form of reaction is never lost. of the volitional impulse may be seen, especially 3. It has already been adequately demonstrated in patients who succeed in breaking through psy- that intrapsychic akinesia is not accompanied chomotor mutism, which far exceeds the muscle 264 35 Lecture 35 area whose activation is intended. For example, a paralysis of volition: Absence of ‘will’ [Ed] patient closes his jaws convulsively, opens his seems to exist temporarily in cases where eyes wide, wrinkles his forehead, dilates his nos- patients—for example—suddenly let themselves trils, tenses his neck muscles, throws his head fall to the ground from a sitting position, or occa- back, elevates his shoulders, presses his arms sionally cannot walk, and then let their legs hang against his body, and then words are uttered in a lifeless while they are being carried. Both were wheezing, forceful manner. observed at a somewhat later stage in the self- In contrast, in the familiar pseudospontaneous same patients who had passed through conditions speaking, which is (for example) the basis of the similar to syncope. Here, I do not want to psychomotor loquacity, the feeling of compul- neglect—at least to touch on—the so-called hys- sion is not evident either subjectively or objec- terical palsies. They have an intimate relationship tively. This is the same difference as that between with conditions just described, even though we autochthonous ideas and obsessive ideas. should not deny their peculiar nature in any way. Gentlemen! A few further facts can be cited The so-called hypochondriacal palsies [W] here, which serve to explain more fully the nature provide evidence that elimination of will can be of the akinetic symptoms. As already indicated, it manifest in localized muscle areas. These palsies sometimes happens that generalized immobility are quite rare, and seem to occur almost exclu- takes the form of a fl accid paralysis, instead of its sively in severe hypochondriacal psychosis. Of being combined with muscle tension. I have seen course they never amount to palsies of individual this for instance in attacks lasting several hours in muscle and nerve areas, but of whole limbs, or at the acute stage, a very severe complete motility least of whole sections of limbs. However, these psychosis, terminating within 6 months in a state should not be grouped with Charcot’s ‘psychic of confusion. In these attacks, which were most palsies’ [4 ] [Ed], which I regard as by-products closely similar to states of syncope [W], a patient of suggestion, so that they can easily take on any acted as though she was totally lifeless; and when favoured form. If these are disregarded, the most someone raised her limbs, they fell back in per- frequent occurrence is hypochondriacal paraple- fectly fl accid fashion, obeying nothing other than gia [5 ], albeit with easy transition to hysterical the law of gravity; pain sensations and refl exes paraplegia. In my own experience, I can report a seemed to be completely eradicated, even includ- case of hypochondriacal hemiplegia, which was ing those to the sensitive mucous membrane of right-sided, complicated by motor aphasia. It the eye; pulse was accelerated but barely palpa- involved a hypochondriacal psychiatric patient, ble; respiration seemed imperceptible. There was who soon stubbornly refused food, and who died no cyanosis, but an unchanged sallow face. several months later, death not being attributed to Artifi cial respiration was employed repeatedly any complication. Careful brain autopsy was car- for hours until, after repeated attacks, the harm- ried out, with essentially negative fi ndings. The lessness of the condition was revealed. Suddenly, right-sided paralysis in this case presented pecu- that is after a certain duration of this condition, liarities, differing at fi rst glance from organically the patient was able to get up, and then began to based hemiplegia, as shown most conspicuously dance about with theatrical gestures, and to sing by the awkward, stiff gait, the affected leg being songs of a pious nature; perhaps she was then in dragged like a heavy weight. One might have an ecstatic semi-rapturous state. I have seen simi- considered this to be simulation, had this been lar states, once again with apparent respiratory excluded beyond all doubt, by the severe course arrest lasting several minutes, which pass rapidly of the mental illness. Unfortunately, I do not into a state of hystero-epilepsy between two accurately recall the condition of this patient’s attacks, when there was a striking, complete arm; but I know that arm and shoulder appeared unsteadiness of the head, just like a fl accid paral- to be deliberately fi xated, and that a very unusual ysis. Moreover, in these states we must not ignore picture resulted, which resembled a simulated that more things are taking place than just a palsy. In contrast, Charcot’s psychic paralysis is 35 Lecture 35 265 usually a fl accid one. One might object that cases back to an absence of volition, that is to occurrence of hypochondriacal paralysis pro- intrapsychic infl uences; and the fact that posi- vides evidence of the possibility of psychic paral- tions imposed on a patient are maintained also ysis in Charcot’s sense, and, as a possibility, this fi ts this interpretation. However, clearly we should not be challenged. However, in separating almost always see that such positions are main- hypochondriacal and psychic palsies, the latter tained for a longer duration if one of us is present may occur in mentally healthy people, and one and busy with patients, than when the patients are fundamental difference remains: that the latter is left to their own devices. As already indicated based on the abolition of the will in the context of above, we must regard this condition as being an a normal, albeit hidden motive; while for the for- effect of suggestion from manipulations per- mer, there is the same anomaly of the will, but in formed by an examiner, that is, an involuntary consequence of an unhealthy motive. If adhere to infl uence derived from existing volitional pro- this, treatment of psychic palsies is the same as cesses. Cases of negativism, with full retention of that of simulated palsy. activity in the sensorium, display just the oppo- Related to the so-called hypochondriacal pal- site: We saw, for example, the following behav- sies are cases of ‘fi xed contracture’ [Ed], which iour: A patient, who is perfectly conscious, sits in sometimes—in rare instances—may remain as bed with his eyes open and evidently notices the residue of the same symptom present during what is going on in the ward. He is requested to the acute period of illness, but after its termina- raise his right arm. When he does not comply, an tion, while all other disturbances of motility have attempt is made to make the movement passively; disappeared. According to the little experience but this meets resistance, increasing in proportion I have had of this, extremities of the limbs seem to the strength used. When the patient becomes to be affected preferentially, so that at one time reluctant, we attempt to explain this diffi culty in contracture was confi ned to both hands, at psychological terms as intentional resistance. another time to one hand with foot-drop of both Nevertheless, from the rest of the patient’s behav- feet, combined, in the fi rst case, with moderate iour, it is shown beyond doubt that he did not lack degree of dementia, and in the second case with a the good intention needed to carry out our severe degree. According to the unusual way in request, and that otherwise he shows no tendency which these contractures originated, it was to oppose other requests of the physician. We impossible to decide if they were combined with then consider the fact that the patient often exerts real paralysis; but one can say, at least, that very great strength in his resistance, out of all patients’ ability for spontaneous work with the proportion to other volitional manifestations; and muscle areas affected was lost. Of course, these so that we get to the idea that volition is [Ed] were not cases of progressive paralysis. I have no present, which cannot be expressed because of hesitation in regarding these cases as analogous internal resistance, and effort is exerted in the to ones already familiar to you—of motor and opposite direction, the patient then usually feel- partial sensory aphasia, whose defi cits remained ing that he is subject to a compulsion. In a similar after a severe episode of motility psychosis; and I manner, in attempting to part the patient’s lips explain them by summation of individual defi cits and separate the lower jaw from the upper jaw, of the psychomotor pathway Zm . the opposite result is produced: The lips become With regard to interpretation of the akinetic more tightly closed, masseters and temporal mus- symptoms, special consideration is needed for cles spring into action, although it is soon appar- pseudo-fl exibilitas, in which perfectly clear and ent that the patient really intended to open his alert consciousness is usually present. A patient’s mouth; at one time, this cannot occur at all, at independent volition to do something other than another, only with great effort. Sometimes we whatever is forced on him by passive movement, gather information after inquiring about motives seems to be absent here, and so one is tempted to for this behaviour, that voices forbad a patient trace the moderate generalized akinesia in these from performing the movements. However, they 266 35 Lecture 35 are the same voices that subsequently prevented In patients who are otherwise immobile, a his making the movement spontaneously: number of muscle contractions appear in the Characteristic assertions include: ‘They do not form of negativism, as soon as the attempt is let me speak; now they strain and drag me’. made to change a patient’s position, possibly I need not emphasize that these voices, with their having signifi cance similar to that of a ‘modifi ed vetoes and commands, do not explain the patient’s cortical refl ex’. However, persisting contractions strange reactions; in our sense, they are no more and those independent of passive movements are than the expression of physical disarray conso invariably combined with states of uncon- nected to the particular situation. I have already sciousness or marked stupor, that one might be called your attention to the irradiation of the voli- compelled to relate them to some form of volitional impulse in such cases. tional action. I confi ne myself to suggesting that Without doubt the most remarkable and most there are suffi cient clinical and experimental data specifi c reaction of patients to passive move- to prove that central projection motor fi elds are ments is the third form, that is, waxy fl exibility. the origin of tonic spasms and contractures. This manifestation, met with exclusively under Gentlemen! In the literature of our science psychotic conditions, might not at once arouse you will come across the term ‘abulia’ [Ed] many suspicions of its being based on an aberrant times, used to designate states of immobility at change in volitional action: It must evidently be different levels of severity. We are now in a posi- regarded as a specifi c cortical reaction to passive tion to show how inapt this term actually is. It movements, which appears in pure form only would be justifi ed only for the akinesia of initia- under certain pathological conditions. These con- tive movements in melancholia and dementia, ditions, however, are ones of severe immobility, albeit even then an unnecessary term. Amongst for only then can it be observed. In other words, motility psychoses, it is not an aberrance of the it occurs only when the ‘will’ [Ed] cannot be will, nor does it indicate the impossibility of hav- exercised in passive movement; hence, as part of ing notions about objectives for actions; rather it this disorder, imparted positions persist in is a disorder of identifi cation between those unquestioning manner. Once we reach this point notions about objectives and the central projec- of view, pseudo-fl exibilitas as well as negativism tion motor fi elds. Hence one can account for the seem to be just modifi cations of Flexibilitas possibility that localized contractions and palsies cerea, [W] which occur when the possibility of can remain even after states of acute psychosis some [Ed] volitional infl uence is retained. have ended; hence also the possibility of hypo- Attempts to make passive movements are per- chondriacal hemiplegia combined with motor ceived within the cortex. At one time, this might aphasia. To assume a unilateral condition of the arouse the idea of a movement to be performed, will would be nonsense, whereas, defi cits in the and facilitates the corresponding volitional function of—or actual interruption of the path- action; at another time, thought of the impractica- ways available to—the will, for activation of the bility of the movement arises; that is, coupled motor centres of one hemisphere, is conceivable with the idea of the movement to be performed, is and not without analogies. Only in this way can also the ‘inhibitory thought’ of the required occurrence of the Affective state of motor disar- expenditure of effort, which, subjectively, often ray, and of numerous and strangely-coloured seems very great. The effect of the will is thus explanatory delusions, and many other symp- inverted into its opposite. From such an overesti- toms, be explained. Under some conditions, one mate of the necessary expenditure of effort, the might observe directly that certain notions about volitional impulse then radiates to wider areas of objectives are initiated by [Ed] motor behaviour musculature, as observed under certain condi- itself, for example, when a patient who is made to tions (see above). drop to his knees, raises his head and eyes 35 Lecture 35 267 upwards and puts his hands together as if in nance of imposed positions; and I have myself prayer; or a body position that is imposed acci- experienced that, as motility psychosis abates, a dentally reminds him of the situation of a fencer type of refl ex muteness, that is, a failure to answer or an acrobat, and, at once, he executes those questions put by a physician—our reactive mut- movements which help to complete the picture. ism—forms the last remaining motor symptom, Pseudo-spontaneous movements, as primary while all the other reactions are prompt, this manifestations, which have been mentioned being seen so often that I have to consider it to be occasionally, often produce Affective reactions a regular feature. That it is ‘reactive mutism’ habitually combined with them, such as ‘cheer- [Ed], and the fact that it emerges when confront- fulness’ [Ed] or ‘attack’ [Ed]. Likewise, empha- ing a physician, is immediately understood, if I sis has constantly been placed on the fact that all remind you of the distinction favoured by a tem- expressions of movement in hyperkinetic motil- peramental colleague, between a ‘super-’ [W] ity psychoses occur without cooperation of the and a ‘subconsciousness’ [W]. Likewise, we will will, to be regarded as primary signs of attendant fi nd it natural that under these circumstances the trains of thought and Affective states. This is true speech mechanism fails, especially for questions even more when strictly localized pseudo- about this very this symptom. Even after lengthy spontaneous movements are repeated rhythmi- persuasion, the only answer you may get is an cally, and which occur in akinetic motility understandable Affective outburst (In a 26-year- psychoses, and where contracture of affected old Jewish merchant a speech impediment of this muscles may precede paralysis. sort existed entirely alone. He consulted me in a Gentlemen! From such arguments, it seems peculiar manner by handing me a note of the fol- that in motility psychoses, consciousness of per- lowing words: ‘Almost always when I want to sonhood—in our sense, that ‘grand complex of speak with deliberation, I am unable to utter a ideas’ [Ed] which makes up the ego—is to a sound, despite the greatest effort. Involuntarily degree detached from motor mechanisms of the I speak very fl uently, likewise in reading and body, over which ‘the ego’ [Ed] has become used singing. This condition has existed since school to exert control. As a witness, the ‘ego’ is con- days, and becomes ever more manifest, so that at fronted with motor processes, and also with the times I believed I might be dumb.’). failure of this machine, and in turn, is initially Gentlemen! I remind you now of the account affected by this. It is evident that only dissolution I gave you of consciousness of corporeality, of associations, our hypothetical process of at the start of these clinical discussions. sejunction, can be the basis for this behaviour. Musculature must have a prominent place in this, Through this connection of events, special light is and indeed we must presume some vague aware- shed on that group of movements which are ness of the state of our muscles, which constantly almost exclusively under the control of the inte- accompanies us in our waking state, to regulate grated personality, namely expressions of speech. posture and gait. We must thus ascribe to the They are the ones most readily damaged, and curve of ‘psychophysical movements’ [Ed], the provide the fi nest indicator of the motor character attribute of their being raised above the general of a psychosis; and we obtain confi rmation of this level of body awareness to a moderate degree of from experiences in the clinic. When you encoun- excitement. If we remember this, we must also ter a new patient who responds to your questions appreciate that expressions of movement in a with striking silence, and thus makes examina- patient, just like those in a healthy person, imme- tion diffi cult, do not omit, gentlemen, to move his diately presuppose a process of excitement, elab- limbs and arrange them in certain positions. You orated within our consciousness of corporeality. will often be surprised to fi nd quite prominent Abnormal expressions of movement, which have symptoms of pseudo-fl exibilitas and mainte- occupied us here, would fi nd their simplest expla- 268 35 Lecture 35 nation by assuming that there was a disorder in Rhythmic repetition in such cases can be based consciousness of corporeality. We might then on existence of a local abnormal stimulus limited modify the defi nition of volition, which you to certain uniform movements, which must grow would take to be present, in such a way that to a certain intensity to produce the movement motor projection fi elds make up a part of bodily itself. At this point, some sort of discharge is consciousness. The idea of ‘expenditure of effected, such that the incentive for movement is effort’ [Ed], necessary for execution of any defi - relieved until the same process reappears. It is nite movement likewise belongs with bodily very similar for the process of verbigeration; here consciousness. Under certain conditions, an too, local stimulation which leads to rhythmical aberrant change in the framework of motor repetition must stick to certain patterns of speech ideas, built one upon another, impacts on aware- delivery. Imperative talking, that is compulsory ness of the whole body. This has the effect of repetition of hallucinated words, gives us an increasing expenditure of effort, to an abnor- example where the starting point for such aberrant mally high level, as judged subjectively, for stimulatory processes in motor areas can also lie every simple movement, so that movements are within central sensory areas, if aberrant stimuli avoided, and immobility is the result. Patients there encroach on bodily consciousness. For pri- adopt abnormal body positions, and—once they mary auditory hallucinations, hearing is indeed to are made to stand or walk—also adopt abnormal be regarded as a stimulation process that arouses stance. This is explained in an equally simple not only acoustic patterns, but also related organ manner as disturbed bodily consciousness, such sensation; and, beyond the intensity of the origi- that relationships between trunk and limbs are nal stimulus, it is only the presence of a well-worn felt to be changed in certain parts of the verte- pathway, which has always served for repetition, bral column or in the normal complementary that explains irradiation to the motor speech area. activation of muscle groups cooperating sym- In this way, in the same cases, this aspect of con- metrically in their relative positions, in their sciousness of corporeality, namely the motor proper association. A patient who initially speech area, turns out to be inaccessible to the remained motionless and, when forced, tried to patient’s will, or harder to access than normal. An avoid locomotion, then discovers that his motor analogue to this reaction of the motor area in mechanism is in a state of confusion. Clearly, bodily consciousness of stimuli streaming into it this process cannot be placed on a par with hal- from central sensory regions, is to be found in the lucinations, for there, aberrant and abnormally following observation. Such a patient is found sit- intense stimulation is the main feature, whereas ting in bed holding his right hand in a position as in our case, loosening of fi rmly established though he were holding something in it, although associations suffi ces as an explanation. nothing is to be seen. Specifi cally, the thumb is Similarly, maintenance of certain abnormal pressed against the fi rst two fi ngers and the ends positions may reveal only subjective sensations of the fi ngers pressed together. This is the same of changed balance between motor impulse and patient who is teased and enticed by voices. I now its collateral and antagonistic [6 ] activation of request him to raise his left arm, which he does defi nite muscle areas [7 ], which cooperate in readily; I then request this of the right arm, but normal positions. Automatically repeated move- without success. Repeating the request leads to ments, distinguished by their uniformity, are the same result. I now try to place his right arm in similar to autochthonous thoughts in the domain another position and at once meet growing resis- of personhood. They are autochthonous ideas in tance, and then vigorous signs of unwillingness the area of corporeality, and are therefore union the part of the patient. Careful examination of form, because everything in this area of the con- the fi ngers shows that the patient has a tiny bit of sciousness is localized. cloth between his fi ngers, that came from his References 269 woollen duvet. After this has been taken away, he References makes all required movements with his right hand, just as he had done before with his left hand. 1. Wernicke C. Krankenvorstellungen aus der psychia- While such examples reveal an abnormally strong trischen Klinik in Breslau. Breslau: Schletter; 1899. vol. 1, Cases 6, 15, and 21 are examples of cyclic infl uence of intercortical pathways, other obser- motility psychosis. vations, in which garbled words are sometimes 2. Wernicke C. Krankenvorstellungen aus der psychia- uttered by the same type of patient, indicate that trischen Klinik in Breslau. Breslau: Schletter; 1899. vol. the infl uence of these pathways—which are 1 (Cases 15 is an example of cyclic motility psychosis.) 3. Heubner JBO. Die luetische Erkrankung der always normally used in speaking—can meet Hirnarterien: nebst allgemeinen Erörterungen zur nor- similar diffi culties in the effect of will on speech malen und pathologischen Histologie der Arterien movements; without this, it is impossible for sowie zur Hirncirculation, eine Monographie. Leipzig: speech movements to be uttered suddenly in FCW Vogel; 1874. 4. Charcot JM. Oeuvres complètes: Leçons sur les paraphasic form. This instance can likewise be maladies due système nerveux. Progr Méd. 1890; generalized. Consider for example that in walking 3:299–359. and standing our movements must be constantly 5. Wernicke C. Krankenvorstellungen aus der psychia- regulated by centripetal stimuli, then here, too, trischen Klinik in Breslau. Breslau: Schletter; 1899. vol. 3 Case 23 is an example of hypochondriacal one must acknowledge the infl uence of intercorti- paraplegia. cal pathways on movement ideas required for 6. Boulogne GBA. Physiologie des mouvements démon- standing and walking. The same inhibition, which trée à l'aide de l'expérimentation électrique et de is responsible for immobility of the patient, trans- l'observation clinique, et applicable à l'étude des paralysies et des déformations. Paris: Baillière; 1867. fers to such intercortical pathways, and then 7. Hering HE, Sherrington CS. Über Hemmung der seems very well suited, just as in the speech area, Contraction willkürlicher Muskeln bei elektrischer to produce the paraphasia (sit venia verbo). Reizung der Grosshirnrinde. Pfl ug Arch Ges Physiol. 1897;68(5):221–8. Lecture 36 36

• Simple or basic forms of acute psychoses in evaluating those cases which predominate in • Mixed and compound psychoses practice. Obviously, we should not attempt to • Examples force them artifi cially into some kind of schema, even if it be one like ours, which has been tried and tested. Nevertheless, our scheme does so much to help analyze presenting symptoms in Lecture these complex cases. Firstly, I remind you that, between any two Gentlemen! familiar forms of acute psychosis, we have already You will recall how strongly I have always found many transitional cases. These are amongst emphasized that our clinical knowledge of the the simplest examples of those more complicated psychoses is still very incomplete. You must also mixed psychoses , [W] as we shall call them. Thus bear in mind that the cases I present exemplify borderline cases of anxiety psychosis and Affective most of the more frequent types of illness; yet, melancholia, which I briefl y outlined earlier taken together they do not constitute the majority ( p. 149), are familiar to you. Because of their high of the main types. In other words, the more com- frequency, they deserve to be emphasized. Less plicated and therefore less familiar cases pre- common are cases of delirious anxiety psychosis, dominate in number. The principle that has briefl y mentioned earlier (p. 147), fairly pure guided me in this selection is well known, and cases of acute autopsychosis whose content was readily understood, namely to serve teaching pur- one of anxious belittlement, in which essentially poses. Thus, you had to be shown simple cases, only the course and contribution from the projec- composed of a few elementary symptoms, where tion system are borrowed from Delirium tremens we could gain as full an understanding as possi- [W]. The clinical picture of agitated melancholia, ble. For us, they form the foundation of a theory which I likewise characterized for you as an anxi- of illness, to which we must refer continually in ety psychosis (p. 148), is perhaps amenable to a order to understand more complex cases. In this uniform explanation, if we assume that the fre- sense we could designate types of illness consid- quent occurrence of ideas of anxiety leads to ered so far as fundamental forms of psychosis. It loquacity and fl ight of ideas. In any case, coinci- is not my intention now to attempt to describe dence of these two manic symptoms with anxiety just those cases which extend beyond the simpler psychosis is quite exceptional. Moreover, agi- situations: However, I cannot neglect a few brief tated melancholia corresponds to one of the more comments on the perspective you will have to use frequent illness types. These cited examples

represent mixed forms, which wholly or partly disorientation via belittlement. We include such include autopsychic disorientation, so that they cases amongst acute allosomatopsychoses, a always remain within the larger illness group of well-defi ned hybrid between allopsychoses and autopsychoses. somatopsychoses. In other cases, this combina- As a transitional case between autopsychoses tion develops on the same basis, while anxiety and somatopsychoses, we have become soon reaches a very high level, with disorienta- acquainted with the example of hypochondriacal tion in all three areas of consciousness, and char- melancholia (p. 162). In Affective melancholia, acteristic content which is fantastic, and at the the ‘overvalued idea’ [Ed] is a feature taking its same time a hypochondriacal, menacing delu- content from bodily consciousness, and whose sional state. This is often a very acute clinical derivation from a hysterical sensation is usually picture of total sensory psychosis, usually associ- unmistakable. In depressive melancholia, the ated with a huge numbers of hallucinations, fear somatopsychic element predominates by far, of being touched and blind defensiveness. In the whenever it is derived from severe hypochondri- autopsychic area, it often comes down not only acal mental illness (p. 262). In both cases, we can to ideas of belittlement, but also to the opposite assume that other sets of symptoms have a condi- picture of grandiosity; and the disorientation tional relationship, but in opposite directions. often has a tendency to gravitate in the latter Thus, in hypochondriacal melancholia, the hypo- direction, while belittling ideas, in the guise of chondriacal element appears as a consequence, phonemes, are strongly rejected, and the while in depressive melancholia, it becomes the Affective state of disarray prevails in this respect. origin of the autopsychosis. In hypochondriacal The helpless compulsion towards movement mental illnesses, we regularly encounter similar described above (p. 232) is peculiar to all these mutual conditionality based on the fact that the cases. As a result of the disorientation, the most symptom of anxiety, which is seldom absent, can diverse acts of disarray may occur: among them, have as a consequence, corresponding autopsy- running about blindly; breaking windows; attacks chic ideas of anxiety, which lead to autopsychic on people round about; and self-harm in most disorientation in the form of belittlement. Thus diverse ways, according to the location of hypo- we conclude that somatopsychoses occur only chondriacal sensations; fi nally, we should explic- rarely in pure form, but usually fi t the concept of itly mention the refusal of all food. Differentiation ‘autosomatopsychoses’ [Ed], and thus really of the clinical picture described here, is mainly belong among the mixed psychoses. You will made in the motor domain, in that we can include fi nd that in my presentation of the somatopsy- only cases in which actual motility symptoms are choses I always took this into consideration. In entirely absent. The clinical picture of acute total contrast, I deliberately said nothing about another sensory psychosis, with content of fantastic combination, which is seen no less often. It con- hypochondriacal menacing delusions, occurs sists of that form of disorientation which often quite often as very brief attacks, lasting only a occurs quite acutely, and which we can designate few hours or days, based either on intoxication or as ‘hypochondriacal delusional state of persecu- degenerative processes. Chronic alcoholism is tion’ [Ed]. Moreover, there exists internal con- particularly involved in the case of intoxication; nection between somatopsychic symptoms, and in the case of degenerative states, those with hys- (in this case), allopsychic symptoms, due partly terical and epileptic disposition make up the to simple explanatory delusions, and in part to majority of the so- called transitory psychoses . the elementary symptom of somatopsychic delu- [W] Prior head injuries predispose to this. For sions of relatedness, which, at the time, we cate- longer states of this sort, I am unaware of any gorized as new-formed associations. In acute deeper aetiological relationship. I need not men- psychoses, the latter connection evidently pre- tion that this is always a life-threatening situa- dominates, and often does so, either just initially, tion. If maintained, a more-or-less severe state of or entirely, even in cases which lack autopsychic exhaustion, with memory defi cit, tends to follow, 36 Lecture 36 273 which may merge into convalescence. A para- Delirium acutum [W]. However, we cannot noid stage is not observed. With respect to the acknowledge this as a special sort of illness, but course of acute fantastic hypochondriacal men- recognize only the readily comprehensible con- acing delusional states, their development up to sequences of a particular clinical picture, with their peak may be reached within a few quarter- acute features, rapidly taking a severe toll on hours in cases of transitory psychosis; in other available energy. Such extremely severe cases are cases it develops over a period of a few weeks, fortunately quite rare, although a proportion of from an initial hypochondriacal stage, in which them also present with additional symptoms from delusions of relatedness with hallucinations in all the projection system, so that they are claimed as the senses occur, as well as explanatory delu- cases of the so-called ‘galloping paralysis’ [Ed]. sions of most diverse kinds. Even for these cases Moreover, you would be wrong if you thought however, as the severe state endures for longer that total sensory psychosis always had charac- periods, a predominantly sensory character and teristic contents of fantastic hypochondriacal evident worsening course tends to develop, menacing delusions. That is by no means true, as mainly with motor symptoms and of various it shows up mainly as mixed cases, with only hyperkinetic, parakinetic, and akinetic types, moderate levels of Affect, and with delusional which can lead, at this stage, to profound exhaus- ideas whose content covers various types of par- tion and death. I have seen many such cases, tial disorientation, differing greatly amongst mainly amongst those with a severe hereditary individuals. For example, somatopsychic disori- predisposition; they deserve to be called acute entation may be limited to delusions of preg- progressive sensory psychosis [W]. One case of nancy, autopsychic disorientation to this kind, involving a 40-year-old kyphoscoliotic accompanying ideas of having sinned, and allo- labourer with hereditary loading, not addicted to psychic disorientation restricted only to certain alcohol, ran through this course within 2 months, time periods and certain relationships, so that the during which the patient lost 24 lb in body weight prevailing situation can still be recognized cor- despite extensive feeding during the last week. rectly. Phonemes and explanatory delusions then Moreover, the majority of cases of transitory psy- form accessory parts of the clinical picture [1 ]. At chosis tend to be accompanied by more specifi c other times, partial disorders of orientation are motility symptoms. found in isolation, at least in their not being Gentlemen! The picture outlined above of mixed simultaneously with signifi cant motility acute fantastic hypochondriacal menacing delu- phenomena, which usually endow the explana- sional states is amongst the most severe Affective tory delusions with a defi nite magical aura in states we know. When it has lasted somewhat their content. You will fi nd several examples of longer, often even after a few days, the general this type, characterized, I should say, by a rela- fi nding is that it leads to a degree of damage of tively rapid favourable course, described as such severity as is found elsewhere only in the mixed acute sensorimotor psychoses, among the most severe general physical illnesses. Shrunken patient demonstrations from my clinic [2 ]. features; general muscular tremor; hoarse, rasp- Mixed forms, lying between motility psycho- ing voice; dry, scaly coating on the lips, tongue ses and more-or-less extended sensory psycho- and teeth. Quite often, and probably then as a ses, are familiar to you, in part from descriptions sequela, signs of incipient blood decomposition I have already given. So I remind you of facts or severe trophic disorders foretell impending highlighted in discussing confused mania, that demise. Disorders of nutrition can also fi nd a hyperkinetic motility psychosis may be associ- basis in pathological anatomy, for example as ated with allopsychic disorientation, for which infl ammatory foci in the anterior horns of the spi- combination I reserve a special place. These nal cord, with multiple gangrenous areas in skin cases have the same menstrual basis, and the (autopsy carried out by Cohnheim). It is mainly same tendency to periodic recurrence as hyperki- such cases, which other authors have called netic motility psychoses, and deserve the name 274 36 Lecture 36

‘hyperkinetic allopsychoses’ [Ed]. Less often we cases. There seems to be no compelling case for encounter the combination of hyperkinetic motil- drawing an analogy between the differentiation ity psychosis, or agitated confusion with more amongst these cases and the quite circumscribed severe hypochondriacal symptoms, yet I have nature of direct focal symptoms in brain diseases. had a few cases of this kind, in which hyperki- I have already emphasized suffi ciently the fact netic symptoms were replaced by (and seemed that cases of akinetic motility psychosis associ- partially to be grafted onto) a hypochondriacal ated with total sensory disorientation and fantas- stage lasting only a few days, with tendency to tic menacing delusions require special severe self-harm. Hypochondriacal symptoms in interpretation, and generally have an unfavour- these cases represent a brief stage at the very able prognosis. peak. Affi liation of motility symptoms with Gentlemen! Cyclic motility psychoses have changed body awareness is thus illustrated again. given us the opportunity to become familiar with At other times, acute hyperkinetic motility psy- forms which mix mania and melancholia in two choses are associated from the start with total dis- opposed phases of illness. Quite apart from orientation, which we learn from the adverse motility psychoses, such combinations, and behaviour at the time of the aroused state, and resulting cases of mixed psychosis, are not rari- later from information given by the patients. Very ties; and we can understand that disorientation recently, we saw an example of this kind [3 ]. of any sort, not itself an effect of mania or mel- I already mentioned that the more-or-less promi- ancholia, is often enough associated with diffuse nent picture of a hyperkinetic motility psychosis augmentation or reduction of excitability in may later be added to a state of total sensory psy- association pathways. Most often, we are deal- chosis; and that this may be the basis of the severe ing with very different cases of illness, which are course taken by certain cases of acute progres- still unknown. On the other hand, certain combi- sive psychosis. You will remember in this even- nations of a more familiar kind are also occa- tuality, that it is not usually a hyperkinetic sionally encountered. Thus I mentioned motility psychosis whose progressive course previously (p. 240) certain cases of manic allo- unfolds, but a complete motility psychosis. psychosis; and, to complete what I said earlier, For akinetic motility psychoses, from the out- would add that in cases of hyperkinetic motility set we should abandon the idea of considering psychosis orientation to the outside world seems only pure cases; the fact that we usually have to to be damaged directly, if patients are at the deal with mixed cases is therefore quite well same time manic, or have presented with a known to you. Nonetheless, I want to emphasize prominent, purely manic picture as the early explicitly that a defi nite combination, specifi cally stage of their illness. that with hypochondriacal symptoms, makes up The combination of allopsychotic symptoms an almost normal picture; again this indicates with mania is important practically, and deserves that motility psychoses should be included with special mention. The clinical picture of choleric the broader concept of somatopsychoses. On the mania [W], found quite often as an independent other hand, in many cases, the fact that complete illness, consists essentially of a combination of allopsychic orientation is retained, has been mania with ideas of anxiety and corresponding established with reasonable certainty. In one such phonemes, but without any necessary allopsychic case, there was complete somatopsychic orienta- disorientation. Usually however, allopsychic tion, yet complicated by fantastic delusions of delusions of relatedness and hypermetamorpho- belittlement, and in general by a picture of sis are present. Complaints of anxiety itself are Affective melancholia. Irrespective of the latter, made, and fear of being approached, and terror we deal here with cases whose course is unfa- are also sometimes observed. A very typical case vourable, whereas other cases, with total disori- of this kind occurred at intervals of exactly 4 entation in the sensory area, recover completely, weeks, and lasted 14 days, without menstrual even though this may be years later in some aetiology being possible, since it was in an 36 Lecture 36 275

18-year-old youth at the stage of puberty, who occurring in stages; the fi rst stage should accord- was strikingly backward physically, and with a ingly be a melancholic one, in the sense used by strong hereditary taint. Choleric mania generally older authors. Had the acute psychosis gone seems, as in this case, to have a favourable out- beyond its peak and developed to a special para- come. Choleric mania in paralytics, which is not noic stage before actual recovery, we would not uncommon, usually makes up no more than one be able to perceive it as an independent stage, in phase of the illness. the sense just suggested. For us, this stage is Through confused mania, I have come into nothing more than the more-or-less pure picture contact from time to time with a further combina- of disorientation, after abatement of those acute tion, not of mania, but of consecutive asthenic symptoms which led to the disorientation. Where, confusion with allopsychic disorientation; and instead, it goes on to a paranoic or, after that, a likewise I have emphasized that the same combi- demented stage, the same refl ection is just as nation is also to be observed in primary, asthenic true, because it also represents a sequela [Ed] confusion (pp. 241, 242). It remains to be decided like the paranoic stage. Moreover, the fi nal out- whether a causative connection exists between come in an incurable state, that is either chronic demonstrable weakness of association and allo- mental disorder or dementia, cannot, for us, be a psychical disorientation. Occurrence of asthenic real stage in this sense. autoallopsychosis in young girls, mentioned in You see, gentlemen, that in this way we can this connection, certainly supports this. exclude from the concept of compound psycho- The intermingling of Affective melancholia ses most psychoses that we know about, be they with these other psychoses is much less familiar simple or mixed. Only in one respect might we than their combination with mania; and then remain in doubt, namely over whether the I need do no more than mention the combination. sequence of contrasting states such as mania and I refer to previously mentioned (p. 274) co- melancholia is to be interpreted as a set of inde- occurrence of melancholia with akinetic motility pendent stages. Here too the possibility is raised psychosis, or with the akinetic phase of a cyclic that increased excitability, which is the basis of motility psychosis. one stage, only prepares for—or induces—the Gentlemen! Besides mixed psychoses, with reduced excitability in the other stage, just as we which we have just been dealing, we can differ- see in the peripheral nervous system: These two entiate compound psychoses [W]. These are dis- stages often follow each other. As you know, tinguished by the fact that in them, illness Meynert [4 ] actually advocated such a causal proceeds in distinct stages or phases, independent connection, and explained it through vasomotor of one another. I make a general comment on the infl uences. The same principle could be extended importance of the independence or individuality to consecutive phases of hyperkinesia and akine- of these phases. In most acute psychoses, we sia. However, I would like to make use of this must acknowledge an initial stage which, as we notion only in so far as I acknowledge that the have seen, owes its hallmark to the specifi c convalescence from mania (p. 209) preceding Affective state of disarray. Disarray can rise to melancholia, and likewise the reverse relation- the level of anxiety and despair; or anxiety can ship, as such sequelae . In either case we should itself be regarded as a special somatopsychic bear in mind the circular mental illness and the form of disarray. We cannot regard this initial cyclic motility psychosis as special cases of com- stage as an independent manifestation, because posite psychoses. If we adopt this viewpoint, it the prevalent Affect is merely a reaction to the gives support to the idea that composite psycho- same elementary symptoms that lead to disorien- ses are encountered far more rarely than simple tation, and which determines the special features or mixed psychoses, as Ziehen already correctly of a defi nite simple psychosis. As you will recognized. remember, this initial stage provided the fi rst rea- Cases of composite motility psychoses [W] son to envisage the course of every psychosis as arouse our special interest, because it is clearly 276 36 Lecture 36 these which led Kahlbaum [5 ] to formulate his psychosis, other forms also often occur, where clinical picture of catatonia. By ‘composite the peak takes the form of a motility psychosis, motility psychosis’ [Ed], we understand quite while, at onset of the illness, some other psycho- generally all those acute psychoses which occur sis prevails. This is particularly common in the in different stages, if one of these fi ts a picture of case of acute hallucinosis—quite similar to anxi- motility psychosis. The most common event is ety psychosis—with which we have already the transition, mentioned several times already, become acquainted, as a particularly progressive from an anxiety psychosis to a motility psycho- form, which can lead to complete motility psy- sis, and indeed we can then speak of a composite chosis. Moreover, the special form of circum- motility psychosis, even if the fi rst stage—the scribed autopsychosis mediated by overvalued anxiety psychosis—has a much longer duration, ideas, may take a similar progressive course. An months at least, so that it cannot be interpreted especially instructive case of this kind involved a simply as an initial stage. Very often, the anxiety 41-year-old night watchman, admitted in psychosis develops into an akinetic–parakinetic December, 1895, who presented initially only motility psychosis [6 ], and then often with a par- with the overvalued idea that a cultured young ticular coloration signifying that the Affect of lady was in love with him, and had led him to anxiety remains, either always intermingled with, recognize this by her conduct towards him (an or at least occasionally breaking through the aki- autopsychic delusion of reference). His detention nesia. The later course of such cases seems usu- led to the explanatory idea that a rival wanted to ally to be unfavourable. More rarely, in cases take his place. After just 2 months, I presented with especially severe Affective symptoms, this patient in an entirely changed state, since he development to a hyper-parakinetic motility psy- now believed that he was being widely perse- chosis takes place. The fi rst stage has thus a con- cuted, his body destroyed by poison, and imag- tent of fantastic belittlement and menacing ined himself to be seriously ill and weak, delusions, with the usual fl uctuations appearing believing that he was a count, and had been to be improvements in the anxiety psychosis. abducted in childhood by robbers; and he became Motor symptoms are more uniform than in hyper- threatening and, at the same time, violent. kinetic motility psychoses; parakinesia predomi- Occasionally, at this stage, hyperkinetic and nates, mainly as expressions of anxiety, for parakinetic symptoms were mixed in. Here, example, as rhythmical yelling. Instead of the therefore an illness which was entirely circum- anxiety psychosis shifting directly into motility scribed, followed a basically progressive course, psychosis, an increase of the anxiety psychosis is right to the point where motility symptoms often seen, initially to total sensory psychosis occurred. The only striking feature of this initial, with content of fantastic menacing delusions, and and otherwise quite pure stage of circumscribed then, with further worsening, to the picture of a autopsychosis, was that it was associated with motility psychosis, a course which, like the numerous, peculiar phonemes—peculiar in that above-mentioned clinical picture, corresponds to they consisted exclusively of terms of endear- an acute progressive psychosis. Instead of a total ment on the part of that young lady, so that the [Ed] sensory psychosis, it is also often trans- patient had coined the technical expression ‘lan- formed into a state where the only impairment of guage of the heart’ [W]. For aetiology, sexual awareness of the outside world involves frighten- abstinence undoubtedly played a part, since he ing hallucinations, without orientation being had lived apart from his wife for 2 years, and had directly affected. In all such cases, motility psy- had too little sleep in the last year; there was no chosis appears at the peak of a worsening and alcohol abuse. The illness of a 30-year-old maid- rather extended trajectory of the illness. servant began in the form of an acute allopsycho- Now, if we acknowledge that the most com- sis with allopsychical disorientation, which mon form of acute progressive psychoses is an lasted several months. She then gradually became anxiety psychosis, escalating to a motility completely motionless and, for about 18 months, 36 Lecture 36 277 presented a picture of akinetic motility psychosis. combination, the manic stage appears to be a After gradual abatement of the akinesia and favourable omen, leading to recovery, either fi nally, also the disappearance of the mutism, she directly or after a further stage of exhaustive stu- now appears to have entered convalescence with- por. Mania proved to have the same favourable out signs of defi cit. The case of a 28-year-old tai- signifi cance, in a case where it appeared as the loress ran in three separate stages: She appeared third stage, after a stage of agitated motor confu- melancholic for 9 months then, with rapid sion, and a second one of residual hallucinosis. increase in symptoms, remained disorientated Severe phthisis came in as a complicating factor, with respect to the outside world and body aware- which prevented signifi cant increase in body ness for a further 3 months, and fi nally presented weight. With regard to aetiology, this female a symptom complex of akinetic motility psycho- patient, a 32-year- old straw hat seamstress, aside sis. I was able to present her to you about 6 from signifi cant hereditary infl uence, presented months after the beginning of the third stage, with overwork, trouble, and worry, haemorrhage when she was totally demented, with contrac- from an external injury, and fi nally, an attack of tures of both hands, a fi xed position of trunk and infl uenza. I would briefl y like to mention the head reminiscent of Meynert’s celebrated optic combination of complete motility psychosis, thalamus case; walking and standing in the Pes defi ned purely by motor symptoms, with severe equinus [W] position or on the outer edges of the hypochondriacal psychosis developing after the feet. Rapid transition of the fi rst into the second motility psychosis had totally abated, leading us stage was characterized by emergence of inco- to the defi nite expectation of imminent recovery. herent delusions of persecution and grandiosity. In one case, a further separate, apparently unfa- The gradual transformation of one clinical vourable stage of delusion-formation, based on picture into the other, and the evident progression sensory symptoms, led to a single attack of which occurs as the range of symptoms extends, cyclic motility psychosis of puerperal aetiology. results in the separation of special stages in such One case must arouse our special interest, in cases seeming somewhat artifi cial; the opposite which a 16-day stage of ordered mania was fol- view is held only by those observers who see the lowed by an apparently lucid interval of 2 days, patients only rarely, with long intervening preceded by an akinetic motility psychosis, intervals. which continued for 4 months; and even in its The situation is quite different in a number of full picture, never reached the level where the other cases. Thus, some time ago, I showed you patient’s personal hygiene lapsed, and which a patient presenting a picture of akinetic motility was then followed, in turn, by a paranoid stage psychosis with marked stupor, who, allegedly, and fi nally by dementia. Notably, the manic pic- was acutely ill. Certain indications in the case ture of the fi rst stage, at times of greatest excite- history led us to suspect that we were dealing ment, had a mixture merely hinting at a motility with a paralytic illness, and, in fact I could show disorder, in that the patient sometimes persis- you the same patient not long afterwards, free tently adopted domineering postures, and from motility symptoms, but in a state of that thereby presented a rather rigid manner of fantastic grandiosity, which we recognize as a expression. This 20-year-old patient had some specifi c paralytic form of expansive autopsycho- hereditary loading, and a mentally ill brother. sis (p. 219). Here, one condition had replaced In addition, the picture of choleric mania, the other. Mania also commonly includes a stage which is itself already a mixture, may occur as a of composite motility psychosis. This can follow stage in a composite psychosis. This was so, in a an akinetic motility psychosis, either immediately case of hereditary, degenerative aetiology in a or after an intermediate stage of apparent 15-year-old boy, leading to a second stage of dementia, usually not quite pure, but with hyperkinetic motility psychosis, followed by a admixed hypermetamorphosis or agitated confu- further stage of severe exhaustion-stupor; the sion with sensory mediation (pp. 235, 236). In this patient, who had repeatedly had brief attacks of 278 36 Lecture 36 psychosis, was initially perfectly well. Recurrent only one point, that progressive paralysis, when it attacks of choleric mania, lasting only a few proceeds as a composite psychosis, often also hours at irregular intervals of 1–4 days, whose produces a stage of choleric mania, and espe- interim periods were sometimes approximately cially at the time of acute onset of the illness. normal, were sometimes largely replaced by states of anxiety with terrifying hallucinations. This led to the second stage of a composite psy- References chosis lasting 6 months, starting with anxiety 1. Wernicke C. Krankenvorstellungen aus der psychia- psychosis lasting about 1 month. Residual trischen Klinik in Breslau, vol. 3. Breslau: Schletter; sequelae involved severe confusion with auto- 1899. Case 9. psychic and allopsychic disorientation corre- 2. Wernicke C. Krankenvorstellungen, vol. 1, Case 28 sponding to previous hallucinations and a and vol. 2, 1899. Case 2. 3. Wernicke C. Krankenvorstellungen, vol. 3, 1899. moderately irritable mood. This 52-year-old Case 20. female patient presented no prospect of further 4. Meynert T. Der Bau der Grosshirnsrinde und seine recovery, and was transferred to a secure unit. For örtlichen Verschiedenheiten, nebst einem pathologisch- further examples of compound psychoses, I still anatomischen Corollarium. Leipzig: Engelman; 1887. 5. Kahlbaum KL. Die Katatonie oder das return, on occasion to the aetiological grouping Spannungsirresein. Berlin: A Hirschwald; 1874. of psychoses, and I would like to emphasize here 6. Wernicke C. Krankenvorstellungen, vol. 2 Case 21, vol. 3 Case 18 are examples of this. Lecture 37 37

• Progressive paralysis, an aetiological group of differences in symptomatology. Thus, it gives us diseases an example of a brain disease in which anatomical • Prodromal symptoms fi ndings and symptoms correspond with one • Spinal and cortical symptoms another. Of course, up to now this principle has • Various forms of paralytic psychoses applied only to symptoms arising in the projection • Course as a compound psychosis system, and to the symptom of disintegration, • Paralytic dementia namely dementia. However, by analogy it is per- • Remissions and paralytic attacks missible to conclude that what applies here, • Atypical paralysis applies also to an equally large diversity of clini- • Worsening paralysis cal psychiatric pictures, if one were in a position • Diagnosis to locate these clinical pictures symptomatologi- • Treatment cally. Thus, progressive paralysis offers us a way • Anatomical fi ndings into a general anatomical foundation for the psychoses. You see, gentlemen, that from this point of view, we again need to hold to the view that progressive paralysis represents no more than an Lecture aetiological recapitulation of psychoses, which otherwise differ widely from one other. Gentlemen! Paralytic aetiology shows itself to be related We have often met Progressive paralysis in the most closely to toxic effects, with the sole differ- course of these discussions, and in such different ence that it is a toxic effect to be seen as arising forms that you will have already reached a con- repeatedly anew within the organism. The pro- clusion as to the importance of this group of ill- gressive deleterious character of the disease can nesses. However, the main theoretical signifi cance be explained in no other way. This necessary con- of the group is far greater: For, alone among all cept can be explained by analogy with the spinal the psychoses, cases in this group show almost disease Tabes dorsalis [W] and an assumed constant anatomical fi ndings, and in addition, as ‘metasyphilitic toxin’ [Ed], in contrast to the we also know, the constancy of this fi nding cor- syphilitic aetiology. Despite this, you still cannot responds with constancy of certain symptoms avoid accepting bacterial action as the basis for common to almost all cases; while, beyond that, this peculiar behaviour. But I want to comment very different localization of the disease process here that sporadic exceptions to this deleterious is also to be found, but with corresponding progression are to be seen. Over the years,

however, amongst thousands of cases of severe disorder [W] ranges between two opposites, paralytic psychosis with a clear syphilitic basis, a which we can describe as ‘stumbling over sylla- few cases have recovered completely, and not bles’ [Ed], and blurring of speech—if you prefer relapsed. As you can see from these comments, I to avoid the anatomical terms of cortical and bul- perceive paralysis to be the epitome of syphilis- bar speech disorder. To assess stumbling over related psychoses, a viewpoint fi nding increased syllables, you can use test words to be repeated, general recognition, and which appears justifi ed like ‘civilization’ [Ed], ‘army reorganization’ by experiences in our Clinic. It would already be [Ed], ‘extraterritoriality’ [Ed], etc. The voice clear to you from my periodic utterances that a becomes tremulous, up to the point of aegoph- certain psychosis cannot be said to have an exclu- ony. If these symptoms, which are decisive indi- sive [Ed] causal relationship to syphilis. You can cators of palsy, are missing during the prodromal never recognize anything more than the prefer- stage, diagnosis may still be possible, as soon as ence [Ed] of a particular aetiology for a particular you can detect characteristic spinal symptoms. form of illness. These spinal symptoms [ 3] [W] sometimes pre- With this restriction, you must consider as cede all other paralytic phenomena, and are specifi c to paralytic psychosis, the fantastic therefore the most valuable diagnostic tools. grandiosity, that is the earlier-mentioned Here, they indicate no more than signs of the so- (p. 219) expansive [W] form of autopsychosis called ‘column disease’ [Ed] of the spinal cord, [W], seen almost exclusively in the context of symptoms derived partly from dorsal columns, syphilis. But I have already alluded (p. 220), partly from lateral columns. From the former, though not often, to the occurrence of one must expect rigidity of the pupillary refl ex. Kahlbaum’s [ 1] so-called Progressiva divergens Without doubt, little value can be placed pupil- [W], which probably was not syphilitic—and I lary inequality. I particularly draw your attention presented to you the case of an 86-year-old to certain characteristic signs of combined woman with the same fantastic grandiose delu- columnar disease, although there are two types sions—which certainly was not. The fantastic that are equally valid: Respectively, they are grandiosity, like other yet-to-be mentioned, and increased passive mobility of the legs with more distinct psychoses, often forms the fi rst simultaneous increase of tendon refl exes; and stage of a composite psychosis [2 ] usually lasting reduction of passive mobility, producing promi- only weeks or months. nent rigidity, together with reduction or even a The prodromal symptoms [W] of progressive total absence of tendon refl exes. Through pro- paralysis, usually accompanied by feelings of longed observation, we see one of these patterns severe illness, are well known. They consist of being replaced by the other; for example, return headaches, insomnia, and irritable mood, and of a lost knee jerk! As regards their diagnostic can precede outbreak of acute psychosis by 1–2 value, it is important to note that in neurasthenia years. However, quite often, headaches are there may be an increase in tendon refl exes, but denied. In this prodromal stage, often indistin- never a reduction. guishable from severe neurasthenia, you often As for the immediate precipitant of the illness, also hear complaints of forgetfulness and failing undoubtedly strenuous mental activity has often ability to perform, although these symptoms preceded it. However, we would be giving a false cannot be verifi ed objectively. However, early on impression if we took into account only the in some cases, and in this prodromal stage, ‘quantum’ [Ed] of work; we often see men with symptoms derived from the projection system unceasing and strenuous mental activity who may be prominent. To recapitulate briefl y, they reach their later years full of vigour. Indeed, usually consist just of a suggestion of facial I would like to suggest that strenuous mental palsy or tongue deviation; the so-called ‘para- work is even benefi cial to health. What is harmful lytic speech impediment’ [Ed]; and a tremor of by itself is to work under emotional pressure. the voice, tongue, and lips. The paralytic speech Whoever fi nds himself forced to work beyond 37 Lecture 37 281 his individual strength, under tight time pressure, emphasized (p. 174). However, this is neverthe- taking on responsibilities beyond his capacity, less rare. Mostly, one is struck by the dominance must struggle with excitement, grief, and sor- of the twilight state, and the impossibility of row which can easily lead to impairment in patients being awakened from this state. The purely. Undoubtedly all-pervading careerism most obvious outward feature is clouding of the encourages such damage. From this fact, and sensorium, so that one can speak of a paralytic similarly from the increased prevalence of syphi- stupor [W]. Delirious features that add a peculiar litic infection, we can explain the signifi cant pre- colour are often no more than adjuncts derived dominance of the male sex, particularly amongst from the projection system through muscle or educated classes. The age of maximum risk is vocal tremor, and muscle rigidity. Instead of rest- between 30 and 50 years, especially 35–45. less movement, akinetic behaviour prevails. Alongside expansive autopsychosis we fi nd Of other allopsychoses, I must mention one paralytic mania; in this respect I refer again to my case in which the purest picture of presbyophre- earlier remarks (p. 219). Usually, the picture of nia showed up in its delirious form for several mania is coloured by simultaneous presence of days. Its nature was then clarifi ed as a case of fantastic grandiosity. At other times, it is not so paralysis, when a paralytic attack occurred, with pure, in that hypermetamorphosis or hyperkinetic subsequent specifi c paralytic symptoms derived symptoms accompany the mania. Nevertheless, from the projection systems. Instructive as the cases of almost pure mania of paralytic aetiology case is for relations between concepts, I intro- undoubtedly occur [ 4]; and after running its duce it only as a rare occurrence. Of the halluci- course, only very rarely is there complete recov- natory allopsychoses, I remember an equally rare ery, although there is often very good remission case involving a prostitute, who was in the clinic over a prolonged duration. At other times, the for 2 years as ‘chronic hallucinosis’ [Ed] to be mania subsides, but is transformed into a more presented as such every semester. You will restrained state of simple fantastic grandiosity. remember that, at her last presentation, to my sur- Affective melancholia may also have a para- prise, symptoms derived from the projection sys- lytic aetiology, even if it is not usually entirely tem became noticeable, which shed light for us on pure but rather an admixture with either mild the paralytic aetiology, a diagnosis which was delusions of relatedness, or symptoms of anxiety confi rmed during the subsequent course. psychosis, or both, these being foreign to pure Moreover, with regard to acute hallucinosis there melancholia. It is widely known that melancholia are cases with paralytic aetiology whose true sig- occurring in the age range 35–45 years raises sus- nifi cance becomes apparent only after the para- picions of paralysis. noid stage has ended, through striking defi cits, Depressive melancholia of paralytic origin has loss of retentiveness in memory, and paralytic already been mentioned. Here, too, delusions of speech disorders. However, exclusion of alcoholic relatedness are frequent additions, so that the dif- pseudoparalysis (see later) is often diffi cult, and ferential diagnosis of pseudomelancholia comes can be achieved only through a detailed knowl- into question. edge of the case history. Here, I want to mention Amongst paralytic allopsychoses, I stress the that the belief about the rarity of hallucinations in importance of paralytic delirium [W]. In contrast paralysis, which is still widely held, is quite to previously mentioned forms of paralytic psy- wrong. In our clinic, we have had many acute chosis, which occur preferentially in initial stages paralytic psychoses in which hallucinations were of the illness, the delirious condition can appear represented as strongly or even more so, than in in any phase of the illness, often quite suddenly corresponding cases of different aetiology. and unexpectedly. In most cases, it is therefore When discussing anxiety psychoses, I have not diffi cult to make a correct diagnosis. already stressed (p. 149), that they often have a Incidentally, the clinical picture can be the same paralytic aetiology. In particular, hypochondria- in all detail as that of Delirium tremens, as already cal anxiety psychosis raises suspicions of 282 37 Lecture 37

paralysis, as indeed does the large class of with hardly any Affective component, such as somatopsychoses which provides some of the having no head, no heart, no lungs, no stomach, most severe cases of paralysis. I already men- or being completely hollow, ‘only a tube’ [W], tioned examples, amongst which bouts of most as one educated patient put it so starkly. This severe somatopsychic disarray and disorienta- phenomenon stands on its own, in no way depen- tion occurred, one of which led later to a purely dent on the dementia, which may show up at demented form of paralysis (p. 163). However I about the same time. You will fi nd a typical case must also include here an earlier-mentioned case of this sort in the patient presentations from my (p. 74) of severe hypochondria that I cited as an Clinic [ 5]. However, for weeks, in an earlier example of residual hallucinosis, with a favour- acute stage of his illness, the same patient pre- able outcome after acute psychosis. Already, in sented the picture of most severe somatopsychic this fi rst illness there was a suspicion of paraly- disarray, admittedly not as agitation, but only as sis, since a history of syphilis was known. After almost total inaccessibility and helplessness, 5 years of perfect health, a relapse occurred, this while only occasionally were there isolated time taking the form of expansive autopsychosis expressions and actions pointing to total loss of whose deleterious course led to death within a bodily orientation. year. A case with the most rapid course deserves With regard to motility psychoses of the para- mention here. Initially there was a simple intes- lytic variety, I have already often mentioned the tinal somatopsychosis for some weeks gaining hyperkinetic variety. Usually their manic features, no fantastic signifi cance, and it was treated as a fantastic grandiosity, and hypermetamorphosis genuine intestinal disorder. However, this was are mixed together, this clinical picture develop- followed by a phase of hypochondriacal symp- ing mainly at a later stage of the illness, over sev- toms, which were quite fantastic in character: eral weeks. If worsening sensory psychosis The patient described schemes that were running reaches maximum severity, then hyperkinetic through his brain, in which an entire factory symptoms often join in with the paralytic aetiol- operation, with all manner of manipulations was ogy [6 ]. A relatively frequent event, I should going on; and soon it developed into the most emphasize here, is the isolated loquacity [W] of severe threatening hypochondriacal delusion. paralyzed patients [W], a loquacity linked to Amongst other things, the patient had been tor- fl ight of ideas, yet without any specifi c hyperki- mented over the last few weeks by a tiger lying netic shading, and also without actual mania. This on him and tearing away at his liver. The entire peculiar isolated loquacity in otherwise appar- course of illness in this 38-year-old man lasted 4 ently circumspect behaviour is limited almost months. It had been preceded 10 years earlier by completely to paralytics, the only exceptions syphilis and had been treated several times. known to me being the mildest cases of circular When total sensory psychosis occurred, as mental illness. Isolated hyperkinetic-parakinetic already mentioned (p. 273), acute worsening symptoms such as verbigeration, and stereotyped psychoses occurred, presenting in paralytic movements are met with very often in paralytics form, as a so-called ‘galloping’ [Ed] form of at later stages. You will remember that I have paralysis. Moreover, in such cases, at the very often used paralytics to demonstrate just such beginning or in the subsequent course, symp- symptoms. Even in their relationship with aphasia toms of threatening hypochondriacal delusions and paralysis, these cases are sometimes very become clear. During cases mentioned, Affective instructive. A type of Echolalia [W] may be states that are downright fearful made them- touched on briefl y here. It is occasionally seen in selves manifest, but sometimes, according to the paralytic patients at the same time as severe motor severity, with content of different coloration; and disarray, producing such a rapid ‘refl ex’ [Ed] in other cases, which fortunately are more fre- reaction that it is uttered simultaneously, rather quent, just the opposite is seen. The most severe than being repeated later. You will fi nd an exam- hypochondriacal presentations show themselves ple of this in patient presentations [7 ] from my 37 Lecture 37 283

Clinic. Incidentally, elsewhere one usually fi nds memory should not be forgotten. One of the more responses in echolalia limited to a one- to two- frequent possible combinations is one in which a syllable echo, sometimes in patients who are stage of fantastic grandiosity is followed by one already quite demented, and in expressionless of mania, with allopsychic disorientation, and paralytics. The following conversation would be fi nally a stage of marked hypochondriac symp- relatively typical: toms. However, just as often, a course is observed which is widely regarded as specifi c: cases of ‘Are you big?’ simple psychosis, distinguished from other ‘Big.’ simple psychoses only because of their rapid ‘Are you small?’ transition to dementia, and an admixture of ‘Small.’ above-mentioned symptoms derived from the ‘Are you a husband?’ projection system. Alternatively, it amounts to a ‘Husband.’ colourful mixture of ever-changing symptoms, ‘Are you a wife?’ and thus to a complex clinical picture related ‘Wife.’ etc. only remotely to each simple psychosis. The regular outcome in dementia here sup- Akinetic motility psychosis in progressive ports the view—highlighted at this time particu- paralysis is encountered relatively rarely in pure larly by C. Westphal [9 ]—that paralysis almost form, given that widespread muscle rigidity of always allows one to detect early signs of demen- paralysis originates specifi cally in the spinal tia. This is true even for cases developing just as cord. Hints of it are not so rare in later stages. simple psychoses, in which, by the nature of their However, in some cases that I know, prominent entire clinical picture, more detailed analysis is akinetic motility psychosis appeared as the fi rst often impossible in this regard. Nonetheless, the acute stage of the paralysis, followed by a second easiest symptom to establish here is reduced stage of agitated sensory confusion, and then a attentiveness, albeit not absolutely attributable to third stage of paralytic dementia with paralytic dementia. Even this loses its signifi cance when seizures. Every so often, you meet clinical pic- there is a very severe Affective reaction. On the tures exhibiting a peculiar mixture of a paralytic other hand, there are cases where no trace of defi - delirium with akinetic motility psychosis. cit or loss of attentiveness can be found, like the Moreover, akinetic-parakinetic conditions that examples of paralytic mania already cited. obtain special coloration through predominance Fantastic grandiosity in such cases does presup- of motor disorientation and disarray should be pose a defi nite defi cit in judgment, since the real- mentioned [8 ]. ity of things is apparently ignored; however, Finally, I do not want to omit mention of cer- herein we fi nd a contradiction that is no greater tain twilight conditions, with clouding of the sen- than the known fact (and in my opinion also sorium, which occur after paralytic attacks just as wrongly evaluated as a symptom of defi cit)—the they do after epileptic attacks; usually they have failure that all mentally ill people show, to criti- certain focal symptoms, for example, combined cize the veracity of their hallucinations. with signs of sensory aphasia, and they tend to Incidentally, you can fi nd an example of paralytic regress after lasting several days. mania without [Ed] fantastic grandiosity in my If we survey the whole picture of progressive Krankenvorstellungen [10 ]. paralysis, in so far as it can be regarded as a genu- In a substantial proportion of cases, progres- ine psychosis, then in most cases, it is virtually sive paralysis follows a course, not as one or sev- the very model of a composite psychosis, passing eral periods of psychosis, but as a more regular successively through all different stages. Each progressive dementia—sometimes more regular, stage may be a pure, simple psychosis; yet usu- sometimes more intermittent—a continuous form ally the clinical picture includes strange compo- that has led to it being designated Dementia par- nents, amongst which common falsifi cations of alytica [W]. I come back to this course when 284 37 Lecture 37

I deal with acquired dementia. In all such cases, progresses to provisional cure, that is, one lasting either prominent spinal symptoms or paralytic more than a year and a day. attacks with subsequent focal symptoms, can be The paralytic attacks [W], as Lissauer [12 ] found, occurring at the same time. Loss of mental (see later: p. 290) fi rst noted so incisively, acquisitions comes about here without the circu- undoubtedly signify an increase in acute features itous route of some other psychoses, just as does of a disease process, already known to be present. the gradual increase of direct focal symptoms in I come back later to discussing the anatomical organic mental illness; it begins with autopsychic fi ndings, but note here that current monographs defi cit, and ends in physical disorientation. deal with progressive paralysis in a wholly inad- Included in the latter course, the most uniform equate way on this one point, relapsing in a ques- and continuous trajectory is manifest as a curve, tionable way into antiquated ways of thinking. rising slowly in its extent, and actually belonging I restrict myself to the most essential clinical amongst the chronic psychoses. Whenever actual data: Paralytic attacks are sometimes simple psychoses appear during the course, the illness fainting episodes, or even just attacks of vertigo, always shows an acute character, at least tempo- while at other times they may be longer-lasting rarily, and Meynert [11 ] explicitly classed it with states of syncope, sometimes apoplectiform, the acute psychoses. sometimes epileptiform seizures. At the begin- Gentlemen! This description is still not ning of the illness, simple fainting or attacks of enough to capture the multifaceted picture of pro- vertigo are to be seen, almost always followed by gressive paralysis. It lacks some of the variations a short-lived speech impairment and faciolingual in intensity of the disease process that become paresis. After a duration of hours or days, such established in most cases of longer duration and, symptoms tend to dissipate. The speech disorder may represent stages in the more-or-less uniform can differ greatly in severity, but can amount to progression of the illness. These variations show motor aphasia for a short time. Apoplectiform up in opposite ways as remaining aspects of the seizures can be very similar to apoplectic attacks illness: as the so-called remissions, and as acute of organic brain diseases; they usually leave exacerbations—the so-called paralytic attacks. behind hemiplegia or hemiplegic symptoms in a Remissions [W] are often immediate outcomes of wider sense, such as hemianopia, sensory or acute paralytic psychoses, most often with para- motor aphasia, unilateral paralysis of the trunk, lytic grandiosity, or specifi c paralytic autopsy- tactile anaesthesia of one hand, etc., generally chosis as already mentioned, or of paralytic matching the usual picture of fresh hemiplegia. mania. One can usually differentiate remissions Epileptiform attacks are sometimes actual [Ed] as being good or bad, by indications of insight epileptic seizures, resembling exactly those of into symptoms of illness in acute psychosis. If epileptic neurosis; however, they show a remark- insight into the illness does not appear, while just able propensity for recurrence, and meet criteria the acute symptoms of illness disappear or abate, for Status epilepticus [W]. More often the pattern remission usually lasts only for weeks or months. of the attack corresponds more closely, or However, in exceptional cases, even this incom- entirely, to that of the so-called cortical epilepsy, plete remission (in an anatomical sense), as in that initially, without loss of consciousness, a judged by the criterion of insight can lead to specifi c muscle area such as the faciolingual defi nitive recovery. This was so in a case known region is affected, the onslaught then spreading to me for 13 years, in which lack of insight in the further with the familiar regularity. In addition, early years was shown through repeated com- these bouts of cortical epilepsy tend to leave focal plaints, sometimes quite extreme, about our symptoms in their wake, including, quite remark- clinic. Good remissions are characterized not ably, even those of a sensory nature, such as sen- only by insight into the illness but also some- sory aphasia or hemianopia, and often also times by almost complete disappearance of defi - combined sensory symptoms right up to the level cit symptoms. Quite often such a remission of asymbolia. Such focal symptoms tend to 37 Lecture 37 285

disappear rapidly, often within a few hours; but projection system is quite characteristic, espe- once seizures of this type have appeared, they cially if the latter show up in near-complete form, tend to recur in just the same form. Accompanying and at the same time, dementia is already promi- focal symptoms then tend to last longer and lon- nent. If cortical or spinal symptoms are rare, the ger, and fi nally to remain as permanent features. following points should be considered: Chance It is from such cases that Lissauer [ 12 ] derived occurrence should always be considered when a his fundamental views on paralytic seizures. That spinal disease coincides just with a psychosis, for bouts with bulbar and spinal character can occur example, when a person with Tabes [W] or spas- in progressive paralysis was fi rst shown by Cl. tic spinal paralysis or a chronic myelitic focus Neisser [13 ] in a commendable work. Severe suffers acute psychosis with no internal connec- paralytic seizures are also associated with a sig- tion between the two illnesses. In such a chance nifi cant rise of body temperature. concurrence (which, in my experience, is If we start by disregarding focal symptoms extremely rare), the case history will then indi- arising in the wake of the paralytic seizures, then cate that an independent spinal cord disease each case is clinically important as a portent of existed long before. More frequently, actual para- detectable emergence of dementia. Following a lytic psychosis is combined with pronounced paralytic attack, but especially after each series of paralysis arising in the spinal cord, and simple such attacks, there is a stage of stupor, whose paralytic dementia is most likely to develop. regression follows slowly, step by step to a degree These cases have been well distinguished as a of dementia more severe than seen before. With worsening form [W] of paralysis, or have been regard to the frequency of paralytic seizures, there assigned the name Taboparalysis [W]. Meynert is hardly a single case where they are not at least ascribed to them a particularly rapid course, evi- hinted at. About half of all attacks are quite prom- dently having in mind only cases of actual para- inent, while a lasting residue of distinct focal lytic psychoses, not those of simple paralytic symptoms is seen in only a fraction of cases. After dementia. If there is no historical evidence of bed-rest as treatment was generally introduced, long pre-existing spinal cord disease, then, detec- paralytic attacks in our clinic became relatively tion of the so-called dorsal column or lateral col- rare. One encounters exceptional cases where umn symptoms, or more defi nitely, a combination apoplectiform or epileptiform seizures with sub- of both with the near-universal symptom of refl ex sequent focal symptoms dominate the clinical rigidity of the pupil in paralytic disease of the picture, so much that they must be attributed to spinal columns, the diagnosis of a paralytic psy- organic brain diseases, according to clinical crite- chosis can be made safely. A mere difference in ria. Such atypical cases [W] of paralysis have pupil size, shown by the existing light reaction likewise been studied in greater detail by Lissauer has long been known to have no diagnostic value. [14 ], and their anatomical fi ndings established. It should be noted that certain symptoms of In the course [W] of paralytic psychoses, the Tabes , such as gait disturbance, or the Romberg clinical form taken by each illness has some infl u- sign can be completely concealed by the increased ence, as I repeatedly indicated. Moreover, the sense of personal agency in paralytic mania. duration of individual cases, right up to the lethal Similarly, it should be considered that psychosis outcome, differs widely and can range from a few could coincide with cortical symptoms just by weeks—galloping forms—to more than 10 years. chance. In this respect, it is particularly important On average, a large proportion become patients to recognize that each earlier phase of motor for a period of about 1¼ years from the time of aphasia, though outlasted successfully, and other- entry into institutional treatment. wise well-compensated, can leave behind promi- Gentlemen! Diagnosis [W] of progressive nent, long-term, stumbling over syllables. It has paralysis is easy in most cases, since the combi- already been emphasized repeatedly that certain nation of a distinct psychosis with the above- paralytic psychoses meet diagnostic criteria mentioned symptoms deriving from the through their specifi c clinical form. 286 37 Lecture 37

The main diffi culty in diagnosis is not psycho- occurred earlier, or that signs of mental disorder ses of other aetiology, but organic brain diseases. had been noted. If you learn of any earlier- An especially diffi cult case here is that mentioned striking dementia dating from a particular point earlier, of atypical paralysis designated by in time, and if you are dealing with the most com- Lissauer as ‘abnormally localized’ [W]. Such mon age of paralysis between 35 and 45 years, cases are defi nitely not to be diagnosed as deriv- then the probability is very high. Usually the ing from foci of organic brain disease, especially behaviour of the pupils can be used diagnosti- when you consider their great rarity, compared to cally, because pupillary rigidity is one of the most the relatively common occurrence of cortical epi- common spinal symptoms of paralysis [3 ]. Other lepsy in tumours of the cortical mantle. Apart spinal symptoms are unlikely to be useful, since from such cases, the main task is differential the apoplectic attack can lead either to a fl accid- diagnosis from cerebral syphilis, and probably as ity or—admittedly more rarely—to some degree much from gumma, as from syphilitic endarteri- of limb rigidity. However, it should be noted that tis, or from the frequent combination of both. The the very hemiplegia of a paralytic attack can be main criterion here is maintained insight into the identifi ed because, very early on—that is after illness, which is found for cerebral syphilis. If 1–2 days—it may be associated with reduced there is even any [Ed] underestimation of exist- passive mobility. The timing depends on return ing focal symptoms, one is led to suspect paraly- of spontaneous movement, which is always to be sis. The speech disorder is not such a useful expected very soon after the paralytic attack. criterion, for the reason given above; rather more Moreover, the hemiplegia of a paralytic attack useful is the very characteristic disorder of hand- has no special features; at most it could be writing, arising from a combination of irregular emphasized that in a paralytic attack conjugate tremor and paragraphia. If focal symptoms have deviation of the eyes, and sometimes of the head developed slowly with no previous apoplectiform as well, to the opposite side is more common than or epileptiform seizures, this favours neurosyphi- in attacks of the so-called organic brain diseases. lis rather than paralysis. By its very nature, the The hemiplegia of the paralytic attack is usually clinical picture of paralysis can develop later out quite short in duration, sometimes only a few of that of cerebral syphilis; and corresponding to hours, but more often a few days. It usually tends this, transitions between the two illnesses occur to regress completely, as does existing motor quite often. You will fi nd an instructive example aphasia or other focal symptoms. Therefore, you of this in my patient presentations [10 ]. You will can understand the great importance of having a readily grasp that this question is of utmost proper diagnosis, to predict the near future. Of importance, since in paralysis we have an illness course prognosis for the distant future in a para- that is no longer infl uenced by specifi c treatment, lytic attack is much more gloomy. On the other whereas cerebral syphilis requires most energetic hand, if you are faced with an apoplectic or an anti-syphilitic treatment, but is then curable. epileptic attack, or Status epilepticus [W], then Diagnosis of a paralytic attack claims an inde- the differential diagnosis is to be made in com- pendent signifi cance. Gentlemen! You are so parison with genuine or symptomatic epilepsy or often called to deal with a so-called ‘stroke’ [Ed] the so-called eclampsia where, in any case, the that your fi rst question must be whether you are medical history—and where necessary a urine dealing with a possible paralytic attack. If you test—will provide evidence. Blood sampling is fi nd that the attack is not simple apoplexy but absolutely contraindicated in a paralytic seizure. also includes increase in temperature and epilep- Gentlemen! In terms of treatment [W] of tiform symptoms, then paralysis becomes more paralysis, certain tasks fall to the medical practi- probable. As always, a careful case history is the tioner. I confi ne myself just to general measures, only way to fi nd out whether familiar prodromes mainly in the fi eld of prophylaxis. If you know of paralysis had preceded the attack, or whether a that your patient has previously survived syphilis, dizzy spell with transient speech disorder had and you fi nd the prodromal symptoms I have 37 Lecture 37 287 described, or other symptoms of the so-called mainly the end result of a fl orid anatomical pro- cerebral neurasthenia, or if there is perhaps a cess, just as cirrhosis forms the outcome of liver marked predisposition to disorders of the nervous disease. The outcome is atrophy of the cerebral system, or to psychosis, you must not shy away cortex, most obviously in its documented loss of from the most drastic measures to counter the weight. This loss is not spread evenly across all impending danger. However, anti-syphilitic treat- parts of the cortical mantle, but, averaging across ment is indicated only when existing syphilis can brains, the greatest shortfall occurs in the frontal be detected, be it in the brain, or in other organs; lobe—although it should be noted that the frontal and then it is to be carried out with the utmost lobe in Meynert’s [11 ] sense also included the caution, so that any weakening of the constitu- anterior central gyrus. However, this average tion, especially a decrease in body mass, is conceals the fact that isolated cases preferentially avoided. The fi rst condition for initiation of such involve temporal, parietal, or occipital lobes; or, treatment must therefore be that the patient cur- for these three lobes, or when there is mainly a tails his occupation, and soon fi nds himself in the bilateral illness with the same localization, role of patient. Any measures applied while the ‘abnormal localization’ [W] does occur, as the patient pursues his occupation are often quite atypical cases of Lissauer prove. I have assem- unhelpful. The most expedient is any invasive bled the following values from Meynert’s table, treatment combined with long-term bed-rest and which has never been surpassed by more recent over-feeding. If there are no traces of fl orid syph- authors in the care taken in weighing, and in the ilis, antisyphilitic treatment is contraindicated. number of cases. In a substantial proportion of However, potassium iodide administered in small cases, weight loss also involves the brain stem. doses (from ½ to 1 g per day) over a long period, The cerebellum seems always to be least affected, appears to work favourably. Nevertheless, the so that from it, one has fi gures for comparison main thing is to enhance nutrition and correct with values for other regions. those noxious infl uences that we have come to Taking brain-weight of manics to be approxi- recognize as immediate causes of paralytic psy- mately normal, their averages (in grams) were: choses. Should occupational activities bring such damaging effects with them, the patient should Total Cerebral not shy away from interrupting them for a half to weight cortex Brainstem Cerebellum a full year and, when this is ineffective, should 39 males 1,376 1,082 148 146 not fl inch from giving them up altogether. An 53 females 1,221 957 131 133 investigation of spinal or cortical symptoms of paralysis will usually provide the criteria you Paralytics, on the other hand, gave averages of: need, to decide about such interventions. If you no longer have any doubt, and paralysis Total Cerebral is established to be present, it is your job to bring weight cortex Brainstem Cerebellum it to an end as quickly as possible, since any delay 145 males 1,215 933 135 146 results all too frequently in material and social ruin 29 females 1,068 819 119 130 of the whole family. If you are in any doubt over whether and when to bring the patient into a men- The parts of the cerebral cortex had the tal institution, it is always safest to decide in favour following proportions amongst manics: of this. Admittedly, in many cases, a specialist will postpone the date of containment for a long time. Total Frontal Temporal Occipital Anatomical fi ndings [W] in progressive paral- weight lobe lobe lobe ysis are best described by dividing them into Among 1,376 450 251 380 macroscopic and microscopic. The macroscopic men fi ndings are [W] prominent only after the illness Among 1,221 404 213 339 has run a prolonged course, since it represents women 288 37 Lecture 37

Amongst paralytics, on the other hand the with caution, to avoid the decortication. Only a proportions were: small proportion of cases prove to be exceptional, where examination of thin slices reveals real Total Frontal Temporal Occipital adhesion of the pia to the brain surface. It is weight lobe lobe lobe known that the same phenomenon of decortica- Among 1,215 380 216 337 men tion occurs in other conditions favourable for Among 1,068 323 202 294 maceration, especially when cortical tissue is women pressed against the tightly stretched translucent pia by Hydrocephalus internus [W], in meningitis or by a brain tumour, and the convolutions are Apart from loss of weight, atrophy is expressed fl attened outwards and against one another. In by visible change on the brain surface and in the contrast to these main cases of decortication, one ventricles. On the brain surface there is more or often also encounters the opposite reaction, of a less extensive loss of cortical substance, distrib- markedly thickened pia, richly saturated with uted in a very irregular way. Often the entire cere- fl uid and usually also hard to tear. In these cases bral cortex, and at other times large sections of it, the pia tends to be very easily removed from the show reduction in the cortical grey substance of brain surface without any loss of substance. up to half or a third of the normal width; occa- The gyri differ in their prominence, with many sionally you even fi nd scattered locations where depressions and pleats, corresponding to the cortical substance is missing entirely. The medul- grade of atrophy; their texture is apparently lary strips of the gyri and the common underlying thickened. In all old cases, you also fi nd expan- white matter are likewise revealed as signifi cantly sion of ventricles and Hydrocephalus internus narrowed. Corresponding with this atrophy of the [W], a sign of general atrophy. Ventricular walls cerebral cortical substance, there is usually an are very often abnormally fi rm, presenting the so- increase in free cranial fl uid, as Hydrocephalus called Ependymitis granulosus [W] found espe- externus [W]. cially at certain preferred sites, and this can even The reaction of the pia mater shows two con- extend to the fourth ventricle. I hasten to add trasts. Most obvious by far, you fi nd that the pia that despite this fi nding on the ventricular sur- is relatively soft, although often cloudy, the latter face, hydrocephalus is no more than a result of again especially over the frontal lobes, and thus diffuse atrophy, arising to fi ll the vacuum. We the pia adheres so fi rmly to the brain surface that also fi nd such consequences in the roof of the it appears to have fused with it. In any case, if you skull and in the dura mater. In the roof of try to separate the pia, shreds of brain tissue the skull diffuse thickening is often present with remain adhering to it, often to a great extent, but no other structural deviation. Sometimes, how- often also only on the crests of the gyri [Ed], and ever, there is a more-or-less widespread loss of there remains an ulcerated cortical surface, which diploë, and a type of eburnation. This fi nding soon turns reddish on exposure to the air. This might be interpreted independently as syphilitic so-called decortication [W] was formerly taken bone disease. Frequently changes of the so-called to be evidence of widespread infl ammation of the Pachymeningitis haemorrhagica [W] are to be brain surface—‘periencephalitis’ [W] or ‘menin- found on the dura mater, usually by chance, and goencephalitis’ [W]. People have usually dis- undiagnosable in life. These consist in part of iso- tanced themselves from this view, since lated blood stains, and their organized remnants, microscopic examination does not confi rm the and in part as recent signs of major bleeding next interpretation. From experiences in our clinic, to multiple membranous formations left as resi- this is almost always a sign of maceration, which dues from previous haemorrhagic episodes. Only takes a little time to form. If one has the opportu- rarely does the extent of the bleeding reach as far nity to perform an autopsy soon—or only a few as the base of the skull; usually it is mainly the hours—after death, it is almost always possible, convexity that is affected and one hemisphere 37 Lecture 37 289 can also appear fl attened by such a pool of blood. In what follows, I restrict myself just to the However, it is most likely that atrophy of brain quintessential, and most important microscopic substance and the vacuum so created fi rst pre- fi ndings, stressing that I have secure knowledge cipitates these bleeds. As regards symptoms of of modern neuroscience teaching and how it is haemorrhagic pachymeningitis, I have already applied to disorders of peripheral nerves and spi- noted that, in my own view, even cases in late nal sections in degenerative neuritis. Primary dis- stages of paralysis with very prominent anatomi- integration and necrosis of neural elements, cal changes are usually undiagnosable. Only in analogous to degenerative neuritis in the periph- the case of unilateral papilloedema, which has eral nervous system, is, from the onset, and often been observed when the bleed extends right throughout the course, the essential process into the sheath of an optic nerve (according to determining all symptoms of paralysis. Earlier Fürstner [15 ]), will diagnosis sometimes be changes in supporting vascular tissues and in possible. fi bres of glia-like cells, which have been taken as In some cases, especially in the atypical form signs of primary infl ammation, are secondary or of paralysis mentioned above, a gross anatomi- reactive to changes resulting from the primary cal fi nding of marked atrophy of the optic thala- necrosis of neural structures. They are thus con- mus on one or on both sides can be seen in sequences and outcomes of the illness, a quasi - addition to the above fi ndings. The white scar [W] formation, replacing healthy tissue, not Stratum zonale [W] of the thalamus may thus the actual disease. The disease is generally pro- appear grey over large stretches, the appearance gressive and pernicious, so that I had earlier [ 20 ] being altered so much that for example the pul- drawn a parallel between it and progressive mus- vinar protrudes like a sharpened ledge; and the cular atrophy. We can explain this by the pres- texture becomes spongy. Lissauer’s work grew ence of a constantly-unfolding toxic effect which from such fi ndings. has the specifi c effect of causing degeneration of All the above changes can easily be regarded the neural elements of the central nervous sys- as sequelae of the underlying process of tissue tem, mostly in the cerebral cortex. Necrotic decay destruction as revealed in microscopic fi ndings is detectable fi rst in axons, but they are to be [W], whereas earlier, following Virchow’s [16 ] regarded as the main targets of toxicity only doctrine of infl ammation, the belief was always because they are dependent on nerve cell bodies that there was a primary process of infl ammation for their nutrition. Corresponding to this, the fi rst in the supporting vascular tissues, and in the success was to detect degeneration of nerve neuroglia. For true insight into the real process fi bres; and indeed we have known since Tuczek we should thank Exner [ 17 ], for his discovery of that axons are usually lost initially in the most the abundance of myelin in the cerebral cortex, superfi cial cortical lamina that which Meynert and Tuczek [ 18 ], for his work based on this. [ 21 ] identifi ed as the fi rst, purely grey lamina. Perfection of Weigert’s [ 19 ] method of staining Later, the network of fi ne fi bres in supraradial myelin sheaths, and the work of Lissauer have and intraradial layers is affected, and fi nally the provided us with the most signifi cant advances radii themselves. At fi rst, cell bodies seem to be in our knowledge. (Preparatory work for a com- quite unchanged. However, in later stages, one prehensive publication is included in part in the concludes [20 ] that there is signifi cant cell loss in posthumous draft of a habilitation thesis. A revi- all layers of the cortex, so that the cell layers sion of this manuscript, often understandable become uniformly narrowed. In addition, I have only to the most well-informed, is one of the always found cortical sites where the number of next tasks for the workers in my clinic. It will ganglion cells is visibly reduced, and the micro- emerge from this, just how far Lissauer was scopic appearance of the cortex is changed in ahead of all his co-workers in his penetrating such a way that, instead of the normal, regular, knowledge of the paralytic process. His only and delicate delineation, a disorganized jumble publications on this are given below: [12 , 14 ]) of fi bres, cells, and glial components is found. 290 37 Lecture 37

Now it is known from the work of Nissl and his involved sites where myelin degeneration of the successors [22 ], that ganglion cells of the cortex, cortex was also prominent. in every case of paralysis, also suffer severe In Lissauer’s cases, thalamic tissue also changes. (Nissl’s methylene blue stain is equiva- showed itself to be abnormal, providing evidence lent in its importance for pathology of the gan- that secondary degeneration occurs in subcortical glion cells as is Weigert’s myelin sheath stain. ganglia whose importance von Monakow has The reader will fi nd information about the method rightly emphasised. Moreover, this degeneration in refs. [23 ] and [ 19 ]; see also [23 , 24 ].) However, leads to disappearance of axons and cells, so that credit for fi rst fi nding cell shrinkage of the only coarse spongy tissue remains, within which entirety of the cortical layers undoubtedly goes to the regular, delicate markings of thalamic tissue Lissauer. This researcher succeeded in proving, are completely missing. According to the type of in cases of atypical ‘abnormally localized’ [W] focal symptom, different regions of the thalamus paralysis, a laminar degeneration in those cortical showed themselves to be changed in this manner, regions in the parietal and occipital lobes which confi rming Monakow’s [ 25 ] theory of the tha- were identifi ed as the point of onset of the focal lamic nuclei. The anterior region of the thalamus symptoms. Cell loss in these cases did not extend and the lateral geniculate body appeared to be continuously over the cortex, but came in unaffected by secondary degeneration in cases irregularly-distributed patches, and involved mentioned, while the medial geniculate body mainly layers of densely arranged, small pyra- behaved as the other nuclei of the thalamus, with mids, arranged in rows, and increasing in size secondary degeneration and sensory aphasia as a inwards, in other words, Meynert’s second and result of the paralytic disease of the temporal third layers. Macroscopically this can be identi- lobe. fi ed on the hardened brain as a bright stripe run- Lissauer’s fi ndings show that the paralytic ning parallel with the cortex, in the middle of the process can differ greatly in intensity and extent, grey cortical substance, darkly stained by chro- so that, at certain locations, it can progress to mium solution. These cases also enabled Lissauer actual paralytic focal disease in the cortex and to show that secondary degeneration of myelin- that this progression becomes manifest in the ated fi bres from these locations could be traced form of paralytic seizures. The white matter through the otherwise intact medullary white pathology consistently shows the hallmarks of matter to other locations, and especially down- secondary degeneration. (This sentence from wards into the corona radiata and internal cap- Lissauer fi nds striking confi rmation in the work sule; and that generally changes of the white of Starlinger [ 26 ]). Thus some fundamental matter in paralysis are consistently based on sec- empirical facts have been gained, that are no less ondary degeneration. Clinically, Lissauer’s atypi- important than Tuczek’s work. cal cases were distinguished, in that mainly only Regarding the localization of the paralytic focal symptoms of the parietal and occipital lobe process, the following should be noted. In all his were present, namely loss of tactile sensation and cases, Tuczek found the frontal lobe to be hemianopia, and that these had developed in con- involved, and had come to the view that fi bre loss nection with paralytic attacks in the manner indi- generally progressed in an antero-posterior direc- cated above. ‘The paralytic attacks then appear as tion, and would go no further than the region of a sudden violent surge of the paralytic process in the central gyri. However, in contrast, Zacher certain cortical territories.’ That the changes in [27 ] had already found that the parietal, occipital, the white matter were largely to be regarded as and temporal lobes were also abnormal, systematic, was already highlighted by Tuczek, sometimes more so than the frontal lobes, and who emphasized especially that the degeneration that Tuczek’s statement that fi bre loss always he demonstrated in six cases, in the shortest asso- started in tangential fi bres of the outermost corti- ciation bundle lying just deep to the cortex— cal layer, only later to involve the deeper layers, Meynert’s Fibrae propriae [W]—always had no general validity. Lissauer’s fi ndings also 37 Lecture 37 291 suggest that the paralytic process has a very lymphatic system. It drains mainly into areas irregular, patchy distribution, by no means formed by glial sheaths and areas for collection beginning exclusively in the outermost cortical on the brain surface. Here the accumulated lymph layer. Common to virtually all cases, however, is fl uid of dying tissue changes by coagulation and a remarkable fi bre loss in the insula, Broca’s hyaline necrosis, but it also evokes hyperplastic gyrus [ 28 ], and the lower extent of the central processes in the adjacent pia and its vessels. In gyrus, corresponding to clinically detected consequence of the latter, partial adhesions of the speech disorder, and paresis of the faciolingual brain surface to the pia mater occur, with sclerop- area in almost all cases. Such mainly focal local- athy of large sections of the epicerebral space, ization, as in the other atypical cases, is however relocation of the confl uences of extra- and intra- very rare. vascular lymph spaces.’ It is readily apparent that Moreover, it is noted that the paralytic process in this way the outermost cortical layers can easily is not limited to the cerebral cortex: Beyond the succumb to a maceration process after death. thalamus, other subcortical regions can also be Moreover, it seems to me that Binswanger overes- affected. Thus, A. Meyer [29 ] demonstrated loss timated the infl uence of these processes on the of myelinated fi bres in the cerebellar cortex; and course of the disease, and he is particularly mis- H. Schütz [30 ] showed that the myelin of the peri- taken in their application to paralytic seizures. aqueductal grey matter and motor cranial nerve Gentlemen! If you ask me what fi nal result is nuclei had been attacked. Perhaps the diversity of to be drawn from these cortical fi ndings for the paralytic seizures is connected with this. theory of illness, it is briefl y as follows: The para- Since Weigert has taught us about normal dis- lytic process almost always leads to rapid loss of tribution of glial cells in the brain, we are also in neural elements of the cerebral cortex, which is a position to evaluate also the localization of glial signifi cant, but subject to great local variation in cell proliferation. Amongst other things, Meyer’s its extent. According to Meynert [11 ] loss of fi nding in the cerebellum is confi rmed in weight within a year amounted to about 100 g. Weigert’s [31 ] great work. Proliferations of glia Corresponding to this is the dementia that accom- arise everywhere where neural parenchyma have panies the course of the illness in most cases degenerated; therefore, the location of this indi- from the outset. This dementia is therefore depen- cates localized loss of nerve cells. At a particular dent on the extent, not the localization of the stage in such proliferation, we have observed the paralytic process, and is thus to be regarded clini- occurrence en masse, of giant astrocytes; and cally in its entirety. Preferred localities for early indeed they correspond to the more recent stage, attacks, as described above, correspond on the seen temporarily soon after loss of neuronal tis- other hand to the most frequent cortical symp- sue. Later, for the most part, they disappear again, toms derived from the projection system. With but a proliferation of fi brous glia remains perma- this concept there need be no surprise that Zacher nently. In some cases, however, such a glial reac- also found extensive loss of fi bres in the cerebral tion fails to occur; and all that remains are regions cortex among senile, alcoholic, and epileptic with a wide-meshed net of normal glial fi bres demented patients, and that this has been conforming rarefi ed stripes or patches. fi rmed many times since. Here too, breakdown of Recently Binswanger in his careful monograph the clinical phenomena coincides with anatomi- [32 ] obtained similar results with regard to the cal fi ndings. primary parenchymatous nature of the disease. As for the changes in the spinal cord, they are We learn from him about occurrence of infl amma- certainly based in part on secondary degenera- tory changes and, where it applies, disintegration tion, for example when, in late stage of the ill- of adhesions of the pia to the cerebral cortex. ness, general helplessness occurs, with muscle ‘Destruction of cortical tissue, with its conse- rigidity and increase in tendon refl exes. On the quences, leads to greater accumulation of patho- other hand, the above information on premature logically-altered lymph fl uid in the extravascular recurrence of spinal symptoms in paralysis 292 37 Lecture 37 reveals that severe illness of the spinal cord often 14. Lissauer H. Klinisches und Anatomisches über die takes place independently. The connection with Herdsymptome bei Paralyse. Vortr Ver ostdtsch Irrenärzte am 2.3.1891. Zbl Nervenheilk Psychiat. the paralytic process in the brain is evidently the 1891;2:295–7. production of the same active toxin. We also 15. Fürstner C. Weitere Mitteilungen über den Einfl uß know from the Tabes dorsalis [W] that it, like einseitiger Bulbuszerstörung auf die Entwicklung der paralysis, is a sequela of syphilis. That at one Hirnsphären. Arch f Psychiatr. 1882;12:612. 16. Virchow R. Die Rolle der Gefässe und des Parenchyms time only the spinal cord is affected, while at in der Entzündung. Virchows Arch. 1897;9(3):281. other times, the brain is involved exclusively or 17. Exner S. Über das Sehen von Bewegung und die predominantly in a form of paralysis, and that Theorie des zusammengesetzten Auges. Sitzungsber Tabes [W] sometimes persists as such, while at Wiener Akad Wiss. 1876;72(3):156–90. 18. Tuczek F. Beiträge zur pathologischen Anatomie und other times after existing for many years, can still zur Pathologie der Dementia paralytica. Berlin: L lead to paralysis, must be considered as depend- Schumacher; 1884. ing on the respective predisposition of different 19. Weigert C. Die Markscheidenfärbung von Fibrin. individuals and particularly on the functional Ergeb Anat Entwickl Gesch. 1897;6:3–25. 20. Wernicke C. Lehrbuch der Gehirnkrankheiten, für harmfulness of the process. Aerzte und Studierende. Kassel: Fischer; 1881. p. 539. 21. Meynert T. Der Bau der Grosshirnsrinde und seine örtlichen Verschiedenheiten, nebst einem pathologisch-anatomischen Corollarium. Leipzig: References Engelman; 1887. 22. Nissl F. Mitteilungen zur pathologischen Anatomie 1. Kahlbaum KL. Die Gruppierung der psychischen der Dementia paralytica. Arch Psychiatr. 1896;28: Krankheiten und die Eintheilung der Seelenstörungen. 987–92. Danzig: AW Kafemann; 1863. 23. Nissl F. Über eine neue Untersuchungsmethode des 2. Wernicke C. Krankenvorstellungen aus der psychia- Centralorgans zur Feststellung der Localisation der trischen Klinik in Breslau, vol. 3. Breslau: Schletter; Nervenzellen. Neur Centralbl. 1894;13:507–8. 1900. Case 14 is a good example of this fantastic 24. Alzheimer A. Beiträge zur pathologischen Anatomie grandiosity. der Hirnrinde und zur anatomischen Grundlage eini- 3. Gaupp RE. Über die spinalen Symptome der progres- ger Psychosen. Mschr Psychiat Neurol. 1897;2:90. siven Paralyse, Psychiatr Abhandl, vol. 9. Breslau: 25. von Monakow C. Gehirnpathologie. Wien: A Holder; Schletter; 1898. 1897. 4. Wernicke C. Krankenvorstellungen, vol. 3, Case 30 a 26. Starlinger J. Zur Marchi-Behandlung; ein Apparat zur case of paralytic mania, is relatively pure. 1900. Zerlegung in dünne, vollkommen plnparallele Scheiben. 5. Wernicke C. Krankenvorstellungen, vol. 3, Case 26. Z Wiss Mikrosk Mikrosk Tech. 1899;16:179–83. 1900. 27. Zacher. Über das Verhalten der markhaltigen 6. Wernicke C. Krankenvorstellungen, vol. 2, Case 8 is Nervenfasern in der Hirnrinde bei der progressive a good example of paralytic hyperkinetic motility Paralyse. Arch Pychiatr Neurol 1884;18:p. 60, psychosis. 1899. p. 348. 7. Wernicke C. Krankenvorstellungen, vol. 2 28. Broca PP. Nouvelle observation d’aphémie produite Supplement, Case 18. 1899. par une lésion de la moitié postérieure des deuxième 8. Wernicke C. Krankenvorstellungen, vol. 2, Case 18 is et troisième circonvolutions frontales gauches. Bull an example. 1899. Soc Anat. 1861;36:398–407. 9. Westphal CFO. Über einige durch mechanische 29. Meyer A. Ueber Faserschwund in der Kleinhirnrinde. Einwirkung auf Sehnen und Muskeln hervorgebrachte Arch Psychiat Nervenkr. 1890;21(1):197. Bewegungs-Erscheinungen. Arch Psychiatr Nervenkr. 30. Schütz H. Anatomische Untersuchungen über den 1875;5:792–802. Faserverlauf im centralen Höhlengrau und den 10. Wernicke C. Krankenvorstellungen, vol. 3, Case Nervenfaserschwund in demselben bei der progres- 30. 1900. siven Paralyse der Irren. Arch Psychiat Nervenkr. 11. Meynert T. Klinische Vorlesungen über Psychiatrie 1891;2:525. auf wissenschaftlichen Grundlagen für Studierende 31. Weigert C. Beiträge zur Kenntnis der normalen men- und Aerzte, Juristen und Psychologen. Vienna: schlichen Neuroglia. Frankfurt: Diesterweg; 1895. Braumüller; 1890. 32. Binswanger O. Die pathologische Histologie der 12. Lissauer H. Sehhügelveranderungen bei progressive Grosshirnrinden-Erkrankung bei der allgemeinen pro- Paralyse. Dtsch Med Wochenschr. 1890;16:561–4. gressiven Paralyse mit besonderer Berücksichtigung 13. Neisser C. Die paralytischen Anfälle. Klinischer der acuten und Frühformen. Jena: G Fischer; 1893. Vortrag. Stuttgart: F. Enke; 1894. p. 169. Lecture 38 38

• Notes on the aetiology of acute psychoses the puerperium, and lactation usually act as • Aetiological groupings of the psychoses disease- inducing factors in this way, but the same • Alcoholic psychosis can be said for untimely or excessive low-fat or • Alcoholic jealousy mania vegetarian diets, prolonged gastritis, continued • Alcoholic stupor grief and sorrow interfering with sleep and nutri- • Pseudoparalysis tion, and fi nally, acute illnesses. Amongst the lat- • Cocainism ter, endemic infl uenza should be highlighted, • Polyneuritic psychoses through lead poison- because, it meets at once the prerequisite of pro- ing and arsenic poisoning, in tuberculosis and ducing rapid reduction in body weight. syphilis Monographs on various acute illnesses as causes • Hereditary psychoses of psychosis teach you that it would be quite • Epileptic psychoses wrong to propose a regular relationship between • Perseveration this type of illness and the clinical forms of subsequent acute psychosis. Nevertheless, if, by way of example you speak, hear, or read of ‘exhaustion psychoses’ [Ed] as a specifi c clinical entity, Lecture this is the same misunderstanding to which I have already repeatedly drawn attention. Even more Gentlemen! can one say, with some justifi cation, that in the Progressive paralysis deserved a detailed dis- sense just discussed, by far the majority of acute cussion; but I repeatedly made reference to the psychoses are ‘exhaustion psychoses’ [Ed]. aetiology of acute psychoses. My lecture today is Of course, a certain degree of inanition due to a summary, with some expansion of my earlier such illnesses or other injurious infl uences is usu- comments. ally no more than a trigger. What is also needed is Every specialist is forced to some general a pre-existing disposition, before mental illness notions: Very often we fi nd some debilitating occurs. This predisposition may be either congen- event being specifi ed as a proximate cause or ital or acquired. You will long have known the occasion for outbreak of acute psychoses, that is, major role that innate predisposition or (according some infl uence that signifi cantly reduces the to Griesinger [1 ]) heredity plays in mentally ill nutritional status and general wellbeing in a short people, and in the so-called functional nervous space of time. Blood loss, or repeated blood disorders. Evident degeneration, which can be losses through Menstruatio nimia [W] pregnancy, followed in many families, is based on this. I want

© Springer International Publishing Switzerland 2015 293 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_38 294 38 Lecture 38 to make just one point here, that I still do not fi nd certain toxic effects, foremost amongst which is suffi ciently emphasized: that a strong hereditary prolonged alcohol abuse. predisposition may be present without its ever I have repeatedly drawn attention to the fact leading to acute or a chronic psychosis. However, that times of normal physical change, such as in all cases where it is present, a doctor must bear puberty, menopause, and fi nally senescence, are in mind the need for his patients to avoid, as far as particularly likely to predispose to onset of psy- possible, aforementioned adverse triggers. choses, based on the great importance that bodily Nonetheless, hereditary disposition does not in changes have for consciousness. This widespread itself enable diagnosis of a mental illness to be general predisposition will certainly have an made. I should not forget to mention here that I effect, as it does normally and even when acquired fi nd phthisis to be specifi ed surprisingly often disposition already exists through previously among the forerunners of acute psychoses; yet it mentioned organic changes. is a well-known fact that this does not generally After such general preliminary remarks, we worsen the prognosis of the fundamental heredi- can proceed to study the infl uence which certain tary predisposition, this depending, as usual on aetiological events might have on the nature and the clinical form the psychosis takes. course of mental illnesses to which they lead. It is The acquired predisposition to mental illness best to start from familiar territory: We have is based usually on adverse infl uences that are come to know Delirium tremens [W] as an acute also expressed as organic changes in the brain. psychosis [W] that is specifi cally alcoholic [W], These include Hydrocephalus internus [W], even a form of delirious allopsychosis almost always if this has reached the stage of recovery, as we due to chronic alcoholism. However, I have often see; but we also see it even where no con- already pointed out certain exceptions that, at spicuous alteration of the head has been left least, deserve our attention. behind, but only partial adhesions or diverticular I remind you that we have learned about the formation within the cerebral ventricles, a fi nding chronic and protracted Delirium tremens; but I rightly emphasized by Meynert [ 2] in particular. have occasionally mentioned an even more acute Survivors of childhood meningitis, and any head alcoholic psychosis: It is commonly referred to as trauma that has defi nitely been accompanied by pathological intoxication [W], and we know that concussion, also imply acquired predisposition. it usually takes the form of a very acute allopsy- I should comment that recovery from meningitis, chosis with allopsychic disorientation and dream- and also from tuberculars, should be recognized like hallucinations. The content of this altered more readily than has been generally accepted. state seems always to be fantastically threatening, Childhood cramps, for whatever reason, although and corresponding to this is an extreme Affective successfully outlasted, must likewise be regarded state which accompanies pathological intoxica- as noxious infl uences predisposing to mental ill- tion, which is different from Delirium tremens. ness. The impact of epileptic seizures, especially This condition lasts no more than a few hours, so if they are clustered, is, in itself, not only a conse- that we can regard it as an example of a transient quence but at the same time, also a cause of gross psychosis. It is followed by deep sleep, usually anatomical changes in the brain that cannot with complete amnesia. I have already mentioned always be totally repaired. Similarly, the relation- that very similar transient psychoses can occur ship between acute psychoses and severe infec- after a single bout of alcoholic intoxication or tious diseases such as typhus or malaria, survived even without one, whenever there is a strong pre- from earlier times, must be taken into account. disposition to mental illness. We assume that during the course of these ailments, I dealt with acute hallucinosis in greater detail anatomical changes can become enduring features earlier. However, I may have presented the prog- in the brain. Finally, I mention as one of the most nosis of the initial illness in such cases too common precursors of acquired predisposition, favourably, because recently I have repeatedly 38 Lecture 38 295 encountered a state of chronic hallucinosis, con- them a very instructive case of abortive anxiety tinuing after acute hallucinosis in alcoholics. On psychosis [4 ]. the other hand, it has long been known that the Alcoholic stupor [W] deserves brief mention. clinical picture of chronic hallucinosis ( pp. 102, Here, clouding of the sensorium, and somno- 103) that I mentioned earlier, whose content is a lence, comparable only to that found in tumour state of physical persecutory delusions, is often patients, can exist for several weeks or even found among alcoholics. months, making the clinical picture so similar to Polyneuritic psychosis, which we have also that of organic brain diseases that, for my part, I discussed already, is often mainly alcoholic in do not doubt that it has an organic basis in hydro- origin. This illness, which is usually curable, cephalus internus [W]. Moreover, the gait distur- can, under some circumstances, progress to a bance that such patients show as soon as they can clinical picture of visual agnosia and asymbolia. leave their beds, can be compared only with that You will recall such a case from my patient pre- of senile hydrocephalus internus [W]. sentations [ 3 ]. Correspondingly, the pulse can be fairly slow. So far, whenever we have had to deal with General muscle stiffness, with great increase in various forms of allopsychoses, autopsychosis mechanical excitability of muscles, is common also comes our way, this, of course, being not both in these cases and in senile hydrocephalus exactly alcoholic in origin. I mean here the ‘sec- internus [W]. Papilloedema tends to be absent in ond state’ [W] also called Semmelwochen [W]. both cases, but, as a residue after surviving alco- It is even likely that the same condition always holic stupor, I have seen atrophy of the optic occurs among the so-called ‘degenerates’ [Ed]; nerves with signifi cant visual impairment. but there is the added possibility of the condi- Generally the disease is curable, sometimes most tion being self-infl icted through alcoholism in defi nitively so, if permanent abstinence can be some cases. achieved. In other cases, stupor can turn into a The importance of a circumscribed autopsy- state of defi cit to which traits of asymbolia may chosis based on an overvalued idea probably be added, although to widely varying degrees. includes the so-called delusional jealousy of Cases of the so-called pseudoparalysis [W] drinkers [W]; at least, this is a feature of several claim a special place amongst alcoholic psycho- pure cases of this type. The overvalued idea on ses. They are seen especially after long- continued, one occasion was based on a husband having very severe excess of alcohol intake. The para- been repeatedly rejected in his claims for marital lytic character of the resulting acute psychoses is intercourse, by his slightly-older wife, already expressed as disturbances of speech—by now richly endowed with children. In a second case, familiar—and of the cranial nerves, just as in the underlying Affective experience could not be delirium tremens, and probably is again organi- defi nitely proven, but was presumed to be a simi- cally based. Beyond this, signs of disease of the lar situation, and delusional jealousy was thus spinal cord, differences in pupil size, and pupil- actually identifi ed, because the subsequent delu- lary rigidity may be present, as they are in genu- sion of reference was directed so specifi cally to ine paralysis. The acute psychosis usually has that single issue, that the entire clinical picture added delirious features at least initially. Later could be understood only as a circumscribed the picture corresponds mostly to acute halluci- autopsychosis based on this overvalued idea. nosis but with added independent states of anxi- Although these cases are chronic in character, ety, temporary allopsychic disorientation, and they also belong amongst the acute psychoses on traits of dementia. Moreover, a paranoid stage account of their more acute stage of origin. does not develop. A highly fl uctuating clinical Much more often, perhaps even most often of picture can exist for years and yet fi nally reach a all—if you also include abortive cases—are anxi- state of recovery. At other times, at least a moder- ety psychoses in drunks. In my patient presenta- ate degree of defi cit remains, which need not tions you will fi nd a few such cases, amongst progress further, given abstinence. I note 296 38 Lecture 38

explicitly here that the recovery relates only to a brain weight of 1,250 g, moderate Hydrops the psychosis and the specifi c paralytic concomi- ventriculorum [W]. The illness closely preceding tants of speech disorder, tongue tremor etc.; the this was a cystitis that lasted several weeks. With actual spinal symptoms tend not to recover. remission of the motor restlessness, rigidity of Fainting spells, which occur in the course of the her legs, and ankle clonus could be demonstrated; illness can make diagnosis of true paralysis even a few days before death, paresis of the left facial more complicated. nerve, of peripheral origin, appeared. I have One often encounters psychoses [W] related come across similar cases of mixed sensorimotor through combined morphine and cocaine abuse psychosis, whose course proved severe, and sud- [W], although I have yet to see real psychoses denly fatal, which seemed to have no basis in the caused exclusively by morphine abuse. Sudden clinical symptoms; inter alia [W] there was a occurrence of physical persecution delusions, typical anxiety psychosis which became fatal with rapid systematization and, strange tactile within 7 weeks; and at autopsy, despite signs of and combined hallucinations of the skin, so that developing phthisis, no other explanation for the the patient sees and feels ‘fungus’ [Ed], or mould rapid decline could be found. Conversely, [Ed], or hair-like structures growing out of their I remember a patient in the last stage of long- skin, which seem fairly specifi c to such cases. standing pulmonary tuberculosis who, in his last Closest to the alcoholic psychosis are isolated 14 days presented one of the purest pictures of cases that in all probability can be attributed to akinetic–parakinetic motility psychosis. In all lead or arsenic poisoning. In connection with the such cases, one could not dismiss out of hand the former, I have in mind the example of a 30-year- suspicion that the acute psychosis is a polyneu- old typesetter whose clinical picture consisted ritic one with unusual clinical symptoms. mainly of sensory confusion, continuous pres- Regarding the polyneuritic psychosis [W]— sured speech, generally incoherent fl ight of ideas, which belongs here because it owes its name to with very prominent hypermetamorphosis, but no it—I refer you to my earlier lecture. In the litera- signifi cant addition of any Affective reactions. ture, you almost always fi nd it called ‘Korsakoff’s After an illness lasting about 10 months, he psychosis’ [Ed], terminology also recently started to become demented, and was failing accepted by Jolly [5 ]; and it was in fact Korsakoff physically. Death occurred a year later, after gen- [6 ] who fi rst directed attention to certain typical eral muscle tremor had occurred, with temporary features of the clinical picture seen amongst states of excitation including a content of hypo- those suffering from polyneuritis. However, you chondriacal fantastic threatening delusions. will fi nd the cases described by Korsakoff in this Polyneuritic symptoms were not present in his group to be far more complex than the picture I extremities. For chronic arsenic poisoning, I have painted, which was condensed as tightly as should probably go back to the case of a 50-year- possible. For this reason, even now, I consider the old maker of artifi cial fl owers, who had had much name ‘polyneuritic psychosis’ [Ed] to be more to do with arsenic green for 30 years. She suf- accurate, while far from wishing to disparage fered headaches for many years, and fi nally also Korsakoff’s merits. The main objection, which dizziness, and suddenly became ill with symp- could be levelled against my preferred name, toms of anxiety psychosis and hallucinations. gives him special credit, in my esteem. As I Soon however, pseudospontaneous movements wanted to suggest through previously mentioned of the mouth also developed, with rapid increase cases, the polyneuritic basis for psychoses of all symptoms (confused pressured speech, applies, in a broader sense, to degeneration of grandiose ideas, verbigeration, transitional para- neural elements in the brain, similar to polyneuri- kinetic movements, spatial fi xation of her eyes, tis, assumed to have an anatomical basis in psy- yet orientated temporally). She then showed a chosis, but probably extending far beyond the sudden physical decline, despite adequate food narrow concept of the so-called polyneuritic psy- intake, and died within 18 days. Autopsy revealed chosis. Since we have also made corresponding 38 Lecture 38 297

fi ndings in paralysis, the above facts confi rm only particular form of primary dementia, which sets the long-established fact that degenerative neuri- in at the time of onset of puberty, particularly tis develops most often in the context of syphilis, among children with a heavy hereditary loading. chronic alcoholism, and tuberculosis. Beyond With regard to mania, Affective melancholia, and this, as already mentioned, the high incidence of circular mental illness, I refer you to my earlier tuberculosis as a forerunner in individuals with comments on their aetiology. acute psychoses of the most varied types, gives It cannot be denied that amongst psychoses one pause. related to heredity, extremely severe cases some- One can only speak in most general terms of times occur. Nevertheless, these are outweighed hereditary psychoses [W], since a hereditary pre- by far by milder cases, and notably by the so- disposition in the broader sense is very frequent called borderline ones, which suggest a more among acute psychoses: In my estimate it is pres- bourgeois existence than do severe acute psycho- ent in about half of all cases. The percentage ses. On the whole, I would impress upon you, might be even more marked, if you include not that a genetic trait certainly can increase the ten- only chronic psychoses, but also the frequent dency to mental illness; but, except for a few spe- cases on the borderline between psychoses and cial cases, these have a no more severe psychosis, mentally healthy persons. I have already men- but rather a milder course, when it erupts. Of tioned this point (p. 104) when referring to course, one must also acknowledge an increased Magnan’s [7 ] work. In the latter category, those tendency to its recurrence. suffering from obsessions are special cases, but Epilepsy [W] plays a very important aetiolog- so also are healthy individuals. Obsessional psy- ical role in psychoses. In general, the so-called choses tend to have a severe hereditary loading; twilight state can be recognized as a specifi cally but it is again highly instructive that I could pres- epileptic psychosis, but with limits on its aetio- ent to you a very pure case of obsessional psy- logical relationships, that we have already met. chosis [8 ] in which it was certain that only senile As a main feature of the twilight state, we know involution of the brain was implicated as an aeti- of clouding of the sensorium, with total allopsy- ological component, heredity being totally chic disorientation. This disorientation in the epi- excluded. As with obsessional neurosis, hypo- leptic twilight state not uncommonly grows to the chondriacal neurosis also fi nds its main members point of asymbolia, when an easily understand- amongst those with hereditary loading. You will able failure of will—a real abulia—may also be recall that, amongst hypochondriacal psychoses present. At other times, dreamlike actions are which I reported to you, some particularly severe carried out, especially ones of a severe violent cases occurred similarly in persons with severe nature, apparently under the infl uence of dream- loading. Such individuals are particularly predis- like hallucinations. When such twilight states are posed to febrile delirium, which is regarded as a seen, lay people are always surprised by the dis- special form of symptomatic psychosis. Again, turbed, and weird actions of the sick person, pro- amongst more marginal cases, are otherwise duced by allopsychic disorientation. These states healthy people, prone to unhealthy impulses. are usually quite short-lived, lasting half an hour, Frequently, the effect of suggestion plays a role up to several hours, and seldom more than a day. here, such as the almost-endemic suicidal impulse Their behaviour in epileptic seizures is different. that prevails in some families. No less common Predominantly these states make their appear- in the same ‘degenerate’ [W] families is klepto- ance post-epileptically, but sometimes pre- mania [Ed] at the time of menstruation, sexual epileptically or as part of an epileptic attack. perversions, etc. Transitory psychoses, including Mostly, there is no later recollection; however, pathological intoxication, show unambiguous except for one—albeit cursory—reminder, we predilection to affect individuals with a heredi- fi nd that the violence was perpetrated as defence tary burden. Finally, I mention once more ‘moral against a threatening situation. While minor autopsychosis’ [Ed] (pp. 193, 194), and a actions are quite common in this twilight state, 298 38 Lecture 38 the epileptic tantrum [W] in its most typical form ‘Who am I?’ is only the blindest thrashing, screaming, and ‘Cousin Georg.’ drooling as a defensive Affective reaction, ‘Who is this gentleman?’ enhanced to maximum extent. These attacks of a ‘Cousin Georg.’ ‘frenetic’ [Ed] twilight state, which can be com- ‘Who is the other gentleman?’ pared only to the behaviour of a cornered animal, ‘Cousin Georg.’ last only for minutes, or at most half an hour, and are followed by total amnesia. In contrast to this, The patient in this conversation, a 22-year-old prolonged twilight states are sometimes seen, woman, with an epileptic father, had herself suf- which can even last for weeks, with harmless fered epilepsy from childhood, and had survived delirious urges to keep moving. Such patients, severe Status epilepticus [W] 3 days earlier. You like those with delirium tremens, can focus their will not have forgotten her strange movements, attention momentarily, but cannot hold it as long which I described to you at the time as the lan- as in a delirious patient; yet, on the contrary, their guidness of a dandy, but with the greatest exag- retentiveness is surprisingly well preserved. At geration. Even these movements had a tendency other times—but rarely, or so it seems—exactly to be repeated, for example when she attempted as in those with genuine delirium, the twilight to embrace me as her supposed cousin. The state only becomes obvious when a patient is left patient looked weak and frail, stumbled visibly to himself; otherwise, he may seem quite bright from her weakness, and in the ward lacked any and attentive. Moreover, in these cases, well- initiative, even to the point of keeping herself retained retentiveness is quite striking, and clean. She showed such striking resistance to should be regarded as a feature of delirium spe- change of position, and maintained such persis- cifi c to epileptic bouts. You will remember a case tently uncomfortable positions, that we were led, [9 ] in which retroactive amnesia existed at the involuntarily to compare her with Goltz’s [11 ] same time, and then differential diagnosis from decapitated frog. We could attract the attention of polyneuritic psychosis could be made, due to the this patient only with diffi culty, and allopsychi- well-retained retentiveness. cally, she was totally disorientated, not actually Where the twilight state dominates more dazed, but appearing ‘mentally empty’ [Ed]. For strongly, the symptom of perseveration [W] that reason her retentiveness could not be tested. (Neisser [10 ])—persistence with previously used Only the simplest instructions or questions were expressions, well known from organic brain dis- understood; she failed everything else, and tired ease, notably aphasia—often becomes very very rapidly. As you may remember, I attempted prominent. This symptom is best illustrated by a to differentiate such symptoms of exhaustion conversation that you yourselves witnessed, in a from other symptoms of the twilight state, as recent clinical demonstration. temporary consequences of the Status epilepticus [W]. However, there is no denying that the resid- ‘What is your name?’ ual state of fatigue which often remains after epi- ‘Martha Glockner.’ leptic seizures and which is referred to as ‘How old are you?’ post-epileptic stupor [W], shows smooth transi- ‘Martha Glockner.’ tions to any kind of actual twilight state. ‘Where are we?’ The same female patient, who I have just ‘Martha Glockner.’ introduced as an example of a post-epileptic twi- ‘How old are you?’ light state, 6 months previously had become an ‘22 years.’ exception, on account of a post-epileptic psycho- ‘Where are we?’ sis; but at the time, it was a totally different situ- ‘22 years.’ ation, namely a hypochondriacal psychosis, ‘What is your profession?’ whose main symptom was a supposed unilateral ‘22 years.’ paralysis, on the left side. It was not a genuine 38 Lecture 38 299

paralysis, and weakness was evident only for the specifi cally hysterical in nature, I would regard as fi rst 3 days. Facialis muscle and tongue remained not clearly resolved, despite the case that I per- unaffected; passive movement and refl exes were sonally experienced, mentioned earlier (p. 191). normal; but sensibility was markedly involved. French authors emphasize that such states are Eight days later, the patient could be discharged distinguished from others in the same series, as recovered. This report will call to mind a case, through a certain stereotyped character of behav- again post-epileptic, of hypochondriacal paraple- iour, with precise recurrence of the same actions, gia of short duration, with fl accid paralysis of as was the case in the example already men- both legs. The particular mode of origin of the tioned. However, exactly this uniformity of paralysis, through disturbance of psychomotor attacks seems also to apply in the so-called sec- identifi cation could be demonstrated in an ond state. Moreover, we observed exactly the instructive way in this case [ 12 ]; but it was a rare opposite: namely a rather ‘polymorphic’ [Ed] occurrence. behaviour for the various seizures in the same Far more often, one sees severe sensory psy- individuals. choses with extensive disorientation, with content If we look elsewhere for characteristic fea- mainly of fantastic hypochondriacal threatening tures of psychoses related to epilepsy, a rapid delusions, almost always mixed in with grandiose sequence, usually leading to a recovery, is com- ideas, and hyperkinetic and characteristic paraki- mon to almost all cases. However, there are netic motility psychoses, usually post-epileptic almost always recurrences. Cases of epilepsy and with a duration not exceeding one or a few complicated by psychoses tend fi nally, and often weeks. Thus, I remember an epileptic who, during quite soon, to lead to dementia. Moreover, such his psychosis, practised the most dangerous acro- epileptic psychoses involve mainly, but by no batic tricks while mute, and apparently allopsy- means solely, the so-called twilight states. chically disorientated. The complexity of these However, the sensorium can be completely clear, movements distinguished these cases as real psy- and allopsychic orientation totally intact. If the choses; but we also see, and far more often, that psychosis does not exist in a twilight state, it restlessness of jactation accompanies deep uncon- tends to show Affective coloration, with sudden sciousness of post- epileptic stupor, sometimes fl aring of angry outbursts being particularly com- lasting for hours or days. mon. There is often actual muscle twitching, or You have already come to know, (p. 134), a exaggerated, expansive, violent, and purposeless typical example of the fearful hallucinatory states movements that occasionally fall outside the clin- seen amongst epileptics. One could summarize ical picture typical of motility psychoses. We these states, by their essential characteristics, as seem to see in these phenomena, suggestions of cases of the most acute hallucinosis. They last for increasing motor excitability being due to adverse half an hour, or a few hours; they are related to consequences of repeated epileptic seizures. It is the ‘frenetic’ [Ed] twilight states, but are distin- known, that in many epileptics, hints of focal guished from them by their allopsychic orienta- symptoms are also to be found, which become tion. I have yet to see cases of epileptic especially pronounced after severely-adverse melancholia. In contrast, manic states are seen in impacts, and after a series of seizures. The same rare cases, albeit not quite pure ones, since they is also sometimes refl ected in the epileptic psy- are combined with isolated hyperkinetic symp- choses, particularly with hints of paraphasia. toms. You have yourselves occasionally seen an Furthermore, persistence—or perseveration— example of this [13 ]. both in sensory and motor relationships, can be Whether the so-called ‘second state’ [Ed] regarded as a common peculiarity of many cases occurs in actual epileptics or is rather more of epileptic psychoses. 300 38 Lecture 38

References 7. Magnan V. Psychiatrische Vorlesungen. Vol. 1. Über das ‘Delire chronique a evolution systematique’, Paranoia chronica mit systematischer 1. Griesinger W. Herr Ringseis und die naturhistorische Entwickelung oder Paranoia completa. Leipzig: Schule. Arch Physiol Heilk. 1842;1:43–66. Georg Thieme; 1891. 2. Meynert T. Der Bau der Grosshirnsrinde und seine 8. Wernicke C. Krankenvorstellungen, vol. 2, 1899. örtlichen Verschiedenheiten, nebst einem Case 17. pathologisch-anatomischen Corollarium. Leipzig: 9. Wernicke C. Krankenvorstellungen, vol. 2, 1899. Engelman; 1887. Case 7. 3. Wernicke C. Krankenvorstellungen aus der psychia- 10. Neisser A. Krankenvorstellung (Fall von trischen Klinik in Breslau, vol. 2. Breslau: Schletter; ‘Asymbolie’). Allg Z Psychiatr. 1895;51:1016–21. 1899. Case 9. 11. Goltz FL. Beiträge zur Lehre von den Functionen der 4. Wernicke C. Krankenvorstellungen, vol. 1, 1899. Nervencentren des Frosches. Berlin: A Hirschwald; Case 12. 1869. 5. Jolly F. Über die psychiatrischen Stoerung bei 12. Wernicke C. Krankenvorstellungen, vol. 3, 1900. Polyneuritis. Charité Ann Berlin. 1897;22:580–612. Case 23. 6. Korsakoff SS. Über eine besondere Form psychischer 13. Wernicke C. Krankenvorstellungen, vol. 2, 1899. Störung kombiniert mit multipler Neuritis. Arch Case 24. Psychiatr Nervenkr. 1890;21:669–704. Lecture 39 39

• Continuation of aetiological grouping of the role. This so-called emotional stage of hystero- psychoses epileptic seizures thus falls within the area of • Hysterical absences delirious allopsychoses. • Hysterical delirium The so-called hysterical delirium corresponds • Pubertal psychoses or hebephrenic psychoses even more closely to this concept—it being an • Kahlbaum’s Heboid acute psychosis that occurs independently, with • Senile psychoses an urge to move induced by sensory factors, and • Menopausal psychoses with total allopsychic disorientation, but with no • Menstrual psychoses defi nite prevailing Affective state. Due to their • Puerperal psychoses. multiple sensory distractions, spontaneous • General and special aetiology expressions of these patients are also highly inco- • Inanition delirium herent, refl ecting their hypermetamorphosis. • Symptomatic psychoses Only occasionally and momentarily can patients’ attention be fi xed suffi ciently to obtain answers from them. Tactile hallucinations and phonemes, localized with abnormal precision, play a major Lecture role. Addition of asymbolia is likely, as indicated by the patient’s behaviour towards food intake Hysterical psychoses are related to epileptic psy- and bodily care. General muscle tremor, occur- choses in many respects, for example in their ten- rence of the so-called lateral column symptoms dency to so-called twilight states. Some variety is [1 ], and physical decline can accompany the psy- often seen in this, especially among hystero- chic symptoms, and lead to death within a few epileptics in connection with seizures, which weeks. Moreover, mainly hypochondriacal French authors defi ned as a unique stage—the symptoms may be seen during hysterical delir- hystero-epileptic attack. However, it is not so ium. In like manner, in a severe case, after much the ‘pre-syncope’ [Ed] of the sensorium, as 6 weeks, the sensory agitation made way for a the total allopsychic disorientation—usually of typical picture of agitated motor confusion, only short duration—that forms the main feature namely a hyperkinetic motility psychosis with of these conditions. Patients behave as if they are manic features. This reversal appeared to be in a fantastically altered situation, intensely attributed to recovery of strength and general Affect-laden. In particular, any misfortune that condition as a result of continued artifi cial feed- has befallen them—loss of relatives etc—plays a ing. An equally rapid reversal led to full restitution

© Springer International Publishing Switzerland 2015 301 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_39 302 39 Lecture 39 with insight into the illness; but a recurrence ‘twilight state’ [W] for such cases, for reasons happened 18 months later. I am not aware of the mentioned earlier: The sensorium is not impaired, outcome. although existing mental material is restricted in I have already mentioned (p. 253) the so- its extent. There is a ‘narrowing’ [Ed] of con- called catalepsy of hysterics [W], that is, a rela- sciousness, suggesting being hypnotized in a tively short-duration akinetic motility psychosis. waking state. Thus, one sees in otherwise hysteri- The sensorium usually becomes deeply insensi- cal patients, quite atypical cases of psychoses, tive, and often, to judge from the rapturous facial such as a delusion of persecution directed against expression, is fi lled with ecstatic, religious dream only one person, where the sensory presence of experiences. A residual condition of weakness, this person is hallucinated, while allopsychic ori- without a paranoid stage, passes rapidly into entation is retained. I have already said what is healing. However, it also happens that such necessary on the specifi c hysterical ‘second ecstatic states recur, and merge into a clinical pic- state’ [W]. ture of continued total immobility. I saw such a Independent of hystero-epileptic seizures, case end in death: These cases are serious psy- I have often seen short-duration hysterical psychoses. Often enough cases of illness are seen choses lasting a half to several hours, especially that have not so much the pattern of acute psy- in children and school students during adoles- choses, but rather, represent transitional cases, or cence, recurring quite irregularly, often after mixed ones between hysterical degeneration or demonstrable emotions of any kind. They have to impoverished personality, and isolated psychotic be subsumed under ‘transitory psychoses’ [Ed]. symptoms. In psychiatric wards in big cities, Such seizures usually consist of anxious misun- such as in our Clinic, prostitutes make up a very derstanding of situations, similar to the popular large proportion of these very troublesome cases image of Pavor nocturnus [W] of children. In of illness, because of their lax discipline. milder cases, they represent a type of abortive However, illnesses arising in quite civilized situ- anxiety psychosis, that is, not so much a misun- ations raise similar doubts: Is it misbehaviour and derstanding of the situation and people, but a moral defi cit, or illness? Tests on their spiritual vivid display of anxiety, sometimes in the guise endowment [W] and memory retention often of phonemes, with seemingly impulsive drag- show the former to be strikingly restricted, the ging, clinging to family, or blind lashing-out, latter to be signifi cantly reduced. However, these ripping, rummaging, etc. These hysterical psy- are not necessarily lasting defi cits. Treatment of choses, which are rapidly cured with appropriate such cases is extremely diffi cult, with a chance of treatment, but likewise gradually subsiding with- success only if one always starts by assuming out it, are usually precipitated by emotions, and that a patient’s behaviour is conditional on some by any kind of debilitating eventuality, such as pathology. Quite recently, cases have been mental strain, too little sleep, etc. They are usu- described by Ganser [2 ], in which patients with ally accompanied by a precursor stage, with apparently clear sensorium, and quite sound headaches, palpitations, and fainting spells. mind, answered questions put to them in such an Almost always in these cases, phrenic nerve inaccurate and twisted manner that one had to insuffi ciency can be demonstrated as the basis for assume an intent to deceive, the more so since the fear. Twilight states lasting several days some of them were prisoners. However, detection sometimes occur in young people in connection of the so-called hysterical stigmata led the author, with major emotions, with total allopsychic dis- justifi ably we believe, to assume that a so-called orientation almost to the point of asymbolia, twilight state exists in such cases. This is sup- blended with episodes of parakinetic symptoms. ported by the fact that previously-described, Thus—incidentally—I presented to you a undoubtedly hysterical patients, often present 15-year-old apprentice baker, who had too little the same symptom of deliberately meaningless sleep for a long time; short-duration ‘absences’ answers. The only objection is to the name [Ed] in preceding weeks, mostly at night, with 39 Lecture 39 303 subsequent amnesia; and he became acutely ill viewpoint, and can now deal only with hebe- after an act of embezzlement he had committed phrenic aetiology, which is [Ed] of great impor- came to light. tance. Rather than ‘hebephrenia’ [Ed], I am Far more common in our area of interest than inclined to accept Kahlbaum’s ‘heboidophrenia’ hysterical psychoses, are hysterical neuroses. I [Ed] or, for short, ‘heboid’ [Ed], as a specifi c mention only obsessional neuroses and anxiety psychosis of puberty. This clinical picture is neuroses. Exceptionally however, these can lead defi ned far more sharply, as one in which to corresponding genuine psychoses. ‘Affectuosity’ [Ed] (generally uniquely related Gentlemen! You will assume from this to puberty but accentuated here) plays such an description, that hysterical psychoses are fre- important role, and which seems to occur only in quently diagnosable from the clinical picture that the context of puberty. Of course, I must then they present. However, the main means of diag- assume that certain symptoms that are consis- nosis [W] is always that hysterical symptoms can tently present have not been adequately observed be detected before onset of the acute illness. In by Kahlbaum. I mean mainly experiences of this respect it is important to know that the main anxiety, outward signs of anxiety, and hypo- source of hysteria among young girls is increased chondriacal sensations. Otherwise, I refer you to mental work beyond their individual capability. Kahlbaum’s descriptions of relevant cases; they Only rarely will you encounter girls who take are relatively rare, so that I have encountered their Bachelor of Teaching exam without having only a few such. become hysterical. In many cases, detection of Much more common, and again specifi cally the so-called hysterical stigmata at the time of the hebephrenic, are cases mentioned earlier, in acute illness is possible, thereby confi rming the which the clinical picture of the so-called pri- diagnosis. mary lunacy is accompanied by a rapid progres- As for the prognosis [W] of hysterical psycho- sion to dementia. Such cases of illness, examples ses, for a long time it had been decided that this of chronic psychoses, earn the name hebephrenic was not so reliable as it is for the epileptic psy- expansive autopsychosis [W]. However, the clini- choses, which usually recover rapidly. However, cal picture in some of these cases does not remain one is often surprised by recovery in cases that the same, but shifts, sometimes after 3–6 months, seemed clinically unfavourable. Hysterical delir- to a state of atonity, which, for its part, gives way ium almost always seems to recover; in other only to most profound dementia. words, there need be no fear of residual chronic Next most common might be motility psycho- mental disorder. Hystero-epilepsy, in cases com- ses of any kind, but particularly akinetic motility plicated by psychosis, just like epilepsy in such psychosis, which fi nd their next occasion for cases, appears, in the end to lead to dementia. occurrence at time of puberty. The familiar ten- Hystero- epilepsy by itself does not have this out- dency for akinetic motility psychosis to be trans- come, whereas known epileptics, with frequent formed into dementia might be based in part on seizures, always become demented. The progno- this aetiological relationship, as is their tendency sis of acute psychoses is generally favourable; to recur, falsely attributed to this particular form however, the danger of recurrence is great if there of illness. Yet I also know of cases of akinetic is no recovery from the basic hysteria. motility psychosis occurring during puberty that The psychoses of puberty, or hebephrenic were followed by such a complete recovery that it psychoses [W] have already been mentioned a has not disturbed the life-transition of the young number of times. You will remember, gentlemen, men involved; nor had any recurrence occurred. that I have earlier referred to the term hebephre- Thus the unfavourable prediction that Kräpelin nia, and have acknowledged the particular type [ 4 ] makes for such cases, does not always apply of illness described by Kahlbaum and Hecker to those during puberty. [ 3]. However, from experiences in our clinic, I Furthermore, hypochondriacal anxiety psy- have become increasingly dissatisfi ed with this chosis, the particular form of somatopsychosis 304 39 Lecture 39 closely related to simple anxiety psychosis, traits. They are not to be found in the specifi c undoubtedly occurs preferentially during puberty. childhood form, in which, the resulting feeble- Nonetheless, in a proportion of cases, the clinical mindedness in silly and foolish beings, would picture becomes continuous and prominent only seem only natural: Rather than a predilection to after a long period, when up to a year has passed a certain clinical picture which, in its tendency with no more than isolated attacks of anxiety last- to recur, is by no means limited to puberty, there ing no more than an hour, and an unhappy mood; is a prevailing tendency to an unfavourable out- and by then a correspondingly reduced capacity come, or, if there is a favourable outcome, at has emerged. In one case of this sort, which least a temporary occurrence of actual defi cit fi nally recovered, the patient falsely interpreted symptoms; and in the event of a chronic course, perceived pollution and erections, combined with for worsening with each episode, so that the olfactory hallucinations—a stench of death most acute clinical pictures occur in between. referred to his genitals—and attacks of increas- Finally, in cases with the most-acute onset—but ing anxiety as the principal element of the clini- sometimes also in chronically developed cal picture, which slowly faded. Defi nitive cases—it is stressed that they proceed as com- recovery ensued only after some years. In the posite psychoses, that is, by producing totally meantime, reduced retentiveness and rapid different clinical pictures at different periods. fatigue when challenged by mental demands So much is this so, that, in one case, with pro- became disturbingly noticeable even to the found—almost animal—dementia, over many patients themselves. However, the mental status years, I have seen hyperkinetic motility psycho- quo ante [Ed] was never regained. Such a mild sis occurring; and since this occurred during course corresponds perhaps to an ‘abortive’ [Ed] continuous stay in the institution, there were no case of hebephrenic psychosis. In any case, far harmful external infl uences. Consequently, you more often, cases are to be found which could be had the opportunity of seeing a case that I pre- described as slowly worsening somatopsychoses, sented to you in one semester as Affective mel- in which a hypochondriacal psychosis emerges, ancholia; and in the following semester as a in a sense ‘slipping in’ [Ed] unnoticed. It is often picture of hyperkinetic motility psychosis; and bodily discomfort of undetermined or changeable fi nally as the pure defi cit condition of severe localization, but sometimes leading to an out- feeble-mindedness [5 ]. It was in the context of come of complete inactivity. An acute episode this case that I drew your attention to what is leads to total sensory psychosis with a content of frequently seen in cases of hebephrenia: This is fantastic hypochondriacal threatening delusions, the relatively ‘busy’ [Ed] face that gives no indi- pointing to a more fl orid disease process, often cation of inner emptiness. This is particularly developing only years later. The residual defi cit surprising when it is compared with the smooth state then presents with features of Kahlbaum’s and stupid face of most paralytics, even in early hebephrenic weak-mindedness, which is some- stages of this illness. times very striking. Little is known about the infl uence of senes- Finally, I mention the extremely acute psycho- cence or senile involution [W] of the brain on the sis already touched on (p. 244), that I have seen form and course of psychoses; yet here also we repeatedly in young girls. This seems not to be a can group psychoses according to their aetiology, chance occurrence, but supports a hebephrenic namely presbyophrenia, as already described. aetiology for their illness. I already stressed that You will recall that this clinical picture, in its they can still recover without defi cit. essential features, matches another psychosis, of To validate my position on hebephrenia, I polyneuritic aetiology. However, differences can limit myself to the following remarks, which as be pointed out in some peripheral features. Thus you know, are by no means exhaustive. On the allopsychic disorientation of presbyophrenia whole, we must recognize that hebephrenic psy- seems to change in degree over time; at least I choses in most cases show some characteristic have often seen this. With polyneuritic psychosis 39 Lecture 39 305 this feature tends not to change, nor do delirious As far as the specifi c aetiology of senile states of presbyophrenia. Sometimes they occur psychoses is concerned, a stroke is often found to only at night, and there are borderline cases in be the immediate origin of the psychosis, even in which such nocturnal deliria, plus actual defi cit cases where hemiplegic symptoms have regressed symptoms account for the whole clinical picture. completely. This is especially true for cases of I have already emphasized that the notion of presbyophrenia; but it is sometimes also true for senile dementia does not include presbyophrenia. other types of illness. I would particularly like to Here too, the attentive facial expression and mention a case of hemiplegia in an elderly prompt reaction to stimuli are evident, quite apart woman, in whom the psychosis had the content from the curability of acute-onset delirious cases, of a uniquely coloured hypochondriacal delusion which you already know about. of persecution. Specifi cally she believed the per- Moreover, senility seems to produce very dif- secutor to be a man who lay beside her in bed, ferent clinical pictures. Cases of Affective melan- and had taken possession of the paralyzed half of cholia are fairly common, although borderlines her body. cases predominate, which are familiar to you and The infl uence of the menopause [W] on devel- belong more in the area of anxiety psychoses. opment of psychoses is well-known. We can Apart from senility, the prognosis of such cases, probably point to a closer connection with a spe- as you will remember, is generally favourable, cial clinical form of acute psychosis, specifi cally except that the risk of recurrence is greater than of anxiety psychosis, and instances of anxiety usual. We were able to defi ne senility as the sole neurosis, which also prove troublesome at the aetiology in one case of obsessional psychosis time of menopause in otherwise normal women; [6 ], and one of circumscribed autopsychosis due and fi nd ways to understand it in various vasomo- to overvalued ideas [7 ]. We have met examples of tor disturbances. At other times the illness devel- acute anxiety psychoses that showed a special ops chronically, with slowly, creeping delusions course, deviating from usual, in that a very physi- of relatedness; or a subacute outbreak is seen, cal and ‘altruistic’ [Ed] persecutory delusion was with episodic relapses indicating exacerbations. created, which quickly became associated with Menopausal psychoses tend mainly to progress total allopsychic disorientation. We then came to unfavourably; yet even here, the form of psycho- suspect that we should attribute the course in sis is likely to be infl uential, since a case [ 8 ] was such cases to a defi nite senile aetiology. It now presented to you in convalescence, on the border- appears that, right from the start, chronically pro- line between Affective melancholia and anxiety gressing cases of ‘chronic hallucinosis’ as we psychosis. In addition, I can recall cases of com- named it (even without development of the delu- plete menopausal motility psychosis that had a sion systems of physical persecution), can often favourable outcome. lead to the same outcome of allopsychic disorien- Menstrual psychoses [W] have been discussed tation in old people. A 78-year-old woman I have several times already. We have encountered in mind, misjudged everything within a context hyperkinetic motility psychosis, confused mania of imprisonment, yet showed intelligent, level- (or agitated confusion, related to it by its close headed, and active behaviour. Furthermore, a connection with menstruation) as specifi c forms case of akinetic motility psychosis presented, in of menstrual psychosis. I remind you of the fact the paranoid stage with surprising allopsychic that the two clinical pictures have close connec- disorientation. This case is remarkable in that the tions with each other; indeed they can replace psychosis, despite advanced age, proceeded to each other, and they usually tend to recur in full recovery within 2 years. It was only the signs sequential attacks at about 4-weekly intervals. of senile amnesia, which remained for the dura- However, sporadic cases are also seen that like- tion, that prevented real insight into the illness, wise occur within a four-weekly period, and, at because of memory defi cit for the period of acute their best, progress to complete recovery without psychosis. a paranoid intermediate stage. The moment of the 306 39 Lecture 39 outbreak, which is always very acute, is most motility psychoses and anxiety psychoses closely often premenstrual; sometimes it coincides in linked with menstruation occur relatively rarely, time with the period, or the end of it. If, instead of but are still recognizable. this recurrent course, there is continued or longer- On the likelihood of recovery from menstrual lasting psychosis, a paranoid stage remains, usu- psychoses, the general view puts them in a worse ally at the same time as a residual hallucinosis; light than they deserve. In particular, it is proba- but this can also lead to recovery. Outcome in bly the periodic cases and experiences coming dementia is to be feared only if menstrual hyper- from earlier times, when treatment was less care- kinetic motility psychosis or confused mania at ful, that gave rise to this unfavourable judgment. the same time is understood as a hebephrenic In my experience, most cases, even after multiple psychosis. recurrences, tend fi nally to heal, but of course, The next most frequent risk related to men- treatment needs great care. As is generally struation—likewise usually with a periodic or known, when there is a severe hereditary load, recurrent course—is any kind of mixed form of recurrent mania is often seen at the time of mania. Pure mania with a menstrual basis is rela- puberty, or the fi rst appearance of menstruation. tively rare. Of the mixed forms, a special intro- Such cases, which, as I have repeatedly stressed, duction is needed to manic allopsychosis and unjustly bear the name of ‘periodic mania’ [Ed], manic hyperkinetic allopsychosis: These are may in part have been confused with menstrual clinical pictures that would correspond to the psychoses. type of confused mania or agitated confusion, but Gentlemen! Amongst puerperal psychoses with added allopsychic disorientation. Wrathful [W], puerperal mania is best known to you all. mania should be mentioned here—the mixture of However, you have learned that hyperkinetic anxiety psychosis and manic symptoms that I motility psychosis, that, up to now could not be have occasionally described already. Since agi- clearly separated from mania, represents the most tated melancholia represents a mixed psychosis common form of puerperal psychosis. Quite with some components of mania and some of remarkably, puerperal cases of hyperkinetic anxiety psychosis, it is perhaps necessary to motility psychosis tend to show multiple recur- interpret the concept of wrathful mania in some- rences, at about four-weekly intervals, and these what greater detail. Wrathful mania preserves the are the more favourable cases. Equally common general character of mania; in agitated melancho- is when the fi rst attack of puerperal hyperkinetic lia by contrast, despite the compulsion to speak, motility psychosis shows only the beginning of a and the fl ight of ideas, we cannot forget that it is cyclic pattern. Finally, if the regular pattern is an anxiety psychosis. Thus, in wrathful mania we curtailed, a complete motility psychosis appears; fi nd the sophisticated, imperious, brutal, some- and such cases are always judged to be very seri- times even obscene behaviour of manic patients, ous, especially if they go beyond a single cycle. and usually also prominent grandiose ideas and, Less common than these cases, but still seen at least temporarily, abnormal euphoria. The dif- quite often are the pre-existing akinetic motility ferential diagnosis should therefore focus mainly psychoses. Pure mania is relatively rare, but such on the mania, but of course, it is usually very easy cases are distinct by their rapid, favourable in this respect. Pressured speech and fl ight of course. Moreover there are some—mainly ideas are frequently distracted and interrupted by severe—clinical pictures of psychoses related to hallucinated expressions of anxiety, by delusions the puerperium, especially when, apart from the of relatedness, and sometimes by fear of puerperium, other harmful circumstances are approach, while hypermetamorphosis also claims present, such as excessive lactation, febrile ill- attention. All these are symptoms that are foreign ness, or painful mastitis, that have reduced the to pure mania. I have already stated that wrathful levels of energy. In such circumstances the most mania often shows up as a recurrent type, and not severe hypochondriacal psychoses may occur, only when the aetiology is menstrual. Akinetic with allopsychic disorientation. Experienced References 307 experts are unable to agree on whether such Moreover symptomatic psychosis might still puerperal psychoses have a favourable outlook require a more precise study according to the cri- with regard to their curability. teria that you have met here in my clinic. Gentlemen! This overview allows you to see According to my few experiences, symptomatic the benefi ts that an aetiological approach offers anxiety psychoses which come to our notice— for knowledge and understanding of the psycho- dyspneic states being most common—tend to be ses. However, throughout this, it will have con- regarded as anxiety neurosis, as long as such fi rmed for you the maxim that, so often, I sought obvious disease processes are absent. They occur to instill, that aetiological considerations offer a in the wake of diseases of heart, kidney, and lung, benefi t only if we separate them sharply from at all levels of severity, even down to simple cases clinical defi nition of the various psychoses, mak- of anxiety. Moreover, almost all clinical forms ing no claims to artifi cial construction, or to clini- might occasionally appear symptomatically. cal forms defi ned exclusively by aetiology. Thus, for example, I have observed symptomatic Perhaps, at this point, a classifi cation of ‘aeti- Affective melancholia in perityphlitis, and a ological moments’, according to their importance 3-day hyperkinetic motility psychosis with [Ed] is to be recommended. Every reason then febrile illness, caused by pus formation in the suggests that we should always separate the ‘gen- mastoid antrum. However, mostly it is acute eral aetiology’ [Ed] and the ‘special aetiology’ infectious diseases that predisposed to symptom- [Ed] (in the sense of an immediate trigger). atic psychoses, and most commonly with a pic- Sometimes, one or the other type of physiologi- ture of anxiety-coloured, delirious twilight states. cal effect is unaccounted for; but often, both are Symptoms of muscle tremor and speech disorder detectable, or the same adverse consequence can caused by severe physical illness can then give be attributed just as well to general as to special rise to confusion, with delirious states of progres- aetiology. sive paralysis. The prognosis [W] of symptom- I have already mentioned that I cannot recog- atic psychoses depends exclusively on the course nize ‘exhaustion psychoses’ [Ed] as a special of the underlying disease, whose prospects of group, because any [Ed] variety of ‘exhausting course can only be unfavourably infl uenced. moment’ [Ed] can be seen as the immediate cause of illness in the vast majority of acute psychoses. In contrast, a delirious state can be recognized in References states of inanition. We are thus getting near to the notion of symptomatic psychoses [W] that is, 1. Bonhoeffer KFOH. “Seitenstrangerscheinungen” bei those psychoses which, in their appearance and akuten Psychosen. Psychiat Nervenpath Abh. 1896;2. 2. Ganser SJM. Über einen eigenartigen hysterischen course, show unmistakable dependence on other Dämmerzustand. Arch psychiatr Nervenkr. 1898;30: physical illnesses. Each febrile delirium would, 633–40. in this sense be interpreted as a symptomatic psy- 3. Hecker E, Kahlbaum KL. Hebephrenia: A contribu- chosis; but it would probably be better to contrast tion to clinical psychiatry. Arch Pathol Anat Clin Med. 1871;52:349–429. this with actual psychoses, as psychotic states. To 4. Kraepelin E. Über psychische Functionsstörungen. all these delirious states, apart from familiar Allg Ztschr Psychiatr. 1890;46:522–4. symptoms of hallucinations (in particular dream- 5. Wernicke C. Krankenvorstellungen aus der psychia- like hallucinations), occasional ideas of anxiety, trischen Klinik in Breslau. Breslau: Schletter. vol.2, Case 16. and a restlessness more-or-less reminiscent of 6. Wernicke C. Krankenvorstellungen vol.2, Case 27. jactation, an allopsychic disorientation appears 7. Wernicke C. Krankenvorstellungen vol.1, Case 23. always to be distinctive, at least temporarily. 8. Wernicke C. Krankenvorstellungen vol.3, Case 22. Lecture 40 40

• Course of disease them severe Affective states. We should always • Body-mass curve stipulate that a continuous course, uninterrupted • Intensive and extensive disease curve by symptom-free periods, is a criterion to recog- • Accumulating and substituting course nize a psychosis as chronic. We should not expect • Outcome in death, mental invalidity, or para- to include the so-called periodic psychoses noid states amongst the chronic psychoses, since, in reality, • Material confusion they are recurrent or relapsing psychoses, even • Dementia or idiocy and imbecility though recurrences follow so closely on one • Congenital and acquired dementia another that in practice there is no signifi cant • Principal signs of acquired dementia difference. In general, chronic psychoses have a • Causes of the same worsening course, that is, they lead to ever- • Paralytic dementia, post-apoplectic, epileptic, increasing disorientation. This is particularly true alcoholic, hebephrenic dementia when acute psychoses are separated from actual chronic psychoses, and cases of chronic mental disorder remain as I did earlier. In contrast to such cases of chronic psychoses, we can also defi ne— Lecture as we would in general medical parlance—an improving course, provided the condition does Gentlemen! not remain stable and unchanging, which is rarely The factual material that I have presented to the case. The improving course is then synony- you so far allows us to put forward a few general mous with gradual recovery of orientation, with- observations about the course of the psychoses out it ever being fully achieved. and their outcomes. We moved on from there to We must subdivide acute psychoses according differentiate chronic and acute psychoses. to their time course into peracute, acute, and sub- However, closer examination of these differences acute psychoses. This distinction is of practical of the course over time soon showed that acute importance; however, we would only apply it clinical pictures are occasionally to be found in when we deal with a clinical picture of acute col- chronic cases, somewhere along their time line. oration, which has developed slowly over time, to This situation is to be explained by the fact that distinguish it from chronic psychosis. Thus, for acute episodes interrupt the chronic course, but example, paralytic psychoses usually develop also by addition of symptoms that in themselves, subacutely. The differentiation of a peracute ill- or in their practical consequences, bring with ness onset is less useful in practice, but fi nds its

© Springer International Publishing Switzerland 2015 309 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_40 310 40 Lecture 40 use in the so-called transitory psychoses. If you depends solely on habituation, and accommoda- want to include here all cases where a severe clin- tion to external conditions. This course therefore ical picture emerges within 24 h, then a signifi - is continuously worsening, leading to ever-more- cant percentage of all acute psychoses would be remote alienation from reality. One could char- excluded. Of course prodromal symptoms, which acterize such a course—because of its fateful are purely physical in nature, such as insomnia, signifi cance—as a progressive course of acute lassitude of limbs, headache, indisposition, etc., psychoses. You will remember that I often spoke must be omitted. Included amongst the rarities, of acute progressive psychoses in this sense. If are cases such as the previously mentioned there is an improving course following the peak (p. 186) Miss v. F. in whom an acute psychosis stage of the acute psychosis, then evidently we existed in full force from one particular instant— are dealing with three distinguishable stages: an her awakening from sleep—but then continued incremental stage, the peak, and a decremental on an improving course. We might properly con- stage, as has long been known in all acute physi- sider such cases as apoplectiform, and thereby cal illnesses. rare cases would automatically come to mind However, the course just described is still con- of polyneuritis, within which the same clinical tinuous. There are, however, not only continuous picture intrudes. Moreover, these very acute- courses but also remitting and intermittent ones. onset cases remain for some time at the peak In effect, we should call the course intermittent if level of illness, before their intensity diminishes. there are one or more lucid intervals. In this sense, Of course, their outcome can also be death or one could therefore refer to many cases of mania dementia. and confused mania as having intermittent courses. The great number of acute psychoses, in However, in practice, intermissions of the shortest which onset of illness occurs within the bounds duration are best ignored. We should then identify set by the above-mentioned borderline cases, an intermittent or recurrent course only in cases in nevertheless correspond to a trajectory of disease which a series of individual attacks succeeded one that proceeds relatively slowly, compared with another, as is the case in hyperkinetic forms of physical illnesses. Such psychoses thus fi nd closer menstrual psychosis. The intermissions here must analogies amongst certain chronic illnesses, be included in the actual duration of illness, espe- such as Phthisis pulmonum. [W] Correspondingly, cially since they are often beset with states of most acute psychoses, notably all subacute ones, physical and sometimes mental fatigue. There is initially show a worsening course. An example of no question that such intermissions do not merit this is given by acute hallucinosis, which well the term ‘intermission’ [Ed] in its strict sense, if illustrates the preceding sentences. The clinical they do not lead to full insight into the illness. picture, apparently rises rapidly to full disease Such cases would therefore be examples of a intensity in accord with its Affective coloration, remitting course. Sometimes, chronically worsen- and shows a rising course of physical symptoms, ing psychoses show an intermittent start. For and soon also altruistic delusions of persecution example, two distinct instances of a delirious state are added in to an increasing extent over succeed- formed the precursor to primary major and con- ing weeks. Thus, in the paranoid stage, a defi nite secutive delusions of persecution in a 35-year-old peak of allopsychic disorientation is achieved, man who was not a drinker. In such cases, insight while at the same time symptoms that led to this into illness gained in the fi rst intermission was lost are starting to subside. The latter enables orienta- in subsequent ones. Here the course is remitting or, tion to return—a subsequent improving course. probably more accurately, rising in a staggered Repeated bouts of this kind may often result in an fashion. The remitting course often both rises and attack whose outcome is unfavourable. This is falls in a staggered way. Most anxiety psychoses due to the fact that elementary symptoms, rather are examples of such a remitting course, in which than subsiding, continue and even increase, so anxiety, and the autopsychic disorientation based that the aftermath of the Affective outburst upon it, usually exist in a persistent fashion, but are 40 Lecture 40 311 increased in attacks that lead to allopsychic dis- Certainly therefore, we can acknowledge the array and corresponding ideas of allopsychic practical value of the bodyweight curve as a anxiety, in the guise of phonemes. This fl uctuat- mirror image of the disease curve for most cases ing—perhaps ‘remitting’ [Ed] would be better— of acute psychoses; but we should also not over- course of anxiety psychoses has been mentioned estimate it and, above all, should admit a priori repeatedly. [W] that its scientifi c value is provisional and Gentlemen! In remarks just made, you will doubtful. recognize the effort made to express the course of Moreover, theoretical considerations point us psychoses in part in the form of a curve. It would in other directions. In psychoses, as everywhere, be a great step forward if we could obtain a rapid we must obviously differentiate between inten- overview of such illnesses, which often stretch sity and extent of the disease process. Accordingly, out over years, by producing a true disease curve, a special curve must be constructed for intensity as an immediate focus for our attention. However, and extent for each case. What we have to under- we must not hide from the diffi culties in the way stand by extent, is not hard to specify: It is the of such an undertaking. What criteria could guide number of elementary symptoms which can be construction of such a curve, if we want to avoid specifi cally identifi ed in the resulting changes in being quite arbitrary? Surely it would have to content of consciousness; or, in other words, the make exclusive use of tangible objective data. We scope and degree of disorientation. We know of fi nd such data for example in body mass, and psychoses whose extent is consistent throughout from my comments about the remarkable infl u- their course, and in which disorientation varies ence of mental illness on nutrition and metabo- only in degree but not in extent. Thus Affective lism (p. 100), you will not be particularly melancholia and pure mania persist as the same surprised if I tell you that the closest method of symptom complexes throughout their entire constructing such a curve is to use data on body course. Accompanying disorientation (in other mass as the ordinate. In fact, in a large number of words belittlement of self, even to the point of cases, a curve constructed in this manner seems, delusion), or the hubris of grandiose delusions, at fi rst glance, to match the disease curve surpris- remain limited not only to the area of person- ingly well—surprisingly, in so far as all emerging hood, but also to an unchanging and specifi c line clinical variations in the course seemed to refl ect of thought. There are essential variations in the inverse variations of the bodyweight curve [W]. degree of orientation here, and these depend in Moreover, in acute episodes of chronic psycho- distinctive ways on the intensity of Affect. The ses, this behaviour often comes strongly to the name we give—autopsychic anxiety ideas (we fore. Furthermore, it is often seen in recurrent might also call them ‘misfortune ideas’, under- courses of acute psychoses, for example in hyper- mining ideas of happiness) [Ed]—shows their kinetic motility psychosis or wrathful mania, that derivation from an Affective state. As a result, a the bodyweight curve rises in a staggered way in curve of intensity [W] suffi ces in such cases, to intervals between attacks, while, at the same represent the course of the illness completely. In time, clinical forms of these attacks become contrast to such cases, we see gradual summation milder, until the continual increase indicates defi - of elementary symptoms, and substantive nite recovery. However, deviations from this changes in psychoses proceeding in a purely behaviour are [Ed] observed, even when not chronic manner. Here a curve just of extent [W] explained by inter-current illnesses or accidental will reproduce completely the progression of the complications, although frequent occurrence of disease. We could also express this relationship such complications often hinders evaluation of by setting in one type the curve of extent, in the bodyweight curves to measure a disease trajec- second that of the intensity lying parallel to the tory. A glance at chronic psychoses also teaches abscissa. us that often enough the patient’s general condi- Gentlemen! From the overview that I gave you tion is in no way mapped out in his suffering. at the conclusion of the clinical presentations, 312 40 Lecture 40 you will have seen that cases that I differentiated joy, and inclination to laugh, can often be attrib- as the so-called ‘basic forms’ [Ed] or ‘simple uted to the patients’ fi nding the supposedly psychoses’ [Ed], present mainly the same com- changed situation funny. However, I would spe- plex of symptoms throughout their entire course. cifi cally like to emphasize that those Affective For all such cases, the intensity curve is of pre- states which cannot be attributed to disarray must dominant importance. However, this applies only remain unused in constructing the intensity in a broad sense; to be specifi c, there are many curve. I would prefer deliberately to omit more variations in extent. I mention only cases of intes- specifi c information about the shape of the two tinal somatopsychosis that increase rapidly to curves, and their relationship to each other in the almost total disorientation over the entire body. various psychoses that you have studied in greater For the vast majority of acute psychoses it would detail, because this part of our clinical task is still therefore be essential to plot both curves. Take very much under development. I limit myself to the above-mentioned example of acute hallucino- suggesting that the curve of body weight depends sis: There the course is summarized from two predominantly on the curve of intensity, and curves of totally different shape, following the prognosis of individual cases seems related to the overall impression given earlier. The acute onset relationship of the two curves to each other. of illness corresponds evidently to its greatest Gentlemen! I have yet to mention a peculiarity intensity, while the desperate decision of suicide in the curve of extent that is essential to charac- can be viewed just as an external index of this. terizing all those psychoses in which it is of pri- During hospitalization, and probably as a result mary importance: We have seen above that the of it, intensity tends to diminish signifi cantly; and majority of acute psychoses initially take a wors- it shows occasional elevation, related to external ening course. For the curve of extent, this usually causes such as a change in circumstances. Finally, amounts to summation of symptoms of illness, so the Affective reaction is progressively lost, and that we can speak of an accumulating course [W] the intensity curve approaches the x-axis quite of the disease. You will remember my description rapidly. The summary representation of the dis- of composite psychoses. Consider these now in ease process given above could not take such a relation to their curves of intensity and extent: pattern into account; it appears to correspond to a The purest type of composite psychosis is seen one-sided consideration of the curve of extent of when the succession of clinical pictures has come disease, whose shape tends generally to be a about not through an accumulation of symptoms, reciprocal of the intensity curve, that is, the wors- but through some manner of mutual separation of ening form progresses and only later, more or different symptom complexes. Apart from a less rapidly does it approach the abscissa. From cumulative course, we must therefore differenti- this example we also see what yardstick we need ate a substituting course [W], and see that the lat- to represent the intensity of the illness. The ter relates only to the curve of extent. The Affective reaction is the exclusive consideration diffi culty to which I already drew attention in the for this purpose: Its variations in degree give a context of composite psychoses, was that a later good general discrimination. Whatever fear, phase of the illness can simply be regarded as unhappiness, despair, or bewilderment present is augmentation of an earlier phase. This appears in forced on each observer without further thought. a special light, given this consideration. Perhaps I must point out only that a deeper sense of our it would even be correct to restrict the concept of curve of intensity curve requires that all levels of composite psychoses solely to cases character- these different Affective reactions are to be con- ized by substitutional behaviour in the curve of ceived as expressions of the one basic Affect for extent. One could perhaps use different colours all acute psychoses, namely disarray. I even on the curve, to indicate the signifi cant diversity believe that the abnormal euphoria of manics is of symptoms in these cases. due in part to disarray, but surely in other manic Gentlemen! I come now to a brief summary states, such as manic allopsychoses, the evident overview of the outcomes of psychoses [W] and 40 Lecture 40 313 take the opportunity to draw attention to a point The outcome for paranoid states was dealt that I have never found emphasized suffi ciently. with in detail earlier. I want to emphasize once Psychoses, if not conceived too narrowly, are so more (p. 66) that it is expedient to differentiate common that at least two per thousand of the two groups: residual mental disorder which is population are undergoing treatment in asylums, simply chronic, and chronic psychoses which these belonging to the most hazardous and truly develop further. The former fall mainly into two life-threatening illnesses. Even the statistics of different forms. In one, we fi nd, after the acute large asylums, provided that they are not exclu- psychosis has subsided, that certain elementary sively secure units for chronic cases, reveal mor- symptoms persist, either permanently or tempo- tality of about 10 %. If we add the myriad of rarily and hinder recovery of insight into the ill- suicides carried out outside institutions by psy- ness. These are mainly phonemes and delusions chiatric patients who were not hospitalized at the of relatedness. We referred earlier to such cases time, we get a mortality fi gure approaching that as residual hallucinosis. In contrast, other cases of the most diffi cult surgical procedures. Outcome show a straightforward picture—the end-result of in death is intrinsic to all acute mental illnesses, a any acute psychosis: Falsifi cation of contents of fact which, a priori [W] must remain as part of consciousness, naturally without any insight into one’s reckoning. This outcome is sometimes the illness, but often also with no acute elemen- brought about by incidents arising from the tary symptoms. We can call this outcome ‘forg- unpredictability of the sick, such as self-harm, ery of consciousness’ [Ed] or ‘confusion of but at other times as a result of the illness process substance’ [Ed]. The expression ‘confusion’ is itself, as I have repeatedly stressed, along with appropriate to this state, in which we often fi nd many examples. Fever is sometimes present in well-preserved formal logic: Any more extensive such cases, but one can often fi nd—even at forgery of content of consciousness must evoke autopsy—no explanation other than the disease the actual appearance [Ed] of confusion. The process in the brain itself. Between these two requirement for intellectual material to ‘conform’ extremes lie a large number of cases of illness in [Ed], which is necessary for mutual understand- which death is to be explained as a result of insuf- ing between people, falls away here, and there- fi cient nutrition, lack of sleep, and continued fore patients, despite accurate and logical thought restlessness—that is through inanition and resul- processes, become incomprehensible to us. Of tant wasting away. Finally, wound complications, course, linguistic expressions of such patients and internal illnesses should be mentioned. often acquire a different sense, and in particular The exact opposite outcome—in complete may make use of a number of technical expres- recovery—is encountered only in acute or sub- sions invented solely for their own use, and this acute psychoses. Fortunately it is far more com- must further reinforce the appearance of confu- mon than is known in lay circles, averaging at sion. In the expression ‘voices’ [W], you already least 30 %. Nearest to this is ‘cure with defi cit’. know of such widespread technical expressions. Such disabled people do indeed recover, without There are still many such phrases used similarly evident gross defi cits, but are not suffi ciently by mentally ill people in remarkably similar resilient to survive, at liberty and independently, ways. Thus many make use of the expression without help from others. Every adversity they ‘mirror language’ [W] to denote that their own encounter puts them in danger of relapse; and thoughts, in some manner inexplicable to them— hallucinations in particular, usually in the context rather through ‘refl ection’ [Ed]—have become of delusions of relatedness, occur easily in such known to others. I took the following small Affective states. The result is that such patients, sample from a document: after repeated attempts at discharge, fi nally ‘Illness due to withdrawal of My physical regula- remain permanently in the institutions, where tion and of My armour in the civil registry. The they fi nd necessary protection and care, and also collection of lost power-watches that my Holy an opportunity for useful activity. Father gave me, clothing outfi t-power watch, jewel 314 40 Lecture 40

watch, wardrobe watch, sickness watch, health already stressed at the beginning of these lectures maintenance-power watch etc. is in full inter- (p. 54). You might then still suppose that we had course. Because my civil status did not allow me to visit the present ruling imperial house, I have been adequate criteria to claim a reduction of mental ordered into the asylum for the insane in order to endowment [W] only if this had previously been await the end of the collection of my powers and demonstrated to be signifi cant. We might thus the full physical armour. Majesty Elisabeth also have found an essential difference between Margaretha, according to my educator’s time reckoning born 15th. February, 1868.’ innate and acquired dementia. However, this criterion is subject to defi nite qualifi cations, The important outcome in dementia, that is, because, without doubt, much of the mental idiocy or feeble-mindedness, must be discussed endowment [W] is normally lost, as is easily in somewhat greater detail, since the same symp- determined, if you challenge an elderly physi- tomatology often occurs as a primary indepen- cian, lawyer, or mathematician with a test of dent illness. word form in ancient Greek. Loss of positive Gentlemen! We can distinguish congenital knowledge can therefore be seen as abnormal [W] and acquired dementia. [W] Only the latter, only if it has been acquired quite recently, or has which also forms the outcome of many mental been refreshed repeatedly since its acquisition, or illnesses, should concern us in detail here. has found its use. Whether a certain area of Regarding the former, I limit myself to referring knowledge is retained or has been lost can per- you to presentations by Emminghaus [1 ] and haps provide a usable scale for the so-called Meynert [2 ]. In the latter, you will fi nd descrip- memory defi cits. In any case, loss of most com- tions of the main types of deformity of the skull. mon knowledge, assumed to correspond to the Dementia acquired in early childhood should be level of education, can be a valuable criterion of grouped alongside congenital idiocy, because it acquired idiocy. also hinders further development of the brain. We should not regard this as crucial, for there According to Emminghaus (with whom we con- are states where severe defi cits of this kind can cur), in congenital or early-acquired idiocy, three exist, yet patients have full insight into the fact, levels can be distinguished, depending on its and thus retain sound judgment. If such patients severity, based on the level of mental develop- take account of their failures, and at the same ment reached: For the level remaining from earli- time are circumspect and capable of holding their est childhood: idiocy [W]; for that remaining attention, we will rightly be cautious before from later childhood: semi-idiocy [W]; and when labeling them as ‘stupid’ [W]. Special weight has there is no more than an inability to reach full therefore always been placed on a person’s abil- mental maturity from puberty onward: imbecility ity to make judgments; and reduced ability to do [W]. Separating these three from one another is this, was intended to establish the main fi nding— of course quite artifi cial, and in many borderline of idiocy. In fact, we must recognize that this cri- cases cannot be achieved; but otherwise, it is eas- terion, in so far as it includes a quantitative ily applied in practice. element (as we shall soon see, p. 318), in measur- Gentlemen! Let us now move on to examine ing the performance of the organ of association, acquired dementia [W]. Of course we still need appears particularly suitable for use in disorders more extensive and detailed investigation of how of mental activity—because each judgment is we are to understand idiocy or feeble- mindedness. based on this. However, a source of error must be Certainly, it is a ‘failure’ [Ed] phenomenon, a taken into account here: This relates to judgments state of defi cit, and one might be tempted to apply a patient demonstrates towards their own delu- an exclusively quantitative scale, equating idiocy sional ideas, or indeed to all elementary psy- with loss of intellectual endowment [W] or con- chotic symptoms. You scarcely require that a tents of consciousness of any kind. However, you patient distrusts the evidence of his senses and will soon be concerned that normal mental should therefore recognize a hallucination as endowment [W] differs greatly, as I myself have being not real, just in so far as it confl icts with 40 Lecture 40 315 other experiences. Similarly, one might [Ed] [W], so also the primary grandiosity resulting require an open judgment to be made about a from primordial delirium is inexplicable to delusional idea, however absurd it may be in fac- patients themselves, and is therefore regarded no tual terms; yet whoever does this—and you can less as a fact, provided confabulation has not yet fi nd such a view very widespread—disregards gained a fi rm footing. For us, this example is the truest essence of all mental illnesses, which nothing more than a clear a priori [W] symptom consists of the very fact that opposing ideas can of failure—that is autopsychic disorientation— occur, can co-exist side-by-side. Of course this which, within a prevailing feeling of happiness, does not happen without an Affective reaction, takes on a content of grandiosity. Such disorien- even the Affect of disarray (except for a very tation can only be based on dissolution of asso- slow insidious approach of opposites as occurs in ciations, our postulated process of sejunction. If, entirely chronic psychoses). Attempt to balance instead of primordial deliria, it is a question of such opposites made within normal conscious- grandiosity arising through autochthonous ideas, ness is the basis of systematization, already as in the cases of A. and Sch. mentioned earlier familiar to us. Earlier, we learned of the existence (p. 194 seq.), then the mechanism of its forma- of several quite different—and normally mutu- tion is known in only a slightly better way, but, as ally exclusive—groups of ideas lying side-by- before, it is due to sejunction. In such cases, there side in the same organ of consciousness, leading is no real failure of intelligence. Moreover, the to the erosion of personhood, these being out- lack of judgment shown by patients prone to comes of an earlier pre-existing psychosis. I have fi xed ideas, for instance when they produce whin- often drawn attention to the fact that in highly ing complaints derived from their overvalued acute cases of illness, such as most acute attacks idea, is not to be interpreted otherwise; and the of hallucinosis in epileptics (p. 135), analogous viewpoint of Hitzig [ 3 ], who sees it as a lack of juxtapositions of contrasting ideas can be seen. intelligence and a degree of feeble-mindedness is Even Meynert’s intellect, penetrating more quite wrong. By the same token, one could inter- deeply into this phenomenon than any other, did pret allopsychic ideas of anxiety in acute cases, not quite assimilate this fact. When for example that always have contents at odds with reality, but he characterized delusional ideas of paralytics yet with well-preserved allopsychic orienta- simply as ‘idiotic’ [Ed] and fi nds this idiocy itself tion—meant in the strict sense—ideas which vic- to be founded on a lack of association, he toriously assert themselves, as evidence of idiocy. undoubtedly goes too far: ‘When the paralytic Delusions in the somatopsychic area can be of a declares himself to be a rich man, a king, he most far-fetched character without ever permit- shows himself different from the paranoid, who ting one to conclude that there is a lack of judg- almost always raises only claims; but the former ment, a fact that you will understand most easily explains his delusion as facts. The delusional from their particular mode of origin. From these personality must harbour certain attributes: observations, we are entitled to specify a special Something must have preceded [Ed] production form of paralytic, expansive autopsychosis, with- of the delusion, which he would at least have had out concluding that idiocy is present. Where, as to interpret. That the lack of any attributes of a in most cases, idiocy is [Ed] nevertheless present, rich man, or a king, is not noticed by him, it can often be viewed as a completely indepen- amounts to a lack of association.’ These are dent feature. However, sometimes it happens, Meynert’s words [ 2 ]. As you know, however, this and you yourselves have seen a patient of this defi cit in association is a quite general aspect of sort, that fantastic grandiosity is associated with any delusional idea, based on the most funda- well-preserved mental endowment [W], and even mental process of all mental illnesses, namely with good memory retentiveness. You will sejunction. Where the delusional idea comes remember that, at the same time, this patient [4 ] from is therefore of relatively little importance. gave evidence of striking insight into his illness, Just as in such a typical example of ‘paranoia’ but also gave an apt expression of his feelings of 316 40 Lecture 40 happiness, by remarking that ‘one could probably In many cases, feeble-mindedness reveals put up with such an illness’ [Ed]. These grandi- itself through an even more accessible, crude fea- ose ideas, despite their fantastic coloration, are ture, namely a reduction in the number of con- therefore nothing more than a companion piece cepts. I do not mean to identify this symptom to the equally fantastic ideas of anxiety; they are simply with lack of judgment, for which a certain notions of happiness. complexity of the tasks is still required. From these arguments we can conclude that Essentially, it is a lack of discrimination between defi cits of judgment amongst mental patients do related terms. Applying this criterion to more allow one to identify idiocy or feeblemindedness complicated, abstract terms, it can be used to (the lower grade of idiocy), but only to the extent detect even subtle defi cits, which might other- that they relate to matters outside their own delu- wise easily escape notice. Such tasks include the sions or any other existing psychotic elements. differences between ‘civilization’, ‘education’, However, given this proviso, erroneous judg- and ‘culture’ [Ed]; ‘nation’, ‘people’, and ‘state’ ments can probably be used; for example, when [Ed]; between ‘religion’, ‘faith’, and ‘belief’ patients are incapable of judging the behaviour of [Ed], etc. In addition, what we call ‘skill’ [Ed] other mental patients correctly as abnormal, and ‘tact’ [Ed] but especially, choices of an apt when set alongside otherwise appropriate behav- expression, are based on such fi ner distinctions; iour. Also, in planning for the future, a clear and thus a crooked, inaccurate, or quirky expres- inability to make judgments is often revealed, sion can represent the most striking symptom of such as when an accountant can no longer solve a feeble-mindedness [5 ]. By chance, this has led simple arithmetic problem, yet thinks he can to a particular type of wit, as in productions of return to his former position. However, the best that eternal third-year grammar student test of a person’s capacity for judgment is found ‘Karlchen Mießnick’ [W], and the equally in his actions, as we shall soon see. famous ‘Wippchen’ [W] war correspondent of In congenital idiocy we see numerous exam- the Berliner Wespen [W]. However, much coarser ples, that sometimes a person is still able to lead distinctions may also become impossible for an active and useful life, but in simplifi ed condi- these impaired people, for example, between tions. In the rural locations, you come across ‘Prussia’ and ‘Germany’ [Ed], between high-grade feeble-minded individuals every- ‘Parliament’, the ‘House of Representatives’, and where, who can carry out specifi c monotonous ‘Mansions’ [Ed], between mountain and moun- work quite satisfactorily, provided they do not tain range, between lake and pond, between out- need to adjust to any change of conditions. side wall and inside wall, between door and gate, However, if unforeseen circumstances happen between husband, son and brother, between wife, just once, their lack of judgment is revealed by daughter, sister, and girl, between ox and calf, inappropriate actions, often in situations that any steer and cow, and so on. The loss of concepts child would be able to assess accurately. For can go so far that the sense even of simpler ques- example, such a feeble-minded man had, for a tions, such as the season, the skies, religion, is long time, been involved on his own, with the job no longer understood, despite behaviour still of collecting wood, hewn and sawn up in the for- remaining attentive. est, putting it on a wagon, and driving it into the While lack of discrimination between various yard. One day a large stone was lying on the road, concepts reveals a quantitative loss of what we and he ran into it. Instead of moving the stone have called contents of consciousness, the pattern aside, he repeatedly drove his team into it and of conscious activity in the end gives rise to the beat the animals half to death. Likewise, for per- most fundamental symptom of acquired idiocy— sons with acquired idiocy and feeble- mindedness, failure of unsolicited movements deriving from we can make particular use of actions that are intrapsychic activity, the necessary condition for performed under modifi ed conditions, to rate inactivity. In depressive melancholia we already their capacity for judgment. came to know two phenomena: Patients stop 40 Lecture 40 317

talking, and they stop doing anything, as head trauma, unaccompanied by concussion, objective features of intra-psychic akinesia. For nonetheless can initiate degenerative processes in any signifi cant degree of acquired idiocy, exactly neural elements, which then progress indepen- the same phenomenon is entirely to be expected, dently. Of organic brain diseases, multiple sclero- although, according to opinion, it is essentially sis in cases with widespread sclerosis of white cases where idiocy has been acquired somewhat matter is an exquisite example of primary, slowly more acutely, where we see this similarity to the worsening dementia. Such cases are not infre- familiar disease state of depressive melancholia. quently diagnosed from the accretion of paraple- In such cases of more acute coloration it is also gic symptoms, ocular palsies, optic atrophy, or quite natural for it to be impossible to make a even other well-known features of the sclerotic differential diagnosis between this and depres- process. Cerebral syphilis sometimes leads to sive melancholia—which is in itself curable, clinical pictures that are almost indistinguishable and certainly still a viable clinical picture; or from those of multiple sclerosis, but perhaps with between it and primary dementia. Under certain rather more acute coloration, and with its admix- circumstances, reduced retentiveness can also ture of stuporous symptoms. In an adult, follow- be a partial manifestation of idiocy or feeble- ing meningitis I have seen a high level of residual mindedness; but we have also seen that this idiocy, along with profound suppression of veg- symptom is often seen in acute psychoses, in etative functions. The resulting marasmic state circumstances where there is no question of idi- led to death 2 years later. During puberty, a rela- ocy. The situation is similar for attentiveness, tively rapidly developing dementia is sometimes except that this is affected much more frequently seen, which can reach severe levels, without its and in the most varied ways, particularly in rela- being accompanied by other signifi cant psychotic tion to concomitant stimuli; and indeed, the symptoms. At other times, such a primary degen- most severe cases of idiocy will also be charac- erative dementia of puberty develops, accompa- terized by the fact that attention can be activated nied by harmless delusions of relatedness, or captured only with diffi culty, if at all. especially autopsychic delusions of reference, As regards the causes [W] of acquired idiocy and after previous bouts of severe headache. or feeble-mindedness, this is by no means exclu- Outside puberty, I have seen on a few occasions, sively a result of mental illnesses. There are cases of continuous, subacutely developing pri- numerous other causes, which I should address mary dementia that recovered; but I would now very briefl y, so that such important facts are not consider it more appropriate to consider these as completely unknown to you. Idiocy following examples of depressive melancholia, which two head injury is probably organically based. We would in any case be diffi cult to differentiate should probably assume such a link, especially in clinically. We will soon discuss in greater detail, cases where symptoms of concussion appear senile dementia, epileptic dementia, post- after the injury, since we now know that concus- apoplectic dementia, and alcoholic dementia. sion is accompanied by a local change in the Paralytic dementia, separate from idiocy after arachnoid fl uid, with multiple vascular lesions. mental illnesses, will be given special consider- Trauma produced in this way can be so extensive ation as well. Moreover, it should be stressed that that it leads to degeneration of neural elements of there are particular clinical forms of psychosis, the cortex over large stretches. In other cases, the which, if not progressing to recovery, tend to intermediate link of Hydrocephalus internus [W] result in idiocy. In this respect, motility psycho- may play a role, but because we know so little of ses of any kind, especially akinetic motility psy- this rare disease, it seems much more likely that a chosis, are not very different from paralytic proportion of such cases can be traced back to psychoses. head injury. Given the prominence of degenera- Gentlemen! If we now focus on feeble- tive conditions in individuals, the possibility mindedness or idiocy, highlighting those charac- should be taken into account that even milder teristics that differ depending on the different 318 40 Lecture 40 aetiologies, we fi nd only a few relatively reliable and dementia is revealed by both. An example points of reference. Paralytic dementia stands out will best illustrate this: A prison inspector who because of its practical importance, since diagno- has so far conducted himself impeccably, insti- sis of this common disease, upon which depend tutes a capricious rule, in place of the earlier far-reaching implications, depends on detecting orderliness; makes indecent proposals to his dementia. It cannot be denied that most cases of female convicts; fraternizes with his subordi- acute paralysis are associated with early demen- nates; allows himself to be bribed by suppliers; tia—either exclusively, or in company with other spends his time on duty largely in taverns, etc. At acute patterns of disease; and this is prominent his usual dining table he brags about the advan- from the start, and then gradually increases. tages of his position, the many women available Paralytic dementia can now be distinguished par- to him, the incidental revenue that he achieves ticularly by the fact that in most cases, right from through his corruption. If he has to face ques- the outset a change of personality itself is also tions, he probably says that only stupid people included. We fi nd this character alteration [W] would do otherwise. Taken to task by his superi- interpreted by Meynert [2 ] with his usual mas- ors, he has a euphemism for everything; denies tery. The complex, interlocking mental coordina- everything; or construes his behaviour as having tion which represents personality, falls apart in given the wrong impression; judges as false or chronological order, the reverse of their forma- spiteful persons who are hostile towards him, so tion, according to Meynert’s presentation, so that that those not completely aware of detailed con- an ever-simpler, less composite, primary, child- ditions can fi nd almost nothing abnormal in his like personality remains, which in turn becomes speech. The owner of a renowned millinery shop individualized sensory activation of dominant made romantic overtures in a most unabashed impulses for behaviour. This character change is manner, which was also most offensive manner based on aggravation of association through loss to well-liked customers, while he served them. of brain elements. Healthy intelligence includes Another made so bold, on an open street, to begin in its thought processes both synergistic and an abbreviated overture to love by exposing his antagonistic impulses, like the coordination of penis. Nonsensical purchases and acquisitions of movement through synergistic and antagonistic patients fi t in here. Thus an offi cial, of very mod- muscles; but it also has an effect on the most erate means, bought an upright piano, a harmo- complicated area for coordination, since it con- nium, and a barrel organ, all in 1 day. Quite structs personality; and in moments of brain correctly, Meynert remarked that a patient with activity across the whole life-span, while it is advanced paralysis still has the motivation for all defi ning each of those moments, it also assimi- such senseless actions. One undresses himself to lates all those previous experiences. In paralytics, nakedness, and makes the excuse that children from early stages, impulses for action can no lon- were also walking around naked. The fact that he ger perform in accord with that unknowable is not a child does not perturb him. Another coordination; and we understand that the charac- declares himself to be God, yet humbly kisses the ter change represents a smooth transition from doctor’s hand because the trappings of superhu- the forewarning stage. The change in personality man existence never enter his mind. However, so described, for paralytic patients, therefore has even in early cases of paralysis, exactly the same an origin very different from that described ear- nonsensical actions occur; to him the motives of lier, for manic patients. It is based on defi ciency the moment are suffi cient. Although senseless, [Ed] in mental activity and consequently on demented actions are characteristic of paralytic increased predictability based on immediate patients; the change in personality that we take stimuli, whereas in the latter case, there is an from them is only one of the conclusions we can excess [Ed] of mental activity, but a levelling of draw: This is actually a failure phenomenon, a ideas. The changed personality of paralytic failure of associations, the exclusion of links to patients is revealed by their words and actions; time and place. I emphasize this, because, in your 40 Lecture 40 319 expert activities, you will often have to deal with Paralytic dementia fi nds a further early criminality of paralytic patients. A judge will not objective indicator in the smooth and inert, and at easily recognize that a changed personality is times decidedly idiotic facial expression that is abnormal; but if there is evidence of idiocy, sometimes seen. This facial expression is all the namely dementia revealed by actions—he will more remarkable in that it can be associated with readily concede the point. a certain emotional lability, slight irritability, or Nonsensical actions can also occur at times sudden fl aring to boisterous merriment on minor when no impairment has appeared in a patient’s occasions. prudent outward behaviour and formal attitude. It is particularly important to distinguish para- At other times, manic behaviour appears, as a lytic dementia from post-apoplectic dementia part of paralytic mania, along with myriad drives [W]. It is known that most cases of apoplexy have to action, and also the levelling of ideas. However, outcomes where there is no signifi cant defi cit in actions resulting from this alone, such as wander- intelligence. For some cases however, this rule ing around, travel, making plans, and undertak- does not apply, and we see obvious idiocy. We ings of the most diverse kinds, have a different can explain this behaviour as major atrophy in the mode of origin and therefore intrinsically have affected hemisphere, by an ancillary fi nding less direct bearing on the simplifi cation, charac- made by Hitzig, that after specifi c ablation in the teristic of dementia. brain there is often atrophy of an entire hemi- A second equally important characteristic of sphere. In my experience post-apoplectic demen- paralytic dementia, in many cases, is inaction tia has only one specifi c sign, that it offers most and silence, which, a priori [W] is quite strik- severe emotional lability, aptly termed in English ing. It is initially noticed that patients at home ‘emotional incontinence’ [Ed]. tend to become silent and stop doing things, yet Epileptic idiocy [W] usually has likewise cer- at fi rst continue professional duties in the usual tain characteristic features. These consist imme- way. For example, an offi cial remains at home diately of irritability and intolerance unique to 1 day; probably he also answers reproaches of most epileptics, in their tendency to display brute his family by explaining that he is dispensable, force and occasional fi ts of rage. In addition there yet makes no apology for his absence. If you may be an obviously ostentatious, quite superfi - talk to him about this, all you get is euphemisms, cial piety among epileptic patients with idiocy perhaps a promise to get back to the offi ce; but that one might take to be no more than a purely actually he remains at home, passive and indif- chance encounter. Finally, there is often—but not ferent. In such cases, the incentive for conversa- always—a surprisingly intact retentiveness in tion often encourages the patient’s thought memory, apart from just after an attack. The loss processes and answers to become appropriate of concepts is often striking, revealed as a twisted, and correct; nor need there be any sign of speech clumsy manner of expression. Not uncommonly impediment. It is therefore often diffi cult for this clumsiness in selecting words reaches the investigators to understand failures of action, level of isolated paraphasic infelicities. You will which are very characteristic, and to judge them fi nd a good example of these peculiar manners of accurately. However, in such cases, on closer expression in my Krankenvorstellungen [6 ] [W]. examination, one will almost always fi nd other Alcoholic dementia [W] is indicated particu- indications of the diagnosis of paralytic demen- larly by blunted intiative and brutality, which is tia. Experience shows that patients eat unusu- often very pronounced when any defi cit in mental ally large meals, in a greedy manner; tests of endowment [W] is limited in extent. Later, how- memory retention show this to be reduced; side- ever, it always includes a signifi cant defi cit in the by-side terms, such as Prussia and Germany most common knowledge. Obviously, signs of cannot be distinguished. These matters are chronic alcoholism are always present. equally important when prominent spinal symp- Hebephrenic dementia is the most general toms are found. indicator of an immature stage of development, 320 40 Lecture 40 corresponding to the age of puberty. Hence we see retentiveness and corresponding loss of memory childishness and foolishness in behaviour of such for the immediate past. In contrast with this, the patients, highlighted particularly by Kahlbaum memory of the distant past can be well retained. and Hecker. In the near future, I would like to use Every now and then, a tendency to confabulate, the idea of ‘mental laziness’ [Ed] as to some and delirious behaviour at night can intervene. extent specifi c for hebephrenic dementia. It is For age dementia, physical complications are often expressed in quite characteristic ways. quite common: senile tremor, weakness of sphinc- Patients answer questions randomly just as it suits ters, an unhelpful, wide-legged, tripping gait, and them, no matter whether or not they then contra- a bowed body posture. None of these complica- dict themselves. Questions that were previously tions has a close relationship with senile atrophy answered with ‘yes’ [Ed] are soon to be answered of the brain, any more than do pseudo-apoplectic with ‘no’ [Ed]; or the answer consists of a most attacks, yet to be mentioned. These are probably non-specifi c style of talking. Gradually during the based on hydrocephalic effusions, and may be course of examining a patient an unmistakable simple faints, sometimes longer- lasting somno- unwillingness or discontent becomes clear, linked lent or comatose conditions, and they differ from to overburdening of mental effort. From leading apoplectic attacks by the absence of unilateral questions, one probably also learns that thinking symptom profi les. Moreover, patients usually sur- itself is a strain on a patient: An unwilling ‘turn- vive such attacks, even though one of them will ing away’ [Ed], or the expression ‘Leave me fi nally lead to death; and, while recovering from alone!’ [Ed] Under some circumstances, an actual them, weakness and disability of the legs, usually outbreak of anger, signals the end of the interview. coupled with bladder weakness, is the most sur- It is hard to arouse the attention of such patients, prising symptom. Moreover, such attacks can also and particularly diffi cult for purposes of making be seen without any degree of age-related demen- an examination. Memory retention is often sur- tia having existed previously or subsequently. prisingly good, if judged by memory for particu- Senile brain atrophy or senile involution of the lar events. Moreover, one may be surprised by brain is mapped as an anatomical substrate for such patients, in that they occasionally reveal age-related dementia. That a preceding apoplectic fragments of knowledge, for example speeches or attack can give a premature impetus to the same other learned and memorized material, which one changes in the brain, and to corresponding clini- seeks in vain during a systematic examination. cal fi ndings has already been mentioned above. Their facial expression remains one of hebephrenic idiocy, even at times more-or-less distorted— yet mostly very lively—as one might anticipate, References from the level of idiocy. You will fi nd a very obvious case of hebephrenic idiocy after chronic psy- 1. Emminghaus H. Die psychischen Störungen des chosis under my Krankenvorstellungen [7 ] [W]. Kindesalters. In: Gerhardt CJAC, editor. Gerhardt’s The indicator of a twisted, oblique, and inappro- Handbuch der Kinderkrankheiten. Tübingen: Laupp. priate manner of expression is very pronounced in 1887;8. 2. Meynert Th. Klinische Vorlesungen über Psychiatrie many cases, which is easily understood, given the auf wissenschaftlichen Grundlagen für Studirende und chronological age of patients; but in my experi- Aerzte, Juristen und Psychologen. Vienna: Braumüller; ence, in hebephrenia, it is not at an age-character- 1890. p. 274–297; 221–222. istic level, nor is the appearance of inertia of 3. Hitzig E. Über den Querulantenwahnsinn, seine nosol- ogische Stellung und seine forensische Bedeutung. thinking described above. Leipzig: FCW Vogel; 1895. Age-related dementia [W] leads mainly to gen- 4. Wernicke C. Krankenvorstellungen aus der psychia- eral mental dullness, an egotistical narrowing of trischen Klinik in Breslau. Breslau: Schletter. vol.3, interests, which can go as far as the most unwhole- Case 25. 5. Wernicke C. Ein Fall von Schwachsinn leichteren some greed and obvious unkindness to family, Grades. Mschr Psychiatr Neurol. 1897;1:398–409. sometimes rising even to moral aberrations. The 6. Wernicke C. Krankenvorstellungen vol.2, Case 24. main indicator is, however, the almost total loss of 7. Wernicke C. Krankenvorstellungen vol.2, Case 28. Lecture 41 41

• Dissimulation and simulation of mental Clearly, it is only in this way that you can learn disturbance anything more complex about the thought pro- • Functions of institutional treatment cesses of a patient. A prerequisite for this is either • Final remarks on the prospect of a pathologi- the goodwill a patient shows towards communica- cal–anatomical rationale of the psychoses tion, or in illnesses such as mania, when there is an intrinsic desire to communicate. If such prerequisites do not apply, it can happen that patients remain intentionally silent for weeks, months, Lecture even years, or speak only on exceptional occasions. Amongst the best proven ways of bringing Gentlemen! such patients to speak, is a clinical presentation, These lectures can hardly be intended to intro- although of course you should be prepared for all duce you to the practical medical specialist train- manner of surprises and, under some circum- ing course for the asylums. Whoever wants to stances, even quite dramatic turns to the conversa- dedicate himself totally to our specialty is of tion. This deliberate silence [W] naturally has course expecting to spend a considerable part of nothing in common with mytacism, the incapacity his life in mental institutions, and among men- to speak. Usually, it involves negative, suspicious, tally ill people, a task that in some respects you and embittered patients, overcome by ideas of per- can imagine is not suffi ciently challenging, but secution and grandiosity—those paranoid states also not suffi ciently gratifying and interesting. which have already been mentioned. On the other However, each of you will, at some time, be in a hand, it may happen that the silence is deliberately position of deciding on the placement of a patient restricted to those points that a physician needs to in a mental hospital, or having to issue a certifi - know, in order to assess the mental illness; that is, cate that health has been regained, and it is there- the patient dissimulates his delusions. Most fre- fore imperative to give you some orientation on quently such dissimulation [W] occurs in patients practical issues, including the specifi c tasks of who have long survived in a calm state, after hav- the asylum, and the simulation and dissimulation ing previously come through an acute period of of mental illnesses. illness. Having now regained the discretion that is Let us not underestimate the fact that a major necessary to monitor their statements, they are source of evidence in psychiatry is language, in inspired by a lively ambition to rid themselves of other words, the messages that patients themselves restrictions to their freedom, that is, life within a provide about the content of their consciousness. mental institution. They therefore strive, with

© Springer International Publishing Switzerland 2015 321 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9_41 322 41 Lecture 41 greater or lesser success, to deny their delusions, unavoidable, and it was therefore, against vigorous once they have found out what ideas a physician resistance, that artifi cial feeding was enforced might regard as abnormal; this having been learned several times, at which point, he decided to give up in any favourable circumstance, such as their pres- his resistance. After several weeks had elapsed the ence during examination of similar cases. family then decided, much against my advice, to However, in such patients, it is always possible, by remove the patient from hospital treatment. asking appropriate questions, to determine the Apparently they were right, for there was no fur- truth. For this purpose, the method consists of pro- ther recurrence of the delusions he had expressed voking the patient’s judgment about his symp- previously, and he resumed his earlier work in a toms, as previously observed, and thereby business. Even though it appears that, with a his- determining that actual insight into his illness— tory like that, the doctor got it wrong, yet this very the main criterion of health—is still missing. If the case is the most irrefutable evidence that in all patient’s silence persists in a stubborn manner, on similar cases no greater benefi t can be rendered to points that matter, then you cannot consider him the patient than his being forcibly transferred to healthy. Sometimes, it turns out that the patient the mental institution. To be specifi c, when, in cannot give the information you need, because, as such cases, recovery is possible—relatively so, as part of his illness, a memory defi cit exists; and it appears in this case—it is brought about fi rstly then, naturally it is not required that the patient by the fact that the morbid ideas were overcome admits them. Generally, patients seldom deny their by his own forceful protests; and there is no more delusions; and even where it seems appropriate to powerful protest against delusions that are not them to do so, they do it only reluctantly, and are completely fi xed, than to realize that they inevita- easily driven to adjust the boundary where expedi- bly lead to his being detained, against his will in ency might prevail rather their delusion. Compared an asylum for the insane. Thus the patient had with such frequent cases, it may happen, albeit to thank his undeniable improvement, perhaps rarely, that a patient with early-stages of a chronic even his healing, had this been achieved mean- worsening psychosis dissimulates his delusions, at while, mainly to the fact of his transfer to the a time when he is himself still unclear how far the mental institution. (I must now correct these lines, intrusive ideas and alleged observations corre- written about 10 years ago. The patient’s myta- spond to reality. He declares this or that strange cism resumed after a year, and later he became expression he had used, to be a joke or a misunder- incurable.) standing, or he attempts to give it a more harmless After such experiences, we must pose the character. In the end, he probably becomes indig- question: To what extent should everything that is nant, and denies the questioner the right to meddle said by a patient claim the value of an objective in his affairs. In such cases, reliable information symptom? Rather, are not utterances of patients from the family or other persons close to the completely dependent on their volition? Under patient is essential in order to justify crucial deci- some circumstances, could not a healthy person sions that the patient be detained against his will, imitate the speech of a mentally ill person; or, for observation in an institution. Such information apart from this case, could not a patient intention- could be about comments and actions that have ally say things other than what he is actually raised suspicions of mental illness. A case like this thinking? Our standpoint here is briefl y as fol- is before me at present, where my encouragement lows: Language may indeed be infl uenced very led to the patient being admitted voluntarily into much by volition; yet it still remains a function of the institution, where however, his trust was lost consciousness, that is, of that brain activity which on the very next day, when I had to refuse his dis- we have to examine. This function may not charge; from then on, he refused to give any fur- always be so simple, so that the willingness of a ther information. After that, he existed only for his patient cannot easily be assumed to comply discharge, and fi nally sought to force this through, appropriately with questions addressed to him. by refusing food. Under the circumstances, I was Nevertheless, with proper conduct of the physi- extremely embarrassed to use force, but it was cian, and as soon as the patient’s trust is won, 41 Lecture 41 323 only seldom do we fi nd that a mental patient’s of feelings of mental illness coming over him, words are at odds with what is in his heart, and that fact seems like putting a gift into his hands. intended to mislead the doctor. Where a patient is At least the prospect of being transferred to a prone to violent Affective responses, then the mental asylum holds no terrors for him, and self-control that would be necessary for this therefore has no power to motivate his self-con- approach is already ruled out. Usually, the rest of trol. If this is so, a few days of indulgent, confi - the patient’s behaviour enables a reliable judg- dence-inspiring treatment in a mental hospital ment to be made about whether or not he comes usually suffi ces to allow the clinical picture to to meet the doctor willingly. In some cases how- emerge in purer form, and for arbitrary excesses ever, the particular decision on whether, and to to disappear. Of course, there often remains a dis- what extent, a mental patient is simulating, can concerting clinical picture, such as one that does be made only with great diffi culty. Two aspects to fi t any form of illness, or crude violence, or all should then not be ignored in the assessment. manner of shameless acts, coprophagia, etc. Firstly, there are mentally ill people who confront However, such modifi cations become under- their nonsensical intrusive thoughts en masse standable to us, in that, in such cases we are deal- [Ed] with their own quasi-criticism, so that, for ing with morally depraved and neglected people, example, they even laugh about the nonsense that coming mainly from families where they were they produce in given moments. These patients forced to become criminals. In other cases, it usually belong with those otherwise character- turns out that, although mental illness is simu- ized as motility psychoses. The content of the lated, it is nevertheless based on either congenital delusions is often religious, characterized simul- or acquired feeble-mindedness, often compli- taneously by both fantastic coloration and repeti- cated by epileptic seizures. Nothing is as hope- tiveness. The repetitiveness often rises to the less as wanting to turn around malingerers of point of verbigeration. The rest of these patients’ such kind by coercive measures such as starva- behaviour dispels any doubts over whether they tion, etc. Leaving aside these two possibilities, had been serious about their delusions, even after the number of remaining true malingerers, as said achieving success in getting them to confess that above, is very small. they had just been talking nonsense. Of course Gentlemen! During the course of these lec- they then tend to reinforce what they said: It just tures I have emphasized countless times that in came to them; they could not explain it them- terms of the treatment of mentally ill people [W], selves. This phenomenon has a certain similarity your main task consists of timely transfer of the with the compulsive speaking we encountered in patient to a mental institution, forcibly if neces- the same class of patients. The second case is sary. Now, there are experienced alienists who more diffi cult, where usually even external cir- adopt the view that, by properly setting up a pri- cumstances raise the suspicion of simulation. vate residence, the same can be achieved as in This usually involves prisoners, in whom there institutional treatment. We must realize immedi- are suspicions about whether it was true mental ately, when discussing the purposes of institu- illness, or simulation; and they have therefore tional treatment, that this is not entirely true. been sent to the mental institution for observa- Institutional treatment [W] has the following tion. Experience teaches that most of these indi- tasks to resolve: viduals are [Ed] actually mentally ill, even when they are apparently simulating. Pure simulation 1 . Monitoring of the patient [W]. This includes without existing mental illness or feeble- restriction of personal freedom, not to be mindedness is rare in itself, so that even the most separated from institutional treatment. Only a experienced alienist sees only isolated cases. mental institution, with its internal services If you consider that a mental patient usually specially organized for this purpose, its seclu- experiences the inconvenience of imprisonment sion and various measures to make escape of with all the embarrassment of someone who is the patient more diffi cult, can, at the same mentally healthy, and therefore takes advantage time, grant the patient individually benefi cial 324 41 Lecture 41

measures of personal freedom. Where walls incidents caused by unpredictable actions of and fences are missing, as in the so-called mentally ill patients. Even diet makes many ‘free institutions’ [Ed], watchful staff ensure mental patients in need of constant medical that patients will not go beyond the terrain of attention. the institution. Of course, escapes from the 3 . Maintenance of social instinct [W]. Due to institution can never be completely avoided; changes in content of their consciousness and at least those in penal servitude and similar the varying degrees of disorientation and places, with refi ned cunning, and bent only on scope thereby imprinted, many patients are escape, will always fi nd ways and means to almost totally deprived of means of communi- gain their freedom; but here the main obstacle cation with the outside world, and especially standing in their way is not sentries with with people from their own environment. loaded weapons, as tends to be the case else- They are then either continuously resistant, or where: With regard to precautions taken to totally passive and, in any case, in a helpless prevent escape, a mental hospital should in no position, in need of intervention by other peo- way be reminiscent of a prison or penitentiary. ple. Here the deep-rooted herd instinct that Prevention of escape is certainly not the main patients often still retain, comes to the aid of purpose, or one of the main purposes of the medical services, where other means of com- institution; generally one might even claim munication have been applied in vain. The that escape of a mental patient is a harmless example given by other patients in the same event. Nevertheless, a well-established insti- room, who likewise get up, wash, and dress tution will make escape so diffi cult, that at themselves, eat unaided or let themselves be least among those patients where it matters, fed etc., also has its effect, by regular monoto- one can be completely reassured. Foremost nous repetition, in such cases. Participation in amongst such cases are those at risk of sui- walks, in collaborative games, devotions, cide, but next, the not-so-rare cases of delu- singing practice, etc., produces an educative sional patients whose sharp focus is hostility effect in a similar way. against specifi c people. A good institution 4. The possibility of total isolation [W]. In some also provides the best guarantee against any situations, it is desirable to keep patients form of self-harm. totally isolated for hours, days, or weeks with- 2. Constant medical observation [W]. In no out the room or their clothing providing any other type of patient is it so important that means for self-harm. This requires specially any change in state should be detected imme- equipped rooms without any—or with only diately by the doctor, and necessary mea- fi xed— furniture, with solid smooth walls, the sures put in place. Where a patient has same for the fl oor, and with solid, ideally otherwise lost all orientation, he often shares opaque windows. Similarly the bed and the his confi dence with a physician, because the patient’s clothing can be made from fi rm latter may bring the greatest understanding material. We call rooms made up in this fash- to information so imparted. In these cases, ion ‘calming rooms’ [Ed]; the institution pro- responses of an expert physician cannot be vides them, and, even if they are seldom used, replaced by any other, at least by well-mean- and assigned only for specifi c indications, ing relatives who have often been affected in they belong among the most useful and salu- the fi rst place by changed feelings and beliefs tary installations of the institution. Citing the of the patient. In good institutions, doctors special indications for this would go beyond are together with the patients for a greater the scope of this lecture. Moreover in good part of the day; in any institution a physician institutions—and this is particularly stressed— is immediately accessible when a need arises, isolation of patients is always instituted only a situation that occurs quite often, be it due to by special order of the physician, and under- the seriousness of the clinical picture, or to taken under his supervision. 41 Lecture 41 325

5. Appropriate application of means of coercion richness of our clinical material if I tell you that [W] as may become necessary. Use of force is I still encounter cases—indeed not so rarely— required if the patient threatens to harm him- that are so markedly different in symptomatol- self, has already done so, or does not want to ogy and course from anything seen before, that I leave wound dressings on, and so on. The have to classify them as ‘new’ [Ed] and ‘never most protective process under these circum- seen before’ [Ed]. Every older alienist says the stances is a straitjacket with long sleeves that same, as I have discovered through many enqui- are closed in front, and taper down into a type ries. Hence, there is great diffi culty in getting an of belt. In an emergency, securing the patient’s overview of the great body of clinical material, arms to the sides of the bed, or application of and keeping it in mind. The diffi culty of fi ltering the so-called force belt across the patient’s out only the basic facts that can be taken from torso may be required in addition, so that the the material is even greater; and fi nally, we have patient is prevented from changing his posi- the most serious task of selecting the most com- tion too much in the bed. Only a mental insti- mon, or the most important, types of illness for tution offers the appropriate paraphernalia for any attempt at an objective and true-to-life this purpose—or it should at least always have representation. them available. Furthermore, only a mental Certain errors are associated with my task, institution enables continuous supervision of which are inextricably linked, to which I should such coercive measures by medical staff. not avoid drawing attention. My presentation is based on approximately 5,000 carefully kept Gentlemen! We have reached the end of our medical records that have been prepared over the refl ections. And it could be that the large series course of 15 years, under my direction and of new facts with which you have become famil- supervision. Unceasing study of these case his- iar, and the so-very diverse cases of illness that I tories, their monitoring by continuous observa- have presented to you, have misled you into tion, the comparison of similar cases with one believing that you have thoroughly learned about another, in addition to special study of individual existing mental illnesses. I must regretfully dis- symptoms in these patients, required such an agree, and make clear to you that we have not expenditure of time that it was impossible for me gone beyond the fi rst basic concepts of psychia- also to evaluate studies of other authors in the try in these meetings. You will have plenty of literature to the extent that would have been nec- opportunity to convince yourself of this, when essary for my purposes. The individual cases you face the bewildering variety of cases in prac- gave me the advantage that they were very fully tice. I can only take credit for having sorted out examined for my purposes, especially since, certain of the simplest cases from the rich mate- through my photographs, which form an integral rial of my clinic, and thus having gradually pre- part of our medical records, I usually managed to pared you to approach more complex cases with call to mind the entire personality. You will some understanding. I need not emphasize that therefore fi nd many things not mentioned, this diffi culty applies mainly to acute cases. By thought to be important by discerning profes- my naturally very-subjective estimate, those sional colleagues, as well as everything that was acute cases that I have discussed here may make superfl uous to my immediate purpose. In the up only about half of all cases. You can get a naive viewpoint of Griesinger [ 2], who relied clearer idea of the richness of clinical material almost exclusively on material from other insti- that is to be mastered, from the three volumes of tutions in his textbook—material not even clinical cases, totalling over a hundred, which observed by him—in which you will probably I have published, from my clinic [ 1 ]. fi nd the more culpable errors of an opposite type. Overwhelmingly, these were selected for teach- I cannot therefore lay claim to completeness. ing purposes, so that simpler cases predomi- Thus I deliberately did not touch on issues of nated. You might get the clearest idea of the practical importance in judicial psychiatry, an 326 41 Lecture 41 omission not based on a lack of personal experi- results in a striking and systematic preference ence. If you require further guidance in this area, for motor nerves. You should be familiar with I refer you to excellent guidelines on judicial the fact that we are now inclined to view degen- psychiatry by A. Cramer [3 ]. Moreover, for the eration of these most distal ends of the motor diffi cult area of idiocy and imbecility you will nerves always as the result of disease of those fi nd extensive instruction in Emminghaus’ book nerve cells, related to motor nerves by means of [ 4 ], already-mentioned; and for the area of sex- the axonal processes and fi bres of the ventral ual pathology, not a tasteful read for everyone, roots. We have long been accustomed to con- the book by von Krafft-Ebing [5 ]. sider ganglion cells of the anterior horn as nutri- Despite these shortcomings, I believe that I tive centres of the ventral root fi bres. Disease of have generally pointed you in the right direction, the ganglion cell itself can thus remain inacces- and opened up for you some understanding of sible, and concealed from our current methods of psychoses. I also believe that I have gained a investigation. It must now be apparent to every fi rmer foundation, upon which further work can unprejudiced person that the one group of psy- be built. There can be no doubt about the goals choses for which a constant anatomical fi nding that hover over us. In addition to broader expan- is available, namely progressive paralysis, ini- sion in teaching of clinical pathology, our imme- tially produces a similar fi nding—that is fi bre diate task is to substantiate the pathological degeneration which apparently does not affect anatomy of the psychoses. Just 20 years ago, you ganglion cells. I refer to my earlier presentation had to prepare yourself to be ridiculed by clinical in this regard. As Lissauer [6 ] has shown, this representatives of our profession, if you claimed loss of fi bres is now been proved to be a this goal to be in any way achievable in the future. systematic loss, corresponding to secondary This exclusively critical—and sceptically bar- degeneration; and Lissauer also succeeded in ren—viewpoint can expand with no danger to demonstrating the source of this secondary itself. In a few concluding remarks, I want to try degeneration in the destruction of entire cell lay- to show how very much closer we are now to ers, in certain cases. Where he succeeded with achieving that objective. the laborious method of tracking the granular I proposed that, for the vast majority of acute cells, we now see brilliantly confi rmed in and chronic psychoses, anatomical fi ndings are Starlinger’s [7 ] work, using the improved Marchi still pending. Alleged fi ndings, listed in most method. A glance at the table accompanying this textbooks, such as opacity and thickening of the work is suffi cient to bring out the systematic pia mater; increase or decrease in blood supply nature of all these degenerations. Likewise, to the brain; oedematous infi ltration of the brain; thanks to the improved method of Nissl [8 ], increase in ventricular fl uid, and so on, cannot be pathology in ganglion cells is now established used in any way, since they belong among the with certainty in every case of paralysis. As you most common fi ndings in the widest variety of know, paralytic psychoses usually present with a physical diseases; and are caused very often by certain added component of idiocy, right from the type of agonal process, position of the corpse, the beginning. It is probably no coincidence that and other random infl uences, and by complicat- in this very group of psychoses, in which there ing physical illnesses. It would only obscure the are such coarse defi cit symptoms, that a constant facts, if you wanted to give any value to such anatomical change—fi bre degeneration in the fi ndings, for mental illnesses from which patients cortex—has been demonstrated fi rst. On the survive. For most psychoses, their basis in path- other hand, it has been shown that psychoses in ological anatomy stands just as it did for cases of other aetiological groups—senile, alcoholic, and degenerative polyneuritis about 30 years ago. epileptic—show the same changes in the cere- The breakthrough in recognizing these cases bral cortex in the form of axonal damage and came by detection of microscopic alterations in loss, once they have led to defi cit symptoms, just most cross-sections of peripheral nerve, and as in paralytic psychoses (p. 292). Widespread 41 Lecture 41 327

fi bre loss in the cerebral cortex is therefore not pathogenesis. I remember that possibility, when I peculiar to the paralytic process, since the cellu- mentioned a case of agitated confusion after lead lar pathology, substantiated in the case of paraly- poisoning, and in a case of unusually pure aki- sis, according to Nissl’s authoritative account, netic motility psychosis in the last weeks before represents a form of pathology not specifi c to death from long-lasting pulmonary tuberculosis; paralysis. One should therefore be prepared for and further, in various forms of alcoholic psycho- the fi nding that, as a result of alcoholic, senile, sis and the frequent occurrence of tuberculosis, and epileptic aetiology, analogous pathology of as mental illnesses worsen. If we consider that the ganglion cells will be present in the cerebral the paralytic process in the cerebral cortex also cortex. Where it does not reach the level of a carries the imprint of degenerative neuritis, at defi cit symptom, as in all curable acute psycho- least in its usual outcome of fi bre loss, then we ses with an alcoholic, senile, or epileptic basis, are forced to accept the consequence that, for a we might expect to see cellular pathology with- large proportion of acute psychoses, we may fi nd out actual degeneration of fi bres, that is, a cur- the same as in degenerative neuritis of the periph- able process within the ganglion cell. This is one eral nervous system, that they should be attrib- line of thought for which an anatomical basis can uted to the toxic effects of alcohol, of syphilis, be expected in the not too distant future, apply- and of tuberculosis, impacting on ganglion cells. ing to a large number of acute psychoses. Gentlemen! I have repeatedly pointed out that Other facts leading to the same conclusion are paralytic psychoses, in their symptomatology, purely clinical. Already, the one fact that we have not only differ greatly one from another, but often come to know is that a particular form of psycho- represent precisely the same diseases as psychosis, accompanied by polyneuritic changes of the ses with other aetiologies. These cases may even peripheral nervous system, can be assessed for lack the accompanying early signs of dementia, some internal relationship between polyneuritic as I have stated, especially for paralytic mania. disease and that which plays out in the brain, and Since we cannot doubt that there are general rea- produces psychosis. In its symptomatology, this sons for paralysis mediated by a tangible patho- polyneuritic psychosis is identical with the spe- logical process, we must also ascribe to the most cifi cally senile psychosis, presbyophrenia. For diverse paralytic psychoses a characteristic ana- the latter therefore, we can expect the same tomical fi nding. It would be most strange if the change in the brain, especially when we consider same mental illnesses of different aetiology that the symptom of severe memory defi cit is should not likewise yield anatomical changes in common to both diseases. That presbyophrenia is the same localities, although perhaps of a differ- not accompanied by polyneuritic palsies, may ent type, in consequence of a different toxic lead us not far astray here, since polyneuritic psy- effect. choses often have to be diagnosed—on the basis Gentlemen! I have repeatedly emphasized that of the clinical picture—without polyneuritic mental illnesses should be regarded as serious changes being found in the peripheral nervous and life-threatening, compared to other life- system. A truly remarkable case of this kind later threatening internal diseases. Often they are revealed itself to be undoubtedly paralytic. When accompanied by fever, without any complica- the clinical picture of polyneuritic psychosis is tions being found to explain the fact. At other seen, along with fi bre loss in the cerebral cor- times, for no apparent reason, they lead to a rapid tex—but without the anticipated ‘polyneuritic’ decrease in body weight and death, without any [Ed] changes, that is, degenerative neuritis—then disease process being detected in other vital it must be interpreted as an independent illness of organs. In such cases, should not the brain itself the brain, occurring without disease of the periph- be the starting point of the observed clinical eral nervous system. Conversely, there is some symptoms, and also the site of the illness, and possibility that other clinical pictures of disease that these should be detectable, at least micro- can arise from the same basis as the polyneuritic scopically? This expectation has, in fact, been 328 41 Lecture 41 confi rmed in a series of acute psychoses leading are likely to be ruled out completely by such to death, in which the brain has been examined. I behaviour. Even for cases of pure mania, which mention in particular, cases by Cramer [9 ] after completely match the manic phase of circular insolation; cases likewise by Cramer, of the so- psychosis, this conclusion is already true, because called delirium [10 ]; and, fi nally, a very recent we generally encounter conditions of increased work by Alzheimer [11 , 12 ]. In all such cases excitability of the nervous system without major extensive illness can be demonstrated either by anatomical changes. In contrast, for independent Weigert’s method for staining myelin, or using cases of Affective melancholia, which we traced the Nissl method with methylene-blue for stain- back to general reduction in excitability in the ing ganglion cells, be it of fi bres, or cortical gan- organ of association, the possibility of more glion cells, so that the generality of this fi nding in severe damage by analogy with the peripheral most cases of very severe psychoses is not to be nervous system is admitted for some exceptional sidestepped. Determining the nature of this cel- cases, and corresponds fully with the experience lular pathology is still essentially a task for the that Affective melancholia, in exceptional cases, future. For the time being, it suffi ces our clinical is incurable, and leads fi nally to dementia. I have needs that we can distinguish relatively benign deliberately avoided discussing hitherto the and reversible forms of disease from destructive mechanisms of the functional disturbance that forms. Paralytic cellular pathology belongs bring about opposing states of intrapsychic hyper- amongst the latter. Moreover, an important result function and loss of function. However, I must of Alzheimer's work seems to me to be that in mention here, Meynert’s [13 ] quite plausible certain diseases of ganglion cells, the glial cells hypothesis, according to which, in the case of are also affected very early; but in others, this is neurosis in a subcortical vascular centre—proba- not the case. The latter seem to represent rela- bly involving the medulla oblongata—which tively benign, milder forms of the pathology of leads to the opposite states of diffuse hyperaemia ganglion cells. Correspondingly, in paralysis we and anaemia of the organ of association. tend to encounter, almost without exception, glial Permanent anaemia could, under some circum- cell proliferation; yet other non-paralytic psycho- stances, lead to real damage to neural elements, ses of severe form, such as acute motility psycho- which indeed seems quite understandable to us. ses with rapid outcome in dementia, belong Here I remind you of the contrast, in Meynert’s amongst the severe forms with disease of the gan- ingenious approach, between functional hyperae- glion cells, connected with some stimulatory mia due to ‘nutritive attraction’ [Ed] of tissue ele- effect exerted on glial cells. ments, which allows very fi ne localization, and Do the few cases I have in mind allow us to the diffuse hyperaemia, which shuns any localiza- conclude that all [Ed] acute psychoses, as well as tion. Just as with mania and melancholia, one will the less severe cases, would reveal similar ana- have to assign to the ‘functional psychoses’ those tomical fi ndings, were they to reach autopsy? acute and chronic psychoses arising and persist- Admittedly they might not be tangible, but yet ing exclusively in the context of increased, yet not visible microscopically. In my opinion this ques- abnormality of, function. What I have called the tion cannot be supported. We must concede that ‘fi xed ideas’ [Ed], with all their subsequent ‘functional psychosis’ is a broad area, even if the sequelae [W], belong here. Only where phenom- currently prevailing tendency to extend this area ena occur in the further course, independent from without limits is resisted. We are forced to adopt these sources, such as in cases of acute progres- this assumption about purely ‘functional psycho- sive psychosis, which begin as circumscribed ses’ [Ed] because, amongst other reasons, cases of autopsychosis, might one also expect anatomical pure mania and Affective melancholia that appear fi ndings. combined in circular psychosis in such a way that This raises a further question: Could an ana- they can switch from one phase to the opposite, tomical fi nding also be provided in cases of com- within a few hours. Coarser anatomical changes pletely cured, acute psychosis? This would References 329 provide an occasion to evaluate autopsy fi ndings same degenerative processes of neural paren- scientifi cally in those cases of illness that, after chyma, there remain only two standards for recovery, die later as a result of inter-current ill- scientifi c classifi cation of psychoses: These must ness. Of course, only empirical knowledge can be taken either from the different localization of reveal this. Meanwhile, a priori [W] it is likely the anatomical process, or from the diversity of that the organ of consciousness itself can sustain their aetiology. I intentionally avoided detail a degree of loss of nervous elements without any about the diffi cult fi eld of classifi cation in these remaining defi cit being detectable. We had lectures, and must refer you to a lecture [15 ] held intended to demonstrate the site of the most elsewhere if you want to know more about it. severe pathological process, even after recovery However, in conclusion, I want to draw your from illness, using Weigert’s [14 ] method for attention to one point, and that is that these, my staining glial cells. However, where it is really a last comments, should serve to remind you of the case of ‘healing with defi cit’ [Ed], for example in need for those theoretical considerations which the case of severe motility psychosis, which I occupied us in the fi rst half of our clinical studies, mentioned at the start of these lectures, and where but, for you, perhaps often quite diffi cult to partial motor and sensory aphasia remains, then understand. we would almost certainly expect a positive result in such a momentous method of study. You see, gentlemen, diffi cult as the tasks are References that await us, it would be foolish to deny that, given the present state of our knowledge, they 1. Wernicke C. Krankenvorstellungen aus der psychia- can be undertaken with a defi nite chance of suc- trischen Klinik in Breslau. Vols. 1–3. Breslau: Schlettersche Buchhandlung; (1899–1900). cess. Of course we should always remember that 2. Griesinger W. Die Pathologie und Therapie der psy- even a signifi cant anatomical fi nding is meaning- chischen Krankheiten für Ärzte und Studierende. 3rd less if it cannot be brought into close relationship ed. F Wreden: Braunschweig; 1871. with defi nite clinical data. I might expect the 3. Cramer JBA. Gerichtliche Psychiatrie. Ein Leitfaden für Mediziner und Juristen. 2nd ed. Jena: Gustav same anatomical fi nding only in cases that are Fischer; 1900. perfectly matched clinically. Hence preliminary 4. Emminghaus H. Über Kinder und Unmündige, work is needed, in which you have participated in Schwachsinn und Blödsinn in forensischer Hinsicht. these lectures. In: Maschka J, editor. Handbuch der gerichtlichen Medizin, vol. 4. Tübingen: H. Laupp'schen There is no shortage of pessimists who declare Buchhandlung; 1882. that my comments, as expressed previously, on 5. von Krafft-Ebing R. Psychopathia sexualis. 9th ed. the prospect of an anatomical–pathological basis Stuttgart: Ferdinand Enke; 1895. for the psychoses is quite redundant, and, wher- 6. Lissauer H. Klinisches und Anatomisches über die Herdsymptome bei Paralyse. Vortr Ver ostdtsch ever possible, seek to tone down hopes nourished Irrenärzte am 2.3.1891. Ref. in: Zbl Nervenheilk thereby. However, since the views I have Psychiat 1891;2:295–7. expressed, acquired, as they were, on the basis of 7. Starlinger J. Zur Marchi-Behandlung; ein Apparat zur 25 years experience, might also be declared to be Zerlegung in dünne, vollkommen plnparallele Scheiben. Zeitschrift für wissenschaftliche ‘uncritical’ [Ed], I therefore had a very special Mikroskopie und für mikroskopische Technik. reason to dwell on them with some force. You 1899;16:179–83. have learned in this way that the anatomical fi nd- 8. Nissl F. Mitteilungen zur pathologischen Anatomie ings brought forward so far, varied as the cases der Dementia paralytica. Arch Psychiatr. 1896;28:987–92. were, always revealed to us the same anatomical 9. Cramer JBA. Faserschwund nach Insolation. Zentralbl change, namely degenerative processes in gan- f allg Pathol. 1890;1:185. glion cells and myelinated fi bres of the cortex. 10. Cramer JBA. Pathologisch-anatomischer Befund in For overall pathology of the psychoses, this cir- einem akuten Falle der Paranoiagruppe. Arch f Psychiatr. 1890;29(1):1–24. cumstance, that we may confi dently generalize, 11. Alzheimer A. Das Delirium acutum. Monatsschr f is of utmost important. If it is universally the Neurol u Psych. 1897;2:64. 330 41 Lecture 41

12. Alzheimer A. Beiträge zur pathologischen Anatomie 14. Weigert C. Beiträge zur Kenntnis der menschlichen der Hirnrinde und zur anatomischen Grundlage eini- Neuroglia. Frankfurt: Moritz Sierterweg. Aus d ger Psychosen. Monatsschr f Neurol u Psych. Abhandl d Senkenberg naturforsch Ges. 1895; 63–209. 1897;2:90. 15. Wernicke C. Über die Klassiﬁ kation der Psychosen. 13. Meynert T. Psychiatrie: Klinik der Erkrankung des Nach einem in der medizinischen Section der vater- Vorderhirns begründet auf dessen Bau, Leistungen ländischen Gesellschaft zu Breslau gehaltenen und Ernährung. Vienna: Braumüller; 1884. p. 230. Vortrag. Breslau: Schletter. 1899. Editorial Commentary

I. Lecture-by-Lecture Synopses end of the lecture, he provides his classifi cation of symptoms in a three-by-three table: The columns Synopsis of L1: This, the very fi rst lecture, is one are: ‘Psychosensory’, ‘Psychomotor’, and of eight comprising the fi rst main section of ‘Intrapsychic’; the rows are: ‘loss of’, ‘excessive’, Grundriss, outlining Wernicke’s overall under- or ‘aberrant’ excitability (e.g. ‘anaesthesia’, standing of normal human brain processes in rela- ‘hyperaesthesia’, and ‘paraesthesia’ in the tion to subjective awareness. However, he starts Psychosensory column). This classifi cation gains with his basic credo, that mental illnesses are brain prominence in the clinical lectures. diseases. He expresses the view that psychiatry, compared to other specialties, is backward in its Synopsis of L3: The main topic of this lecture is development (although he suggests later that he Memory Images (Erinnerungsbilder ) sometimes has something better to offer). The rest ‘sets the rendered here as ‘remembered images’. Much of scene’ in relation to clinical concepts, clinical the lecture is devoted to separating perceptual/ practice, and neuroscience of the day. sensory images from ‘memory images’. In modern terms this is the distinction between sensation Synopsis of L2: In this lecture, the point of depar- and perception. The former implies ‘awareness’ ture and the topic he understood best is the cere- arising directly from sensory input, the latter has bral representation of language—but this is added implications of a degree of interpretation merely a device to move into other territory. He or analysis of that input, to be given lasting repre- moves quickly at the start of the lecture to clarify sentation in memory. the notion of the ‘supposed’ Conceptualization Centre mentioned in L1. Although he was a pio- Synopsis of L4: The main topic of this lecture is neer for the notion of cerebral localization of the way in which remembered images, acquired function, by the time Grundriss was written he separately, come together to create a coordi- had moved beyond simple localization. Soon nated picture of the external world. In describ- other issues arise, raising several philosophical ing how remembered images of objects are questions. Much of the emphasis is that all symp- assimilated to become representations of con- toms in psychiatry can be reduced ultimately to a cepts, Wernicke sees an exact analogy with for- patient’s movements, which are all a physician mation of memory images from sensations, sees directly. This strongly materialist tone was represented in the primary visual areas by link- common in Germany, after Griesinger, a leading ing various active ‘perceptual elements’ (primary ‘Somatiker’ of an earlier generation. Towards the visual cortical cells).

Synopsis of L5: This lecture focuses on how the hood consist of three components. These are the brain represents our body (using interchangeably sense of one’s own body (corporeality), one’s ‘physicality’ and ‘corporeality’). A conceptual sense of the outer environment, and personal distinction is made between sensory content and memories or beliefs acquired in one’s own life tone of sensation, a near-synonym for the latter experiences. An additional topic introduced here being ‘organ sensation’, a term whose meaning is is not so much the ‘contents’ of consciousness discussed in section XVI: ‘Terminology’). (upon which earlier lectures focused) but the ‘Corporeality’ includes what we now call visceral ‘processes’ by which such contents are laid down, sensation, notably that from the large intestine. and are subsequently manipulated and retrieved. Wernicke knew the importance of this topic, Synopsis of L6: The main topic of this lecture is although current understanding in the nascent representation of movement. Amongst evidence discipline of neuropsychology was quite limited. referred to is that obtained by electrical stimulation of muscles: This procedure, well known at Synopsis of L8: Much of this lecture is psycho- the time, was pioneered earlier in the century by logical theory, about psychological processes, Duchenne de Boulogne, who used it to study rather than content, such as might have been actions of individual muscles and muscle groups. found in writings of his American contemporary, Later, Wernicke discusses how full perceptual William James. This includes the phenomena of awareness depends on combining passive sen- attentiveness, and of ‘narrowness of conscious- sory awareness with exploratory movements. ness’ (i.e. selectiveness of attention), the process The latter notion builds on ideas fi rst mentioned by which memory is acquired, and the role played in L3, on elaboration of tactile perception by by Affective states. Much of the lecture consists combining immediate sensation with exploration of shrewd refl ections based on introspection, (especially manual exploration), an idea now which was easier before psychology became well understood by somatosensory physiologists. ‘objective’ when behaviourism came centre- Wernicke draws exact parallels here between tac- stage. The lecture also brings to the fore the sci- tile and visual perception/exploration. entifi c tradition in which Wernicke is best placed—not so much that of most biomedicine of Synopsis of L7: The subject matter of this lecture his day, but that of natural philosophy (which is how our brains construct for each of us an became physics). This conclusion can be reached image of ourselves as a (somewhat) unifi ed per- not only from his use of analogies from physics son. In English, the word ‘personality’ refers to for processes envisaged to occur in the brain. the unique quality or ‘essence’ of each person. More important are methodological features such Another word—‘personhood’—is used in legal as his balance between experiment and theory, discourse, signifying ‘status as a legal person’. In typical of natural philosophy (but seldom found this lecture, and later, ‘personality’ will be used in biomedicine); his freedom in postulating hid- as just defi ned, while ‘personhood’ is used in a den variables which could not be directly demon- more generic, abstract sense, referring to our strated (as were many concepts in the history of sense of ‘being (to a degree) a unifi ed person’, physics); and notably his close reasoning from whatever the detail of each individual’s personal fundamental principles, based on sensory and quality. Sometimes the phrase ‘personalized con- motor processes. This allowed them to be traced sciousness’ seems to capture Wernicke’s meaning back to the core language of the natural sciences. better than a literal translation. The word ‘individual’ refers to a single human, without imply- Synopsis of L9: Lectures 9–17 make up the sec- ing that he/she approximates to any sort of unifi ed ond main section of Grundriss, dealing with entity. A central notion, to be developed in later chronic states of ‘paranoia’, and dealing mainly clinical lectures, is that memories from which with long-stay patients in his institution. One each individual constructs his sense of person- such patient is described in vivid detail. In this fi rst Editorial Commentary 333 lecture dealing with clinical matters, Wernicke for delusions not mainly as an abnormality in the outlines basic concepts. First he distinguishes process of interpreting experience, but rather as a ‘real mental illness’ from ‘mental disturbance’: more-or-less rational attempt to explain other In lectures so far, when ‘illness’ has been men- subjective experiences, which he sees as primary tioned, the German word was Geisteskrankheit. abnormalities. His concepts appear to be impre- Here he uses Geistesstörungen. Wernicke also cise or over-inclusive. This is perhaps inevitable enunciates a principle, that one should start one’s when there are major gaps in background knowl- analysis with the simplest situations, before mov- edge, and when the most useful way to defi ne ing to more complex ones. He points out (as he concepts is unclear. Sejunction is the obvious often does in later lectures) the similarity between example here, making this one of the more con- normal mental processes and mental processes he tentious of his lectures. This lays him open to a sees in his patients, an emphasis no doubt sceptic’s charge of ‘neuromythology’, especially intended to dispel as far as possible the idea that when components drawn from his analogies are patients were somehow ‘alien’ to the rest of used subsequently as premises for further steps in humanity. It is already clear here that psychiatric supposed scientifi c reasoning. Much of the sec- symptoms are to be the major focus of Grundriss. ond half of the lecture is vividly descriptive, but also attempts to systematize, even to explain. Synopsis of L10: This lecture is a succession of case presentations, continuing those in L9, and Synopsis of L13: The fi rst part of this lecture is referred to in later lectures. It gives insight into about hallucinations (identifi ed as ‘sensory medical practice and institutional life in the asy- deceptions’), recognized then, as today, as most lums of the day, Wernicke’s clinical style, his often of the verbal auditory variety (‘phonemes’ approach to symptoms, as well as initial ideas in his terminology). These are taken as primary about his approach to classifi cation. abnormalities, a consequence at the symptom level of the hypothetical ‘sejunction’ process at Synopsis of L11: The focus here is on separating the neuronal level. Later parts of the lecture deal chronic cases from residual ones where the disease with explanatory delusions, envisaged to arise by process has apparently run its course, and patients quasi-rational processes, as patients’ accounts of have recovered, without their gaining insight into primary abnormalities they experience. their illness. Wernicke outlines his classifi cation, based on which of the three components of mem- Synopsis of L14: The preceding lecture examined ory is falsifi ed—a patient’s sense of corporeality explanatory delusions occurring immediately to (somatopsychic), of the outer world (allopsychic), account for unusual primary experiences. This and life experiences from which personhood is lecture explores delusions distorting earlier built (autopsychic component). Falsifi cation in events, held in memory, as ‘retrospective delu- each of these is seen as secondary, a normal attempt sional explanation’ and ‘falsehoods of memory’, to explain other experiences, whose abnormality is to match current abnormal experiences. primary. Two such primary areas are identifi ed: ‘autochthonous ideas’ (not ‘created by usual Synopsis of L15: Wernicke’s idea that each processes of association’), and hallucinations. patient’s symptomatology arises from a single ‘elementary symptom’ was mentioned in L14. Synopsis of L12: The fi rst half of this lecture Such symptoms, by virtue of a range of internal attempts to defi ne what for Wernicke is a key interactions, lead secondarily to other symptoms. concept, which he calls ‘sejunction’, purportedly The concept of an ‘elementary symptom’ is part a neuropathological process occurring at the level of the title of L15, yet is not well explained. A of nerve cells by which associative links are bro- review by Krahl and Schifferdecker, (1998) [1 ] ken, and through which primary abnormal symp- suggests that he developed the idea in relation to toms are to be explained. As in L11, he accounts ‘anxiety psychosis’ and ‘hallucinosis’, to which 334 Editorial Commentary can be added ‘autochthonous ideas’, plus ‘over- more primary abnormalities, and he suggests valued ideas’ dealt with in this lecture. additional ways in which this may occur.

Synopsis of L16: This lecture is important for Synopsis of L19: The ﬁ rst two-thirds of this lec- both clinical science, and hospital administra- ture give details of the phenomenology of hallu- tion, and Wernicke sketches out systems of clas- cinations in major sensory modalities, and when siﬁ cation to cover both. Much of the chapter modalities are combined. Later, he discusses the attempts to decipher what might be the core theory of hallucinations, starting with the history pathological processes, by excluding other dis- of attempts to provide such theory. Curiously, turbances, seen as normal, albeit working to that presented here is different from, and based resolve tension set up by primary abnormalities, on assumptions different from those relating hal- especially sejunction. lucinations to sejunction (in L13).

Synopsis of L17: A major part of this lecture is Synopsis of L20: This lecture continues discus- devoted to Wernicke’s views on classifi cation of sion of the theory of hallucinations, and in pass- mental disorders. He also introduces the term ing, expands on issues discussed earlier on ‘chronic hallucinosis’. Towards the end, an inter- underlying neuroscience, notably the cohesive- esting section delves into recent history of psy- ness of acquired organization across widely sepa- chiatry, as he saw it. In opening his fi rst lecture, rated cortical regions. Wernicke goes on to he already expressed his scepticism about discuss other symptoms, including motor disor- contemporary categorization of mental disorders. ders of speech, hyperaesthesia, and what he calls Here his critique is expanded, more sharply, and ‘hypermetamorphosis’, ‘an organically produced in greater detail. He appears to reject most cate- compulsion to take note of sense impressions, gories currently in use, favouring something sim- and to fi xate attention on them’. This is presented pler. Following a statement in his fi rst lecture, he as occurring mainly in neurological conditions, prefers to take as a starting point symptoms and this being a precursor to subsequent lectures, the processes by which they arise, rather than where such symptoms arise in the context of supposed disease entities. Terms are introduced mental disorders. referring back to an earlier analogy, where intensity and extent of symptoms over time are plotted Synopsis of L21: This lecture deals with overrid- graphically. These are aszendierend (ascending) ing features of any psychotic state, namely dis- and deszendierend (descending), but henceforth, orientation, and ‘disarray’. The latter is an for clarity (since these words have other senses), Affective state or reaction, and presents problems we use the terms ‘worsening’ and ‘improving’, in translation, (section VIII(g) ‘Wernicke’s unless they clearly refer to anatomical relation- Distinctive Clinical Concepts in Psychiatry’, ships (such as in the gut), or refer directly to the Affective Impact of Mental Illnesses ). These con- original graphical analogy. cepts divide according to the three-way split of contents of consciousness discussed earlier (allo- Synopsis of L18: The remaining lectures in psychic, somatopsychic, and autopsychic), to Grundriss (more than half the series) cover acute which, for the fi rst time, a fourth subdivision— syndromes of mental illness and defect states, as motor abnormality—is added. seen in Wernicke’s practice. In this lecture he introduces the topic of acute mental illness, a Synopsis of L22: This lecture starts by enlarging topic he has already declared as more complex on the concept of an overvalued idea, fi rst dis- than that of chronic disorders. He also explores a cussed in L15, and leads to discussion of illu- topic touched on in L17, the separation between sions. As already discussed for hallucinations, acute and chronic disorders. Later parts expand illusions originate as bias or distortion of percep- on the theme of delusions constructed to explain tion resulting from a prevailing Affective state. Editorial Commentary 335

Illusions and hallucinations thus become hard to The clinical description is vivid, and raises separate, but generally, the former are triggered important scientifi c questions about the nature of mainly by concurrent events and their Affective the abnormal mental state in such patients. impact, the latter arising more in the context of underlying illness. Synopsis of L27: This lecture follows from the previous one, amplifying the description of Synopsis of L23: In this lecture, the style changes. Delirium tremens , but moving on to ‘polyneuritic It deals with identifi ed disorders—‘anxiety psy- psychosis’ (otherwise known as Korsakoff’s psychoses’, including ‘hypochondriacal anxiety psychosis), common in people who have seriously chosis’—and for the fi rst time gives direct advice abused alcohol. We now know this to result from to students about treatment. The immediate symp- nutritional inadequacy leading to thiamine defi - tom clusters, other than anxiety, are recognizably ciency, affecting both peripheral and central ner- psychotic in modern terms, but may rapidly vous systems. Wernicke did not know this, but worsen to produce quasi-neurological symptoms, hints that two pathologies may exist which can- sensory abnormalities or akinesia, perhaps equat- not yet be adequately separated. Later parts deal ing to classic conversion symptoms. with ‘presbyophrenia’, a mental disorder of the elderly. Synopsis of L24: This lecture, using Wernicke’s terms, deals with ‘hypochondriacal psychosis’ Synopsis of L28: This long and complex lecture and ‘somatopsychosis’. The interest for today’s deals with disorders of personal identity (‘acute reader is how concepts of mental disorder which autopsychosis’ for Wernicke). The lecture does today are considered separate, were then brought mention hysteria, but goes into most detail in into relation with each other. They include soma- describing a patient with a ‘second state’. This tisation, eating disorders, and a case of probable had recently been described in France, but the shell-shock from the Franco-Prussian war. Often emphasis here is different, with little stress on these arise in conjunction with abnormal psychic trauma, and more on other ways in which sensations arising from the intestines. A modern such states might arise, including forms of epi- slant is given, attributing these to genuine abnor- lepsy, or episodic binge drinking. Towards the mality of sensations from the body, perhaps end, discussion shifts to forensic topics, as exaggerated and distorted by patient’s inaccurate ‘acquired moral insanity’, a term on which he is lay knowledge about their internal organs. rather sceptical, and which he uses in a more restricted sense than some of his colleagues. Synopsis of L25: The focus of this lecture is ‘Acute Hallucinosis’, regarded by Wernicke as Synopsis of L29: Here Wernicke continues his ‘one of the best -defi ned forms of acute psychosis’. account of ‘acute autopsychosis’, starting with Usually this is the result of chronic excesses of two cases dominated by limited delusional ideas drinking, probably mainly of hard liquor (cognac which distort personal identity, accompanied by is mentioned), rather than beer or wine. The syn- prominent vasomotor symptoms, with acute drome occurs rarely in other circumstances. onset and good prognosis. He gives them a provi- Apart from description of symptoms, detail is sional term ‘acute expansive autopsychosis medi- provided on common patterns of recovery, aetiol- ated by autochthonous ideas ’ . He draws a parallel ogy, and danger of relapse. between disorders arising at the time when autochthonous ideas appear , and those arising on Synopsis of L26: This lecture focuses on a spe- disappearance of thoughts. Later, he deals with cifi c diagnosis, Delirium tremens, starting with a obsessive neuroses and psychoses, commenting case presentation, followed by discussion of on differences between neurosis and psychosis. symptoms, aetiology, diagnosis, differential Finally he deals with the symptom of ‘audible diagnosis, treatment, and post-mortem fi ndings. thoughts’ (‘thought echo’). 336 Editorial Commentary

Synopsis of L30: This important lecture starts by Synopsis of L34: This lecture, one of Wernicke’s presenting two contrasting cases, one of severe longest , complements L32, and deals with what he melancholia (a variety of what is now called calls ‘akinetic motility psychosis’. Early parts deal ‘depression’), the other of fl orid mania. It contin- with symptoms such as ‘waxy fl exibility’, muscle ues with a fascinating account, with cogent rea- rigidity and catalepsy, and also with abnormal soning to suggest that melancholia is primarily a (that is para kinetic) movements. Much of the lec- disorder of ‘will’ (inability to resolve competing ture, while dealing with psychiatric symptoms, claims for action, leading to failure in taking reveals a world-class neurologist at work. decisions). Only when a person grasps their incapacity in daily activities, does it become a sec- Synopsis of L35: This continues analysis of motil- ondary disorder of lowered mood, along with ity disorders, by exploring syndromes combining symptoms such as ‘delusions of belittlement’. hyper- and a-kinetic symptoms (that is, compound The importance of accurately diagnosing the dis- psychoses). It also considers akinesia based on order is stressed, as well as the risk of suicide, disorder of intrapsychic processes (including what and the good response to treatment in hospital (if Wernicke refers to as ‘depressive melancholia’), it can be arranged). and that based on psychsensory processes. It ends by considering the theory of motility psychoses Synopsis of L31: This complements L30, with an (which started with Wernicke, and was retained in analysis of processes occurring in mania. the Wernicke–Kleist–Leonhard tradition). Fundamentally mania is seen as ‘pathological facilitation of acts of association’ and, with it, an Synopsis of L36: This lecture is the fi rst in which overall increase in activity levels in the cortex. It Wernicke starts ‘winding up’ the series of 41 lec- includes ‘levelling of ideas’ (as the level of acti- tures. As an overview, he discusses more compli- vation of every idea is pushed to a similar ‘ceil- cated syndromes, in which different acute ing’), course of illness, mania in progressive psychotic syndromes might be combined either paralysis, combinations of mania and melancho- simultaneously (‘mixed psychoses’), or as separate lia, and chronic forms of mania. phases (‘compound psychoses’). Four components in such combinations are ones he defi ned earlier: Synopsis of L32: This lecture starts with presen- allopsychosis, somatopsychosis, autopsychosis tations of cases which Wernicke calls ‘hyperki- and motility psychosis. In turn combinations dealt netic motility psychosis’, occurring either in the with are: auto-somato-psychoses; allo-somato- puerperium, or in relation to menstruation. psychoses; motility-allo-psychoses; motility- Symptomatology is then extended from motor somato-psychoses; motility-allopsychoses; and manifestations to speech pathology, and to com- lastly, auto-allo-psychoses. pulsive choreatic movements; and there is discussion of what might today be called either akathisia Synopsis of L37: This lecture, another long one, or restless legs syndrome, and other syndromes deals with the disorder mentioned many times driven by unusual sensations. earlier in passing, Progressive Paralysis. While he recognizes that it has some relation to syphilis, Synopsis of L33: This continues from L31, deal- perhaps caused by a transmissible agent (not nec- ing with situations when ‘intrapsychic hyper- essarily the same as that for syphilis), he is function’, described in L31, escalates further. He ambivalent about the relation between the two. thus deals with more severe grades of mania This is understandable, since in 1900, when the (‘confused mania’ and ‘agitated confusion’), lecture was written, the spirochete had not been leading to discussion of ‘amentia’, a term origi- discovered, nor had the Wasserman test to iden- nating with William Cullen and used by Meynert, tify it been developed. Given this, Progressive but which Wernicke believes to be too broad to be Paralysis was of central importance to Wernicke, helpful. because its clinical manifestations overlapped Editorial Commentary 337 with other forms of psychosis, and yet could be Synopsis of L41: Wernicke’s fi nal lecture covers a linked to identifi able neuropathological change, number of general topics, dissimulation (dis- which could be correlated with specifi c clinical guise) of mental illness, the opposite—simula- syndromes. It was thus an important basis upon tion (or exaggeration) of it in healthy persons, which he could conceive a neuropathological and the proper role of mental institutions (and, in basis for a wider range of psychotic syndromes. his view, the inadequacy of alternatives). His fi nal section deals with his hopes for the future, Synopsis of L38: This lecture, spanning all earlier especially the possibility of basing understanding ones, is about aetiology of mental illnesses. of mental disorders on a secure pathological Aetiology had already been discussed in the con- anatomy. Although Progressive Paralysis is an text of Progressive Paralysis (L37), with neuro- important pointer, he is clear that most ‘func- pathological evidence. Here, there is no tional psychoses’ are unlikely to reveal any ana- neuropathology, the focus being on pathological tomical fi ndings, were cases to come to autopsy. processes inferred from symptoms, and ‘proxi- He nevertheless expresses in a closing section his mate causes’, that is the circumstance in which optimism, in the face of numerous nay-sayers, for particular syndromes most often arise. Topics a future when there is a secure scientifi c basis for include psychoses linked to alcoholism, cocaine the subject of his major life’s work. A century (then as now), poisoning by heavy metals (lead, later, his hopes are still to be realized. arsenic compounds), infection diseases (tuberculosis, syphilis), the hereditary basis for mental illness, and links between epilepsy and psychosis. I I . Unnamed Acknowledgment

Synopsis of L39: This lecture continues the aetio- In Wernicke’s Foreword to the 1894 edition, he logical grouping of psychoses, covering a variety mentions an ‘advocate of theoretical natural sci- of topics, especially disorders occurring at transience’ who provided ‘stimulation and guidance’, tional periods of life. Topics dealt with include and may have been a critical supporter, without hysterical absences, psychoses of adolescence whose encouragement this work would never and puberty (including hebephrenia), senile psy- have seen the light of day. Who was this? It can- choses, menopausal and menstrual psychoses, not be discovered from Wernicke’s correspon- and puerperal psychoses. In addition, following dence, since most of it is lost. Was he a recent new concepts in general medicine, he con- neuroscientist, neurologist or psychiatrist of the siders the separation of general and special aeti- time? The most likely such candidate would then ology (the latter originating in specifi c body be Theodor Meynert, his own mentor, whose por- systems or organs). This leads him to consider trait hung on the wall of his consulting room (see delirium due to inanition, and psychoses arising L26); but Meynert died in 1892, 2 years before during other bodily disorders. the 1894 edition. Moreover, Wernicke gives thanks to the un-named person ‘for his stimula- Synopsis of L40: This lecture discusses how the tion and guidance over the hours and days of a overall course of mental disorders might be rep- chance encounter’—hardly the acknowledgment resented and reported, including measures of he would give to his own, recently deceased intensity and symptomatic extent across time. mentor. Was it Gustav Fritsch (1838–1927), 10 The second half deals with dementia, a topic years Wernicke’s senior, Professor of Physiology mentioned frequently in earlier lectures, and now at Berlin University, and who, with Edouard in more detail. Wernicke considers this under Hitzig, fi rst showed, by electrical stimulation, the heading both ‘congenital’ and ‘acquired’ demen- orderly layout of motor representation in the tia, and discusses terms for grades of dementia, cerebral cortex? Was it Paul Flechsig, foremost ways of assessing it, and dementia occurring in German neuroanatomist of the day, also infl u- several clinical contexts. enced by Meynert, and director of the Clinical 338 Editorial Commentary

Institute of Psychiatry and Neurology at Leipzig took the symptoms he found in his patients as the (an easy journey from Breslau)? In his fi rst primary facts. As discussed later, Wernicke’s Lecture, while praising such predecessors, nota- whole approach, and especially his emphasis on bly Meynart, Wernicke sees signifi cant weak- scientifi c reasoning, appears to be that of a natu- nesses in their approach to scientifi c psychiatry, ral philosopher, not that of a typical biomedical and he had little time for some of them (for scientist. In the fi rst eight lectures, many topics instance Hitzig). This suggests that he intended are referred to which correspond exactly to those to attempt something better. In several places in with which Mach dealt. In his obituary Ziehen Grundriss, Wernicke makes it clear that he describes Grundriss as having being written attempts to supersede Meynert’s teachings. ‘almost as if a science of psychiatry did not yet It is noteworthy that he identifi ed this unnamed exist’ [4 ]. Of course it did exist, and had done so person as ‘an advocate of theoretical natural sci- for a century; but Wernicke was independent of ence’, possibly hinting at a theoretical physicist. it. The fi nal sentence of L41 reads as follows: ‘I In the German-speaking world before Einstein, want to draw your attention to one point, and that the foremost theoretical physicist was Ernst is that these, my last comments, should serve to Mach (1838–1916), who, between 1867 and remind you of the need for those theoretical con- 1895 held a chair in physics at the Charles siderations which occupied us in the fi rst half of University, Prague, an easy journey from Breslau. our clinical studies, but, for you, perhaps often Mach is best known for his philosophical and quite diffi cult to understand.’ Clearly, in his fi rst theoretical work. The main way in which this eight lectures, Wernicke was informed by insights might have fulfi lled his role of chair of right outside the fi eld of study of his very able Experimental Physics, was that his philosophy students, which he knew they might struggle to was that of a thorough-going empiricist. Theodor comprehend, and yet which he took to be of criti- Ziehen, who together with Wernicke, founded cal importance. In conclusion, we believe that it Monatschrift für Psychiatrie und Neurologie, and was Ernst Mach to whom this anonymous was much cited by Wernicke in Grundriss , was acknowledgment refers; but we have been unable himself much infl uenced by Mach [ 2 ], and is to fi nd any direct evidence of that ‘chance likely to have met Mach. That it was indeed encounter’. Mach who inspired Wernicke is made plausible In preparing the index for our translation by several other facts: Mach himself made con- (based on a translation of Wernicke’s own index, tributions to both sensory physiology and phi- plus items referring to this Editorial Commentary) losophy of science (both of which pervade we gained another insight into this matter. We Grundriss , especially in early lectures). Mach realized that items which Wernicke chose to himself gained his inspiration in both areas from index were based on fairly orthodox concepts, Gustav Fechner (1801–1887), who spent most of while his most distinctive theoretical ideas, such his life in Leipzig, and was also a major infl uence as sejunction were under-represented. We con- on Wernicke. The three of them worked in clude that, in indexing, he was playing to ortho- neighbouring university cities. Uniquely, Mach dox medical expectations of the time. However, as a natural philosopher did not take variables careful reading of his text leaves us in no doubt such as mass and force as primary concepts, as that he thought the fi rst eight lectures, and his did Isaac Newton. They were derivations, not more distinctive theoretical concepts were a cru- ones related directly to empirical facts. Rather, cial foundation for his clinical ideas; and also that his primary concept was ‘sensation’ ([3 ], p. 82). they were likely to be beyond his audience, Corresponding to this, Wernicke never took dis- despite their being advanced students. Perhaps he ease concepts as the primary facts to be explained, was reticent, shy, possibly even a little embar- these inevitably being indirect derivations and rassed about his theoretical contributions. This is therefore of questionable validity, to which relevant to the 1894 foreword, and the acknowl- symptoms would then be secondary. Rather he edgment to the anonymous person—who we Editorial Commentary 339 think was Ernst Mach. Wernicke probably real- dence of diseases, and precious few national sta- ized that the person to whom he addressed ‘these tistics. In L30 (pp. 210) Wernicke makes apologetic intentions’ really was a supreme sci- impressionistic comments on the high prevalence entifi c theoretician. In any case there is an enigma of melancholia; but only once (L40, p. 313) does about why he did not name this person: The sug- he give any quantitative data on incidence of par- gestion just made is not the only one possible. ticular conditions, when he cites statistics on mortality related to mental illnesses in asylums, probably the nearest anyone could get to accurate III. The Medical Scene at Breslau statistics at the time. In 1893, at a congress of the in Wernicke’s Day; Typical International Statistical Institute, a French physi- Psychiatric Practice cian, Jacques Bertillon, made a distinction, for purposes of epidemiology, between general dis- Breslau, located on the river Oder, was, at the eases and those localized to a particular organ or time of Wernicke’s fi rst edition of Grundriss, a anatomical site (the Bertillon Classifi cation of leading centre for medical research in the German Causes of Death). The fi rst conference to revise empire, with many now-famous names working the International Classifi cation of Causes of there; and a large proportion of contemporary Death took place in 1900, from which, eventually clinical and scientifi c researchers, to whom he the International Classifi cation of Diseases (ICD) refers, were working there, or had done so. It was emerged as an administrator’s instrument. The an exciting time in medical research. Recent dis- distinction made by Bertillon probably led coveries included the transmissible agents Wernicke to write (L1, p. 4): ‘Let us recall the responsible for tuberculosis, tetanus and diphthe- division of brain diseases into focal disease pro- ria (and the toxins produced by the latter two cesses and general diseases; mental illnesses will agents). The neurone theory was coming to be certainly not be subsumed under the former, but generally accepted; and, building on advances in possibly under the latter.’ the German chemical industry, new stains were By the time that Wernicke was revising the text available which led to exciting new work in neu- for the 1906 edition of Grundriss , he was work- rohistology and neuropathology. However, for ing in Halle, and the prestige of the Breslau medi- most disorders, whether in general medicine or cal centre had declined. In its heyday, bacteriology psychiatry, the best treatment that could be and dermatology had been prominent specialties achieved was excellent nursing care and symp- there. Sexually transmitted diseases, especially tomatic relief. In L39 (p. 307), Wernicke writes, syphilis, were major topics for research. Of inter- on psychoses occurring in the context of other est here, what was probably the fi rst effective stat- bodily disorders: ‘The prognosis of symptomatic ute law on medical ethics was passed in Prussia psychoses depends exclusively on the course of in 1900, following a research scandal in the the underlying disease, whose prospects, of dermatology department in Breslau, deriving course, can only be infl uenced unfavourably’. He from research on syphilis. At the time, evidence thus accepts that, for most diseases, there was no on fundamental aetiology for brain disorders was effective treatment, although good general care very limited (except for correlations between favoured natural healing. lesion location and symptoms), a shortcoming Through most of the nineteenth century, Paris refl ected throughout Grundriss. However, per- had been the leading centre for medical research, haps because of the paucity of techniques avail- but by Wernicke’s day, Vienna and several able, those that were used, were employed with German centres were worthy rivals, as French- great care and in meticulous detail. In psychiatry, and German-speaking worlds competed on sev- the one method that was available was docu- eral fronts. International conventions for defi ning menting and analyzing psychiatric symptoms. diagnoses had not yet appeared, so there were no Grundriss describes this in greater detail than cross-national statistics on prevalence or inci- one might fi nd anywhere today. 340 Editorial Commentary

The institution where Wernicke practised infl ammation of arterial adventitia. In L38 included many patients with what are now recog- (p. 294) he refers to ‘childhood cramps’, painful nized as neurological conditions, as we read in muscle spasms which may be provoked by exer- his clinical descriptions. Moreover, many inmates cise and various metabolic or hormonal changes, of asylums suffered from the ravages of tertiary not viewed today as having adverse long-term syphilis; and some of the phenomenology sequelae . In his day, cramps may have been a described by Wernicke (for instance in L20) is ‘proxy’ for some more serious problem, related the result of this disease, rather than what we now perhaps to poverty, poor nutrition, or some other recognize as mental disorder. Various syndromes, aspect of life’s hardships. In his discussion of notably ‘general paralysis of the insane’ (GPI: extended regimes of tube feeding of akinetic German—Paralyse der Irren), now known to be patients (L34, p. 258) he is well aware of the dan- syphilitic, would have been common in the asy- ger of ‘scorbutic’, that is ‘scurvy-like’ lesions. lum populations. In 1903, the causative agent The fact that scurvy could be cured by various was discovered, but the diagnostic test for the dietary supplements such as citrus fruits had long spirochete was not yet available, so the diversity been known. That the anti-scorbutic factor was of syndromes it caused was not yet clarifi ed. ‘hexuronic acid’ (‘Vitamin C’), was not proven Tuberculous meningitis, mentioned in L38 until 1932. Wernicke clearly retained his skill in (p. 294), is now rare in developed countries, but surgery, for instance when he writes L34 (p. 249) is the commonest form of chronic CNS infection of a patient with a syndrome of rigidity in jaw in developing countries, and probably was so in muscles: ‘I decided on “re-positioning” under Wernicke’s day. chloroform anaesthesia, and fi xed his jaw in a Alcohol abuse was also a major issue for psy- half-open position’. chiatric practice. We now know that many of the Public attitudes to psychiatry appear to have psychiatric sequelae of excess drinking are not been a mix very similar to those found today. In due directly to alcohol, but to poor nutrition, and L9 we hear Wernicke, echoed by other enlight- defi ciency of thiamine (vitamin B1). In L27 ened practitioners, expressing concern about the (p. 179) Wernicke refers to ‘alcoholic degenera- poor grasp by the general populace of the reali- tion’ in the context of Delirium tremens . That ties of mental disorder, along with calls for public state is, in itself, a withdrawal syndrome not education. There are hints of diffi cult public rela- linked with neuronal loss, but may become tionships, where he refers to ‘the familiar refor- linked, when combined with chronic alcoholism, matory idea of those philanthropists’. In L17 and thiamine defi ciency. Later in the same lecture (p. 101) he advises his students thus: ‘I cannot (p. 180), he mentions the poor general health and emphasize strongly enough, that you have the cachexia of such patients, an expected precursor right to declare a person mentally ill only when of impaired memory, now known as a sequel of you can produce evidence of this by establishing thiamine defi ciency. Later in L27 (p. 182) he defi nite psychotic symptoms; only then will you writes ‘restoration of function’ after a period in be spared the embarrassment of your opinion hospital. being exposed to justifi ed attacks by lay people’. Throughout the clinical lectures, Wernicke Then, as now, it seems, psychiatrists were targets refers to links between mental disorders and a of public suspicion, for which attitudes Wernicke wide variety of problems in general medicine; had some sympathy. Concern over custodial and clearly he was competent both as a general practices in mental hospitals in German princi- physician and as a surgeon. In the lecture on pro- palities went back to the early nineteenth century. gressive paralysis (L37, p. 286) he mentions By the 1890s this led to the fi rst genuine anti- gumma, a non-cancerous granuloma in tertiary psychiatry movement, and, by the turn of the cen- syphilis which may appear in various organs tury, to calls for tighter legal control [5 ]. Some (liver, brain, heart, etc.), and endarteritis, another diagnoses, especially the so-called ‘moral insan- pathology of tertiary syphilis starting with ity’ linked to the ‘second state’ (dual personality), Editorial Commentary 341 were contentious then, just as today. In L28 master carpenter and his overvalued idea. (p. 193), he writes: ‘You know that this is about Members of the public could initiate proceedings cases of illness, which lawyers, unfortunately against people suspected of being mentally ill, supported by clashing opinions, have been par- which could lead to the latter being detained in an ticularly reluctant to recognize, which, in our institution. There is no evidence of processes for own view, has diverted attention from much of legal scrutiny, or appeal against medical author- both the factual reality of these pathological con- ity. However, in L41 (p. 322), Wernicke writes: ditions and their theoretical basis’. In L41 (pp. 322, ‘After several weeks had elapsed the family then 323) he asks ‘… could not a healthy person imi- decided, much against my advice, to remove the tate the speech of a mentally ill person?’ This, of patient from hospital treatment’: Clearly legal course, has been carried out in an approximate provisions did not give doctors unassailable pow- way in recent times, to draw attention to the ers to detain patients. Medical and judicial sometimes arbitrary compulsory detention in authorities were probably not sharply separated, asylums. There is no suggestion of such activism as was the case in other jurisdictions at the time in Wernicke’s day. In any case, despite early and for some time to come. ‘anti-psychiatry’ rhetoric, public views, as might In some respects, legal provisions and out- be expected, were diverse and not always chari- reach of psychiatric services were far advanced. table. In L30 (p. 210), when arguing for hospital In L24 (p. 158), and again in L25 (p. 170) it is admission in cases of melancholia, we read ‘… clear that patients could admit themselves volun- the general view is that only the insane belong in tarily, a provision not possible in Britain until the institutions’. On public perception of links 1930 Mental Treatment Act. A comment in L25 between mental disorder and violence, the issue (p. 169) suggests that community follow-up was was not schizophrenia (a term not yet coined) but undertaken in the mental health system where epilepsy (which carried similar associations in Wernicke worked. In some places, then as today, the popular mind). In L38 (p. 298) he writes: the possibility of managing short-lived periods of ‘Mostly, there is no later recollection [of acts serious mental illness at home, with intensive committed during twilight states of epilepsy]; support, was given consideration (L25, p. 170). however, except for one—albeit cursory— In L34 (p. 247) we read: ‘Patient feels that he is reminder, we fi nd that violence was perpetrated very severely ill, and asks for reports’: This as defence against a threatening situation’. He should not be taken to imply that patients had the hints here at unnecessary stigmatizing attitudes at right to access their medical reports, a possibility the time towards epilepsy, just as people with in psychiatry which is rare even today. schizophrenia or bipolar disorder are targeted Decisions about whether (and on what crite- today, yet are more likely to be victims than per- ria) to discharge patients were of central impor- petrators of violence. tance, no doubt with fi nancial issues in the In L9, it is made clear that there were legal background, but also taking notice of a patient’s criteria controlling how and when patients might current mental state. In relation to the latter, we be admitted compulsorily to a mental hospital. read comments such as (L10) ‘… the patient’s L41 (p. 321), addressing his class, he states: behaviour is in no way normal but … requires so ‘Each of you will, at some time, be in a position much patience and forbearance … that she can of deciding on the placement of a patient in a exist only in the special confi nes of an institution’ mental hospital, or having to issue a certifi cate (p. 60), or ‘After recovery from actual mental ill- that health has been regained’. The laws were ness, they prove themselves incapable of living broadly the same across Germany, but with varia- anywhere else than in an institution, on account tions in different Länder [6 ]. There are clues to of their social incompatibility, their demanding the lack of rigour (as understood today) in mental and predominantly egotistical behaviour requir- health law, and, just as today, in criteria for coming constant supervision’ (p. 61). Of course, then mittal. In L15 (pp. 92, 93) a story is told about a as now, such criteria might apply to many people 342 Editorial Commentary who never had any mental illness, nor spent time ment called a Pfl egeanstalt. Such places, for in an institution. Overall the quality of care was mentally or physically disabled persons were half as good as could be expected. In L40 (p. 313) we way between an asylum and what in Britain, from read ‘Such patients, after repeated attempts at early nineteenth century, was called a ‘nursing discharge, fi nally remain permanently in the home’. In Britain and the USA, these were places institutions, where they fi nd necessary protection for care of the elderly, under less austere and and care, and also an opportunity for useful activ- unsavoury conditions than obtained in the alms- ity’. In administrative terms, it seems that patients houses of the time in the USA, or the workhouses fell into three categories: ‘Recovered’ (geheilt ), in Britain. In Germany, care of elderly or disabled ‘Residual’ (geheilt mit Defekt ), and ‘Unrecovered’ persons or recuperating patients had long been (ungeheilt ), a system of classifi cation which undertaken by nurses linked to religious orders, probably applied across Germany [6 ]. although in 1869 Rudolf Virchow had recom- In several places in Grundriss, Wernicke mended that nursing be secularized. By the turn emphasizes that the best place to treat and care of the century, a large variety of Pfl egeanstalten for patients with mental disorders is in institu- existed, some secular (e.g. under the Red Cross), tions specially designed for this. In L30 he rec- some religious [7 ]. Wernicke implies that such an ommends this in the case of melancholia, because environment might sometimes be more condu- of the high suicide risk; and later (p. 209), urges cive to recovery than the institution where he that discharge should not be too early: ‘After the worked. They were not free from compulsion, illness has ended, a phase of mild manic exalta- since, in L28 (p. 186) we read: ‘During the tion is seen quite regularly, lasting only a few unusually hot summer of 1886 she was detained days or weeks; and it is always ill-advised to dis- for 2 months in a charitable institution.’ In the charge the patient before this’. In L37 (p. 287) he Third Reich, they often became centres for makes a similar recommendation for progressive euthanasia. paralysis: ‘If you are in any doubt over whether Communities outside the institution might and when to bring the patient into a mental insti- accept or reject a patient after discharge, lead- tution, it is always safest to decide in favour of ing Wernicke to comment (L16; p. 99) this’: Such general advice might not be given ‘Unfortunately, however, it is often inevitable nowadays, in public hospitals at least, simply for that patients return to a life with no structure of fi nancial reasons. One wonders what the fi nancial regular activity nor any ordered social engage- tensions might have been for Wernicke. ment, conditions that are harmful both through In Breslau itself, there appears to have been a the lack of normal interests, and also even by well developed public health system. In L32 predisposing them to emergence of depressive (p. 229) reference is made to a ‘female patient, Affects. Their main interest may then remain previously healthy, had been in the public focused on experiences of injustice; an Affect- hospital’, presumably a public general hospital. laden state of mind sets in, and further delusion- It was, after all, in Bismarck’s Germany that a formation is inevitable’. These lines ring true version of what we now call the ‘welfare state’ over 120 years. Issues of discharge planning, was fi rst adopted. On alternatives to institutional and the social milieu in which a patient might care Wernicke writes (L41, p. 324): ‘there are fi nd him- or herself after discharge, applied then experienced alienists who adopt the view that by as much as now. properly setting up a private residence, the same The harsh realities of care in institutions also can be achieved as in institutional treatment. We seem to be similar then as they often are today. must realize immediately, when discussing the Ward staff are referred to not as nurses purposes of institutional treatment, that this is not (Krankenschwester ), but as ‘warders’ (Wärter, or entirely true’. Ideas circulating then were the Wärterin), although they were probably mainly same as today, facing all the same dilemmas. In skilled professionals (and in L34, [p. 250] L24 (p. 158), reference is made to an establish- Wernicke refers to the warder’s notes recording Editorial Commentary 343 rigid postures adopted by patients). Given the Beliefs shared amongst patients in a long-stay great vulnerability of patients, they are always ward are probably often not symptoms of active likely to be subject to demeaning behaviour and illness, nor (in the above case) of religious senti- attitudes (or worse) not only from the general ment, but social constructions by disturbed peo- public, but also sometimes from staff in the insti- ple confi ned within a very strange environment, tutions, and, as we read in L9, these can lead to one where ‘anything goes’ conceptually, however bitter complaints from patients. In L18 (p. 115) absurd, as part of the ‘organizational culture’ in we read of violence within the ward: ‘On inquiry the ward. Likewise, complaints from patients we learned that he was not suffering headaches may be driven by knowledge of—or resistance but experienced very unpleasant sensations in his to—the abnormal situation of institutional life. head, which he described as dull and dragging— We also read (L10, p. 59) ‘… she is persistently they were a result of mistreatment by the ward- submissive by nature; she rises at each salutation ers’. Then as now, it may be hard to avoid physical and bows, doing this to every fellow-patient, even coercion in restraining agitated patients; although to a very feeble-minded female paralytic patient’. nowadays, there may be guidelines on suitable Such ritualized behaviour speaks of strategies to minimize this, training in ways to do institutionalization. it safely, and routines for reporting diffi cult inci- Families of patients are mentioned a few dents. Although Wernicke is well aware of simi- times . In L22 (p. 140) there are two mentions of larities between normal mental processes and families. Again in L30 (p. 203), we read: ‘… those in his patients, in L9, he confi dently regards takes no notice of visits by her relatives’. Clearly complaints of patients or former patients as ‘false visiting was possible, perhaps into the main sec- readings of reality’. Recovery of insight is more tion of a ward, although, in L23 (p. 151), there is likely for the time of admission than for the fact of a reference to a ‘visitor’s room’, suggesting that, remaining in the institution. He describes the as in many psychiatric wards today, visitors do mental content of many patients as an amalgam of not see the main part of the ward. In the recent delusional and healthy material. memory of RM, this may be obstructed in psy- Some of Wernicke’s descriptions reveal what chiatric facilities, or visitors are shown only into might now be identifi ed as signs of institutional- a special ‘quarantined’ visitors’ room; and even ization, rather than intrinsic features of any ill- in general medicine, when charters for patient ness. In L41 (p. 325) he writes: ‘There are still rights have been enacted in various jurisdictions, many such phrases used similarly by mentally ill visiting rights are not necessarily included (for people in a remarkably similar ways’; and In L29 instance in the European Charter of Patients (p. 199), we read of patients’ words, ‘often heard Rights of 2002) [8 ], the NHS Patients’ Rights, in mental institutions, that thoughts were “drawn 2013 [9 ]). However, in 2011 in the USA, legisla- out of” them’. The specifi c experience described tion was passed about visitation rights [10 ]. How here would now be called ‘thought withdrawal’, that applies to psychiatric institutions is not clear, pathological not so much for the experience itself but is likely to be more restrictive than in general but for the delusional interpretation imposed on medicine. it. However, Wernicke implies that interpretation of ‘jargon’ used by patients requires experience of the ‘local scene’. In other words, linguistic use IV. Wernicke’s Personal Style by patients to describe their experiences is devel- in Psychiatric Practice, Teaching, oped collectively as much as individually in a Writing, and in Scholarly Disputes long-stay ward, as in any other community. Other signs of institutionalization include descriptions From the outset in L1 Wernicke shows that he is such as (L10, p. 60) ‘She regards her fellow- aware that psychiatry, perhaps because of its patients as men of the cloth, usually high-ranking intrinsic complexity, was backward, compared clerics who are here in part for repentance’. with other specialties. At the very end, in a closing 344 Editorial Commentary section of L41, he assures his students that atti- We cannot miss Wernicke’s careful and realis- tudes to the discipline from other physicians, had tic assessment of what might be possible for each improved over the preceding 20 years. He patient. In days when effective treatments were advises (L1) that a teacher in psychiatry ‘should few, assessment of prognosis loomed larger than proceed as in sister disciplines of medicine’. today. So, in L10 (p. 59) we read ‘Frau Reisewitz, Clearly he wanted to adopt standards and meth- whose illness developed gradually over the last 5 ods of general medicine, as did his contemporary years, from barely noticeable beginnings, and is Kraepelin, but in a very different way. In L1 he expected to develop further’; in L16 (p. 97) ‘… also accepts that there may be different types of cases where active illness is fully extinguished mental disease, but as we shall see, his approach …’: Clearly this bore implications for ‘progno- to classifi cation was quite different from that of sis’. The prognostic indicators he used are dis- Kraepelin. cussed later. Footnotes in Grundriss were often A critical aspect of the style of practice of added retrospectively, about the eventual out- any psychiatrist is whether, to what extent, and come for patients he has presented and how, reunifi cation of personhood can be discussed. achieved after it is fragmented by mental disor- A distinctive aspect of Wernicke’s approach ders. This is a core issue, more for psychiatry if appears to be that he did not distance himself practised well than for any other medical disci- unnecessarily from his patients. Although he pline. In L7 (p. 39) we read the following: ‘After refers to doctors working in mental institutions a person has recovered from a mental illness, it as Irrenärzten (literally ‘mad doctors’)—never is required that we ensure that he has achieved ‘alienists’—he often drew parallels between insight into the abnormality of the state he has normal psychological processes and those experienced; for the sum must necessarily be underlying symptom formation in his patients. inaccurate if it contains false elements’. These We see this initially in L9, where the emphasis is words reveal what a fi ne clinician he must have no doubt intended to dispel for his students any been, in his hope that his patients recover full idea that his patients were somehow ‘alien’ to health, and in defi ning his own role in helping the rest of humanity The emphasis is most strik- each patient to regain their sense of ‘personal ing when discussing delusions, seen mainly as wholeness’ to whatever extent this was possible. plausible—even rational—attempts to explain Nowadays, lack of such a holistic approach is more primary abnormalities of experience: In the sharpest criticism made of many of today’s L13 (p. 82) he addresses his audience thus: psychiatric practitioners by service user groups. ‘Should anyone experience a feeling of deliber- We get another clue his compassionate concern ate rudeness when a greeting is omitted etc., then in L18 (p. 113). Unlike many chronic patients this also is an echo of a delusional interpreta- presented in earlier lectures, whose surname is tion’. He skilfully points out similarities, where given, here a patient is referred to just by an ini- they can be found, between the psychology he tial, because he is of some standing in the local sees in his patients, and those in his audience. In community, and likely to remain so after dis- L8 (p. 45) he speaks of ‘herd consciousness’ as a charge (which is to occur soon). He thus wanted social phenomenon, in such a way as to make to avoid his publication—which gives much clear that this also applies to himself, accepting detail about the patient—making life more diffi - that he is not only a clinician and observant sci- cult for him after discharge. Likewise, in L27 entist, but also an object of study. Subject and (p. 180), he uses initials only, to hide not only the object, clinician and patient, appear not sharply identity, but also the former place of residence of separated. In discussing the role of language in a patient who is to be discharged; and in L30 L8, he writes (p. 45): ‘… the main way to acquire (p. 203), for the same reason, an initial is given a particular order to one’s perceptions is through for the place in which one of his patients worked articulated speech’; but later, he steps back from as a nurse. his ‘real self’—an articulate, supremely rational Editorial Commentary 345 clinician-scientist—to defend himself against for childhood or adolescence, almost as one with charges of over emphasizing language in defi ning little knowledge of psychological issues faced by human nature. young persons. Wernicke knew how, as a skilled clinician, he Wernicke’s teaching style is revealed from could use those faculties of a patient still assumed time to time. There was clearly a plan to cover to be normal, along with events occurring inci- the subject of psychiatry comprehensively (with dentally, or engineered by him, as a vehicle to a ‘course curriculum’ referred to in L24, p. 162). correct delusional explanations. So, in L24 In L32 (p. 226) he refers to details presented in a (p. 158) we read: ‘this patient, was discharged ‘past semester’, so, probably the lectures were from the nursing home after 6 weeks, allegedly given across a whole year over two semesters. In completely recovered, probably as a result of the the clinical lectures, he sometimes develops his powerful impression that transfer there must have arguments by referring to cases described by had on her.’ He also knew how, on occasion, he other psychiatrists or neurologists of the day in could use the vividness of a clinical presentation Germany or France (never Britain). Often how- for therapeutic purposes beyond any of the ses- ever, patients were present—even several in suc- sion’s didactic aims; that is, to exert on a patient cession—for at least some of the lecture, or an impact more powerful, albeit subtle, than is sometimes, it appears, in sessions prior to the lec- possible in normal clinical encounters. He writes ture (L24, p. 153). There are occasional hints (L15; p. 94): ‘Clinical presentation of such cases (from comments such as ‘To our great surprise, a has proved useful to me several times, as is the turn-around occurred from yesterday’ [L32, process of ‘internalization’ itself, that is, a con- p. 223], and ‘Chance has favoured us, in that I scious ability to recognize mental illness, and to can present another patient’ [L32, p. 225]) that constantly accept paternal guidance: These are choice of patients each day was sometimes quite powerful and salutary corrective experiences.’ opportunistic. In these clinical sessions he pre- Again in L41 (p. 321) he writes of mute patients: sumably demonstrated to the class his manner of ‘Amongst the best proven ways of bringing such interviewing each patient. Detail of such dialogue patients to speak, is a clinical presentation’. is seldom recorded, but in later lectures, verbatim It is also clear that he does not hide from his dialogue is sometimes reported, showing his own mistakes. In L34 (p. 257), he writes: ‘This interviewing style, including his modelling for happened to me once, and the tracheotomy which his students how to ask about suicide (L30, was carried out immediately could not avert a p. 202). In this situation, he states at one stage: fatal outcome.’ Again in L41 (p. 322) after ‘As you see, his appearance is quite appropriate describing how a patient’s family insisted on the to the situation’, (L9, 56). Clearly, Wernicke has patient being discharged, against his wishes, he his patient in the lecture theatre, seeing no incon- writes: ‘Apparently they were right, for there was gruity about such candid public description of the no further recurrence of the delusions he had patient’s characteristics to the assembled audi- expressed previously, and he resumed his earlier ence. There might be more constraints in today’s work in a business’. world! However, at times his comments leave it The one area where Wernicke seems to have a unclear whether they are the patient’s view or his less subtle approach is with young patients. There own. This ambiguity may sometimes have been are no descriptions of children in Grundriss; and necessary, when a patient about whom he is in L39 (p. 304), when describing hebephrenic speaking is in the lecture theatre; and usually it traits in adolescents, he writes: ‘They are not to does not matter. be found in the specifi c childhood form, in which, As a lecturer, he knew how to engage his audi- the resulting feeble-mindedness in silly and fool- ence, often with personal anecdotes, or references ish beings, would seem only natural’. This com- to typical life experiences which all could share. ment, like ones in L40, betray him, Nonetheless, the lectures are dense with ideas, uncharacteristically, as one with little sympathy arguments and evidence, suggesting that, as delivered, 346 Editorial Commentary they were each followed by extensive discussion, That his lectures were, in large part, research otherwise his students would have been left seminars is clear at the start of L21, when he behind. In L28 (p. 193), he more-or- less invites acknowledges that the patient he is about to dis- discussion: ‘This might be the place for me to cuss is a ‘very complex, and as yet little known respond to an objection that you could easily form of illness’. He conveys that the lectures make’. Indications that this took place can also be were research presentations more-or-less explic- found in the fact that some cross-references to itly, when he writes (L41, p. 329): ‘Hence pre- earlier lectures refer to material, or patients not liminary work is needed, in which you have actually present in the text of Grundriss. For participated in these lectures’. There may, how- instance in L18, where patient K. is fi rst intro- ever, have been other courses, especially for duced, there is no mention of his making a suicide future administrators of asylums. attempt, but this detail is mentioned in L21, when Details are available on several members of referring back to this lecture. In L22 (p. 139) he Wernicke’s class who went on to distinguish revisits the notion of an ‘overvalued idea’ fi rst themselves. Many of the following names pro- introduced in L15; yet specifi c points mentioned duced works cited in Grundriss. Hugo Liepmann in L22 are not mentioned in L15. In addition, (1863–1925), editor of the 1906 edition of sometimes two lectures (e.g. L9 and L10, L19 and Grundriss, was himself a noted psychiatrist and L20) appear so closely connected as to suggest neurologist, who had worked closely with that they were given close together in time, even Wernicke from 1895 to 1899. He was noted for on the same day. Sometimes we are left to infer studies of cerebral localization of function, the the occasions when patients, who are referred to, fi rst to describe several neurological syndromes, have been met in other situations, without know- later becoming director of the Herzberge asylum ing when or where this occurred. Later lectures in Berlin. Ernst Storch was Wernicke’s loyal often cite in-house reports (Krankenvorstellungen assistant, one of his fi rst co-workers. He was aus der psychiatrischen Klinik in Breslau). appointed privat-dozent in Psychiatry at Breslau His audience appears to have consisted of very in 1902, and had previously been fi rst-assistant in advanced students. They were quite familiar with the psychiatric clinic there. In 1901, he published routine neurological problems, since, in L37 Psychologische Untersuchungen über die (p. 286) he writes: ‘You are so often called to deal Funktionen der Hirnrinde, zugleich eine with a so-called “stroke” that your fi rst question Vorstudie zur Lehre von der Afasie [ 11 ], recently must be whether you are dealing with a possible republished. Biographical detail on Storch is paralytic attack’. In introducing L41, he begins: obscure. Karl Bonhöffer (1868–1948) was a psy- ‘These lectures can hardly be intended to intro- chiatrist who worked briefl y in Heidelberg duce you to the practical medical specialist (1903–1904), but moved to Breslau, where, training course for the asylums. Whoever wants under Wernicke, integration of neurology with to dedicate himself totally to our specialty is of psychiatry was possible. He gave detailed course expecting to spend a considerable part of descriptions of Delirium tremens (L26, p. 175), his life in mental institutions, and among men- and may have challenged Kraepelin’s view that tally ill people, a task that in some respects you categorical disorders were to be defi ned by symp- can imagine is not suffi ciently challenging, but tom clusters [ 12]. After Wernicke’s death he also not suffi ciently gratifying and interesting … defi ned the conceptual separation of endogenous it is therefore imperative to give you some orien- from exogenous psychoses. His son, Dietrich tation on practical issues, including the specifi c Bonhöffer was the celebrated theologian who, tasks of the asylum, and the simulation and dis- from within Germany, resisted the Nazi regime, simulation of mental illnesses’. Clearly members and was, imprisoned and executed in the last of his audience are likely to become researchers; days of World War II. Karl Heilbronner (1869– but here, he descends to mundane matters, likely 1914) worked at Wernicke’s clinic from 1894 to also to be important in their subsequent careers. 1898, and between 1897 and 1903 headed an Editorial Commentary 347 observation ward for mentally ill prisoners there. fellow physician, whose situation became pre- Karl Kleist (1879–1960) continued Wernicke’s carious in a local society, on account of his approach to description of symptoms, originated Jewish wife. Heinrich Lissauer (1861–1891) was the terms ‘unipolar’ and ‘bipolar’ for Affective a neurologist and neuropathologist at the psy- disorders, made detailed studies of many head- chiatric institute in Breslau. Despite his early injury cases from World War I, and is known death, his name is associated with several signifi - today as continuing what became the Wernicke– cant advances, making studies on the pathology Kleist–Leonhard tradition. Kurt Goldstein of Progressive paralysis, having a tract in the spi- (1878–1965) became an advocate of anti- nal cord is named after him, and the fi rst to localizationist neurology. When Hitler came to describe visual agnosia. Clearly Wernicke power, being Jewish, he was imprisoned for a thought highly of him; Paul Schroeder (1873– short time in Berlin, then expelled from Germany, 1941) worked with Wernicke in Breslau, with going fi rst to Amsterdam, then to the USA, where Kraepelin and later with Nissl in Heidelberg, and he founded Gestalt therapy. Heinrich Sachs with Bonhöffer in Berlin, to become professor of (1863–1928) was an early researcher on amyo- Psychiatry at the University of Griefswald in trophic lateral sclerosis. After working with 1913. In 1937, he became fi rst president of the Wernicke at Breslau, he became head of the divi- International Society of Pediatric Psychiatry, but sion of neurology and neurosurgery in the Jewish retired the following year. hospital there. Otfrid Foerster (1873–1941) stud- In the fi rst clinical lecture (L9) Wernicke ied under Babinski in Paris, returned to Breslau enunciates the maxim that one should start one’s to become a pioneer neurosurgeon, and spending analysis with the simplest situations, before mov- much time later in Russia. His most famous ing to more complex ones. In consequence, he patient was Vladimir Ilyich Lenin, and it was chose to deal fi rst (L9–L17) with stabilized men- Foerster who recommended that Oskar Vogt tal abnormalities seen long after acute stages of examine the latter’s brain, after his death from disturbance have subsided, before going on to stroke . Edmund Forster (1878–1933) was one of acute states. His maxim may be sound; and given Wernicke’s later students. During World War I, as the realities of practice in his day, was no doubt a military physician, one of his patients was applied correctly. Better this than trainees (then, Adolf Hitler, who was treated and hypnotized by and perhaps still today) being ‘thrown in at the him after a gas attack, and whom he described as deep end’, making it hard for them to reconstruct a ‘psychopath with hysterical symptoms’. He all the steps between normality and severe dys- committed suicide in 1933 under persecution ; function. In psychiatry, the implied alien status of Ludwig Mann (1866–1936) studied with inmates could then only be reinforced. Whether Wernicke and became professor at St this was true or not for Wernicke, it is likely that Georg- Krankenhaus, Breslau. In 1896, he pub- patients most commonly encountered in his insti- lished Klinische und anatomische Beiträge zur tution were those whose acute disturbance had Lehre von der spinalen hemiplegia [ 13 ]. Robert subsided to a stable state, however abnormal. Eugen Gaupp (1870–1953) was an assistant to However, in a number of areas of medical educa- Wernicke at Breslau, and afterwards worked with tion, there is tension between what is best from a Emil Kraepelin at Heidelberg and Munich, later didactic point of view, and what is possible prac- to become a professor of psychiatry at Tübingen tically. For instance, one of us (RM) has argued (1908–1938). He studied the relationship between [ 14 ] that, in teaching gross anatomy, spatial rela- psychosis and personality, advocated for ‘pasto- tionships in body cavities are grasped more eas- ral psychology’, and after World War II, headed ily by starting with, ‘empty’ cavities, and then the department of health and welfare in Stuttgart. adding organs one by one; which is exactly the In 1935, after passage by decree of the opposite of what is normally possible in a dis- ‘Nuremberg Laws’ (‘for protection of German secting room course. The way in which Wernicke’s Blood and Honour’), he came to the defence of a maxim might be applied could likewise be 348 Editorial Commentary questioned in today’s world: Mental states in acuity decreased to 30 cm on the left and 20 cm chronic stabilized cases may appear simple, but on the right.’…‘we discovered particularly poor to understand them fully depends on understand- bone conduction; against the skull or mastoid pro- ing processes leading to this ‘end state’, which cess the clock was not heard at all.’ In testing the are by no means simple. By L17 Wernicke pupillary light refl ex we read (L24; p. 159): ‘His reaches just this conclusion. In today’s psychia- pupils were fairly narrow, equidistant, and wid- try, where most patients recover from acute psy- ened only a little, when his eyes were shaded.’ In chosis, the best place to start education for trainee L34 (p. 397) we read ‘Refl ex excitability of cuta- specialists may be open discussion with people neous capillaries is normal’. Presumably this who are distant from acute episodes, but whose refers to the axon refl ex, producing the reddening memory for, and insight into those episodes is of the skin when scratched, a clinical test which, good enough to help such trainees grasp the we believe, is not routine today. In L8, we read of unfolding processes. Indeed, in L18, Wernicke Wernicke’s simple clinical test to assess ‘short- makes use of exactly such an insightful patient, term memory’, subsequently referred to as ‘reten- who has reached near-complete recovery. tion of memory’. Much as today, this involved In addition, in L17, the last dealing with testing recall of ‘a three-digit number, a foreign- chronic conditions, he writes as follows (p. 105): sounding word which she should have retained ‘… after many years of work I had to decide to after interposing a short question’ (L27, p. 180). reverse my strategy, and to start working from the In L30 (p. 203), we read of long-term memory ground upwards, placing acute mental illnesses, tested separately for recall and recognition. which are still the main source of paranoid condi- Attentiveness was apparently tested separately for tions, as the precursor of the latter [chronic con- each of the three domains of experience (L27, ditions]’: This sentence is important. In L9–L17, p. 285). For speech articulation Wernicke had his spe- Wernicke deals with chronic conditions, paying cial probe words (Zivilisation, Armeereorganisation, little attention to their relation to acute ones. Guiglelminetti, Exterritorialität [‘civilization’, Here, however, he feels the need to reverse the ‘army reorganization’, ‘Guiglelminetti’, ‘extra- emphasis; and later lectures fi ll out details of the territoriality’]). His test of cognitive capacity was shift in strategy. We comment here, that, in the to ask a patient to recognize, count, and make a sequence of 41 lectures we both had the clear tally of a number of coins. At various points he impression that Grundriss is not so much a com- uses the phrase ‘closed train of thought’, attrib- pletely pre-planned presentation of Wernicke’s uted to Meynert. In L20 (p. 130), it becomes clear ideas, but rather a progression of his developing that this phrase describes a method of testing ideas. In particular, in the transition from chronic higher cognitive functions, where he writes of to acute disorders, we felt that later clinical ‘absent-mindedness, that is, the intractable nature lectures were almost superseding earlier ones of thought processes, and inability to follow a (although at times in the later lectures his consis- closed train of thought.’ tency in use of terms defi ned earlier became Wernicke’s written style is hard to separate looser, perhaps because he was writing in haste). from his style of reasoning, discussed later; and At various points in Grundriss, we get glimpses we are ill-equipped to assess it in comparison of Wernicke’s methods of clinical examination. with that of contemporary German researchers. Basic assessment of sensory and refl ex motor Overall, Grundriss is closely reasoned, with capability probably differed little from today. For small phrases in early lectures being developed auditory acuity, a test familiar today is described later, in a meticulous way, and special terms used (L24, p. 158): ‘On admission she understood with great efforts at consistency. However, there speech whispered at 3–3½ m.’ …‘Over the fi rst 2 are many superfl uous words, academic niceties, months there was a clear decrease in her auditory unnecessary qualifying words, double negatives, acuity. This was noticeable even at ordinary con- and tautologies. Perhaps this refl ects how he versational levels; for whispered speech, auditory delivered the lectures. Sometimes there are Editorial Commentary 349 colourful idioms. For instance, in L13 (p. 83) a often underlie a very severe feeling of illness, as young man, embittered against his father, had the proven by occasional examples of rapid onset, intention of ‘setting him straight’, without mur- resolved by relief of muscle pain.’ We inferred dering him ( ihm etwas Ordentliches zu verset- the meaning here in respect of a single word we zen ); in L28 (p. 193), he writes: ‘However, this added, ‘resolved’. What was actually written assertion does not hold a candle’ ( Diese was: Muskelschmerzen liegen Häufi g einem sehr Behauptung hält aber vor den Tatsächen nicht schweren Krankheitsgefühl zugrunde wie ver- Stich ); in L35 (p. 290), he uses the phrase ‘ über einzelte Beispiele rascher Herstellung durch jahr und Tag’, familiar in English as ‘for a year Beseitigung der Muskelschmerzen beweisen. In and a day’; and in L24 (p. 162) he uses the meta- L28 he writes (p. 188): ‘the sensorium is appar- phorical term ‘burnt out’, which has been used in ently well- preserved; on the other hand, to some many ways. In medicine it might refer to the end- extent, there is a break in continuity in conscious- stage of an epidemic, or of an incurable disease ness of personhood, such that two personalities, such as leprosy (in Graham Greene’s novel A very different from each other, override each burnt out case), or to the end-stage of chronic other’; yet later (p. 191), again on the ‘second schizophrenia. In the nineteenth century, it led to state’ he writes: ‘Interrupted continuity in con- mythology about ‘spontaneous human combus- sciousness of personality is totally lacking here, tion’, a case of which is described in Charles and appears only temporarily during the recovery Dickens’ Bleak House; and today is revitalized as period.’ Probably he was pointing to a contrast ‘workplace burn-out’. found amongst ‘second state’ patients, but gives A few points need clarifying, where he is little sign that he is actually making a contrast. In over-concise. For instance, in L31 (p. 219) where L33 (p. 241), what he writes seems to be repeti- he writes ‘… the disorder is mainly one of form’ tious: ‘If … we must acknowledge confused he implies (we presume) but does not say ‘rather mania as an independent clinical picture, and fi nd than of content’; or, in L39 (p. 303) we read ‘the its essential sign as an increase of the intrapsy- familiar tendency for akinetic motility psychosis chic hyperfunction to the point of incoherent to be transformed into dementia might be based fl ight of ideas, we cannot consider it accidental, in part on this aetiological relationship’, probably that such conditions tend to occur especially after referring to (but not mentioning) Kahlbaum’s severe attacks of confused mania or agitated con- concept that transitional periods of life make aeti- fusion’. Occasionally sentences seem incorrectly ological contributions to some mental disorders. phrased, as in L19 (p. 119), where the German Sometimes, the line of reasoning becomes hard reads: ‘erfolgt das Abklingen der Phoneme in der to grasp when describing the ‘second state’ Weise, daß die Kranken nicht mehr deutlich spre- (L28). For instance, in L13 (p. 82), we read: chen, sondern nur ein Flüstern hören ’. We trans- ‘Therefore, it follows from this that, as abnormal late this literally as: ‘the phonemes fade out in excesses of activation continue, phonemes, which such a way that patients no longer speak clearly tend to appear only intermittently in such cases, but hear only a whisper.’ Surely what he meant require a special amplifi cation of activation was ‘the phonemes fade out in such a way that before they come to a standstill.’ We could not patients no longer hear clear speech but only a come to a conclusion of what was meant here. In whisper.’ L17, (p. 106) we read what seems to be a non There are also some signs of Wernicke’s haste sequitur: ‘So, the great mystery remains for in preparing Grundriss. In L6 (p. 34), his usual Griesinger: how such regularity of content can greeting to the class ‘Mein Herren!’ is abbrevi- arise—the occurrence of ideas of grandiosity and ated to ‘M.H.’; and in L39, the greeting is omit- persecution, in which “perhaps among ten ted. In the later lectures, some clinical descriptions patients, only fi ve throughout the whole duration are synoptic, even to the extent of not being fully of the disease, form the main content of the delir- formed sentences; and his index included a few ium.”’ In L24 (p. 162) we read ‘Muscle pains index items, but no corresponding page numbers. 350 Editorial Commentary

Probably this refl ected the pressured existence pioneer of an earlier generation (L19). It is not which he had to maintain, making perfection of clear that he knew of the work of Pierre Janet, written style a minor concern; and also a note- who, although working at Hôpital de la Salpêtrière format may have been habitual amongst busy cli- in Paris during the period when Grundriss was nicians, then, as now. In L32 (p. 228) much of the written, was not so well known, and was at this last paragraph is in note form, but we expand it, time no longer focusing on hysteria [16 ]. Some of to form full sentences. On p. 230 we render such Wernicke’s ideas, notably the division between a fragmentary section as accurately as possible in positive and negative symptoms, and on hierar- translation. Presumably he is reporting straight chical organization in the brain were similar to from Dr Kemmler’s notes. In Wernicke’s index, it those of his English contemporary, the neuropsy- seemed that some items did not refer to the page chiatrist, John Hughlings Jackson (L2; L11, p. 66; he had assigned for them. etc.). Both were fl uent practitioners in areas where Ambiguity about whether views expressed dur- psychiatry and neurology intersect. There is no ing clinical demonstrations were the patients’ evidence of direct infl uence of Jackson, and none views or his own has already been mentioned. of the sources he cites were in the English lan- Usually it does not matter; but a 100 years later a guage. A few are in French; one assumes that little clarifi cation may be needed. In L29 (p. 199), Wernicke could not read English papers. we read: ‘At times she showed a feeling of anxiety, Academic disputes are normal amongst which severely disturbed her sleep because of her researchers, and not always gentlemanly. thoughts’; and in L35 (p. 246) he writes: ‘Stress Wernicke’s style in controversy seems to have and many sleeping drugs were given as the cause been quite generous, sometimes with touches of of the illness’: Of course, sleeplessness, while no gentle humour. In L17 (note), after giving his doubt accompanied by vigorous thoughts, proba- views on his French rival, Dr Magnan, he adds: ‘I bly has its own causes, at the level of brain biol- am delighted to be able to state that in my critical ogy, rather than in the realm of thought content, or opinion of Magnan’s teaching I have encountered ‘stress’. In L34 (p. 246), our translation reads: heat. But furthermore, I believe that in the funda- ‘When she closes her eyes, she sees bright colours. mental ideas that he expresses in his important She must be watched, when she closes her eyes’. book on the delusion of querulousness, despite Here there is a sharp juxtaposition of a clinician’s all the polemic directed against me, I perceive identifi cation of a symptom (based on a patient’s that I detect a pleasing agreement.’ He also writes report), and the patients self-referential statement. ‘Works of an eminent French psychiatrist, Wernicke clearly kept abreast of contemporary Magnan, have drawn us, even here in Germany, developments in other centres: He was well aware in his direction, in the back-and-forth swirl of of developments in Vienna, where he had studied, public opinion’: The hint at enduring hostility as well as other German-speaking centres, includ- between Germany and France can be understood, ing Prague, mentioning Arnold Pick, who he met given that Wernicke had been a surgeon during in 1875 when they had both worked under the Franco-Prussian war. His generosity of spirit, Westphal in Berlin [15 ]. There appears to have does not prevent his making wry jokes over been on-going dialogue with Freud (section national difference. In L4 (p. 22), he writes: ‘Not VIII,(s) ‘Wernicke’s Distinctive Clinical Concepts everyone is a Shakespeare, but you will be sur- in Psychiatry’—Wernicke’s Links to the Emerging prised when we soon pass to the other extreme Dynamic Tradition in Psychiatry). His awareness (among civilized nations!): the vocabulary of an of developments in Paris include several mentions English seaman does not exceed a few hundred’. of Charcot, and L7 mentions a ‘recent case’ (The exclamation mark is Wernicke’s.) In L30 described by him. Since Charcot died in August (p. 207), he writes: ‘The consequence of self- 1893, this was unchanged from the 1894 edition. knowledge of this is a state of pathological indif- Other references to French researchers of the time ference and inner emptiness, whose prototype is include Magnan (L17) as well as a Esquirol, a the blasé attitude, the renowned ‘spleen’ of the Editorial Commentary 351

English.’ Metaphorical use of the word ‘spleen’ dealing with a well-known, and relatively simple has shifted over time—for Shakespeare, it was disease state which is given the accurate name of ‘irritable’; in eighteenth and nineteenth century Paranoia chronica simplex. Then it is easy to England, ‘hypochondriacal’ or ‘hysterical’, or ‘in arouse the impression of intentional deception, bad humour’; and today, ‘prone to outbursts of for both judges and lay people, thereby harming anger’. It is not quite clear what Wernicke thought the reputation of the entire alienist profession.’ to be typical English traits, but he seems not to be The anonymous acknowledgment in the paying any compliments! Foreword of Wernicke’s 1894 edition is some- In L17 Wernicke has sharply critical words times taken to refer to Theodor Meynert, his for- directed against the concept of Paranoia chron- mer mentor. It is thus interesting to see how ica simplex. This refers to one of four types of Meynert is cited. (See [19 ] for a recent appraisal paranoia proposed by Theodor Ziehen [ 17 ], then of Meynert’s scientifi c work.) Certainly Meynert about 30 years old, but who is not named. is the most cited of all researchers in Grundriss. Wernicke’s target may have been more senior, In L1 to L8, he is mentioned with non-specifi c perhaps Otto Binswanger at Jena, under whom praise. So, in L1 we read ‘Work of men like Ziehen was working at the time. In L33 (p. 236) Griesinger, H. Neumann, Kahlbaum, Meynert, there is milder criticism on a matter of terminol- Emminghaus and many others, has not been in ogy. Ziehen later became professor in Halle in vain’; ‘Psychiatry today enjoys more general rec- 1903, 1 year before being replaced by Wernicke. ognition, and this would have been welcomed as From 1897, they jointly edited Monatsschrift für progress by a thinker like Meynert in his time.’ In Psychiatrie und Neurologie, and Ziehen pub- L2 (note), the reader is referred to the collection lished an eloquent and generous obituary therein of Meynert’s ‘popular scientifi c treatises’. at the time of Wernicke’s death. Even with those Sometimes he is cited as having established what who took opposed positions on basic philosophy, by Wernicke’s time had become basic facts about he is generous. Heinrich Neumann preceded the nervous system: ‘We learned from Meynert Wernicke as director of the institution in Breslau that voluntary muscles and sense organs are (with Wernicke as his assistant) until the latter’s linked with the cerebral cortex by conducting death, and was one of the last Psychiker psychia- pathways that extend, in physiological continu- trists, and opponent of Griesinger [18 ]. Despite ity, through the brain, the spinal cord, and the their having opposed philosophies for mental dis- peripheral nervous system. Meynert named the order, Wernicke has no hesitation in citing and aggregate of these pathways, where the ‘law of commending his work, in preference to his own isolated conduction’ predominates, the projection mentor, Meynert (L19, p. 124). The gentlemanly system’ (L1). Meynert’s conceptualization of fac- approach to rival research personalities shifts to a ulties remaining after transection at the level of sharper tone, when dealing with issues , espe- the cerebral peduncle is mentioned in L5, and his cially in L17, those of classifi cation. Following classifi cation of movements, into ‘defence’ and his cautioning trainees against over-hasty diag- ‘attack’ is cited several times. Sometimes his nosis of mental illness without fi rm evidence of analogies are cited. (Meynert, polymath that he symptoms (beginning ‘I cannot emphasize was, included poetry amongst his talents, so nat- strongly enough …’) he continues (pp. 101–102): urally thought in terms of vivid metaphors [20 ]) ‘The “general impression” sometimes relied on The ‘enclosed pipe system’ (L4) as an analogy even by better-known representatives of our pro- for the entirety of associative processes is fession, when they fail to elicit defi nite psychotic Meynert’s, as is the analogy between human and symptoms, is no better than everyday parlance mollusc (L5). Occasionally Meynert’s hypothe- and must elicit the deepest suspicion, when used ses are mentioned, for instance, in L5 (p. 29), as the basis of diagnosis of a paranoid state. It that intestinal sensation might be represented in deserves to be rejected most strongly when, in ‘the ganglia of the striatum’, or that the thalamus cases of this kind, the claim is made that we are was a central station for all sensory pathways 352 Editorial Commentary

(L19, p. 123). A few distinctive phrases and con- elements which are not then called into play’ cepts originate with Meynert. For instance [ 22 ]. This highly metaphorical—and partly vital- Meynert used the metaphorical phrase ‘a train of istic—account by Meynert of the formation of thought’, which goes back centuries, into psychi- associations is an analogy with ‘attraction’, pos- atric vocabulary, describing his own thought pro- sibly magnetic, or of ‘animal magnetism’ (whose cesses (L19, p. 123). It was conceived to have a popularity was still remembered). It applied at clear physical basis in the cerebral cortex. In L31 both cellular (‘molecular’) and mass levels to (p. 215) Wernicke writes: ‘In my introduction, I account for strengthening of connections between developed the idea that a strictly terminated train co-active cortical sites. Wernicke’s version was of thought is the result of practice and training, more precise, and in the fullness of time, became that is, of functional acquisition’ (see also L33, a testable hypothesis. p. 236: ‘closed thought’). These lines probably In L33 Wernicke’s expresses his sincere, but refer to Meynert’s ‘enclosed pipe’ metaphor. nuanced appreciation of his former mentor as fol- The most distinctive concept Wernicke attri- lows (L33, p. 240): ‘I have repeatedly indicated butes to Meynert is ‘primary Ego’ (das ‘Ich’ ), how important I consider Meynert’s clinical lec- dependent especially on the sense of corporeality tures to be; in my opinion, they have provided the (L5, L17). In the fi rst few lectures on chronic foundation for better understanding of the symp- conditions, the only mention of Meynert is to this tomatology of acute mental illnesses. However, it concept (L17). In later lectures he is more ambiv- must be expressly stated that Meynert also suc- alent and nuanced in appreciation of Meynert, cumbed to the general fate of other authors, who certainly not seeing him as an irrefutable author- have laboured hard on their monographs in cer- ity. In L30 (p. 213) we read: ‘Even in the clinical tain provinces, in our discipline … Nevertheless, lectures of Meynert, to whom we owe so much, the chapter on amentia is of lasting value for all you will fi nd this clinical picture [melancholia] time, and indicates the greatest advance psychia- defi ned far too broadly’. In L33 Wernicke men- try has made clinically since Kahlbaum’s work tions Meynert several times, showing how his on catatonia, since it contains the fi rst real theory own associationism grew from similar, though of mental illnesses and especially of acute psy- less well-formulated views of Meynert. choses, founded on hypotheses derived entirely According to Meynert (L33, p. 236), there was a from the condition of the affected organ’. In L36, direct link between local cerebral blood fl ow and he is mentioned again in relation to the hypothe- associative activity in the brain. The more the sis about local blood fl ow, which Wernicke hardly cerebral arteries narrowed and restricted blood believes, and his ‘celebrated optic thalamus supply, the less associative activity could occur case’. In L37, an issue of classifi cation of pro- in regions supplied [21 ]. According to him, active gressive paralysis (acute vs. chronic) is men- brain tissue attracted higher blood fl ow to supply tioned where Wernicke does not quite agree with nutritional needs—an uncanny forerunner of Meynert. He also mentions Meynert’s system for principles on which functional imaging is based cortical lamination, and—with high praise—his today—as in the following quotation: ‘If we data on brain weight in various conditions. In accept Fechner’s theory, that the cortical images L38 he compliments Meynert on his fi ndings and their connections may be stimulated to one of about hydrocephalus internus. L40, on dementia, two variable degrees of intensity, and that in any he is sometimes critical, sometimes full of praise, particular mental act those images which are and in L41, Meynert’s hyperaemia notion is men- actively utilized stand above the threshold of tioned again. Overall, from this survey of consciousness while others remain below the Wernicke’s citations of Meynert, it is hard to level of consciousness, then accepting this the- believe that it was the latter to whom the anony- ory, we may interpret it to mean that elements mous acknowledgment was made, given the bearing processes standing above this level terms in which it was expressed. exhibit a greater nutritive attraction than those Editorial Commentary 353

What about Emil Kraepelin, his real rival? In Basic neuroscience: In1894 Wernicke would L34 (p. 256), dealing with akinetic motility psy- have known of the neurone theory, for which choses Wernicke writes: ‘… in Kraepelin’s text- Santiago Ramón y Cajal and Camille Golgi book, dementia is described as the regular were jointly awarded the Nobel Prize in 1906. outcome for such cases. Here, as well as else- Their conclusion, that nervous tissue consists of where, we come across little by way of thought, discrete cells, not a syncytium, was developed plus an ignorance of facts, which features are between 1887 (when Cajal learned Golgi’s arguably unsuited to a textbook. Moreover, the staining method) and 1894 (when Cajal gave the tendency to recurrence, emphasized by Croonian lecture, focusing on cortical pyrami- Kraepelin, is in no way greater than in most dal cells). Other staining methods in neurohis- other acute psychoses’. It was probably the text- tology were that of Nissl (mentioned in L41, book to which he refers (L28, p. 192) with the p. 323) which stains neuronal cell bodies (the words: ‘as I constantly regret, it is impossible ‘Nissl’ granules in their cytoplasm) but not for me to recommend to you one of the best- axons or dendrites, and that of Weigert to stain known textbooks of psychiatry for your private myelin deep blue, with degenerating portions studies’. Here for the only time, Wernicke ‘takes yellow, and another of his methods to stain neu- off his kid gloves’ in opposing a rival. This is roglial cells. The distinction between neurones the most specifi c and potent personal attack on and glial cells was well understood in Wernicke’s any of his colleagues or rivals to be found in day, as well as some of the subtypes of glial Grundriss . cells, since, in L37 (p. 291) he writes: ‘We have There is one other striking sentence (L31, observed the occurrence en masse, of giant p. 221): ‘When attacks of recurrent mania fi nally astrocytes; and indeed they correspond to the outweigh in duration the lucid intervals, they do more recent stage, seen temporarily soon after not turn into a chronic mania, at least not in the loss of neuronal tissue’. In L4 (p. 24) ‘fusiform’ strict meaning of the term, that I alone can (spindle-shaped) cells in the visual cortex are defend’. (Emphasis added here.) Clearly, mentioned. This probably refers to a classifi ca- Wernicke knew that in some of his views, he was tion of cell types by von Kölliker [23 ], long a lone voice. before the Golgi method was in use. Wernicke suggests that their existence ‘contradicts our intuition to accept nerve fi bres that cannot prove V. Contemporary Knowledge their origin from any nerve cell’, implying that in Neuroscience; Contemporary aspects of Cajal’s neurone doctrine were not yet Practice in General Medicine fully resolved. and Psychiatry in Wernicke’s Day In L16 (note) we also read ‘… we see only remnants of pathological change in the organ of Wernicke’s Grundriss contains much detailed association: That is, growth of glia. Of epoch- description in the clinical lectures, but, through- making importance in this regard is the work of out, he attempts to explain what he saw, on the C. Weigert [ 24] … We would hope that a patho- basis of neuroscience of the day. To understand logical anatomy of psychoses may be built from the strengths and weaknesses of his attempts, it is this.’ The role of glial cells in neuropathology, important to understand what he knew, and, just especially the proliferation of some types of glia, as important, what he did not know about struc- was not proven until the 1920s. However, it was ture and function of nerve cells, nervous tissue, shown by the Romanian, Georges Marinesco functional organization of the brain, and the state (1863–1938) that non-neuronal cells acted as of clinical knowledge at the time. In this section, phagocytes, removing remnants of injured or common knowledge, and prevalent misunder- dying cells [25 ]. This was published in 1900, but standings are described. Wernicke’s own contri- may have been known earlier; and Wernicke may butions come later. have been alluding to this. 354 Editorial Commentary

With regard to signals carried by nerve cells, nerves (long and short)—the visceral innervation there was some crucial knowledge, but many of the eye itself (as opposed to the retina)—most gaps. In L1 the law of isolated conduction (ini- of which knowledge went back to the eighteenth tially proposed for the peripheral nervous system, century [28 ]. L6 touches on the possibility that but implicitly applying to the central nervous there is position sense in the eyeball, transmitted system) is mentioned. This states that signals via the ciliary nerves. remain isolated in each axon, despite transmis- The laminar layout of the cerebral cortex was sion over long distances [26 ]. This extended fi rst described by Bailarger, with more detailed Johannes Peter Müller’s Law of Specifi c Energies , description provided by Meynert; but terminol- which stated that the function and subjective ogy was not settled. References to cortical lami- impact of activity in a nerve pathway depends on nae include: ‘the cortical layer (or layers) what it is connected to, rather than what initiated immediately adjacent to white matter would rep- the activity (be it a sensory stimulus, applied resent consciousness of corporeality’. (‘Die electrical or chemical stimulus, or whatever). schichtenweise Übereinanderlagerund der Conduction velocity in peripheral nerves had Ganglienzellen der Hirnrinde begünstigt eine been measured in 1850 by Helmholz, but nothing solche Annahme wonach die der Markleiste was known of conduction time in central axons. nächste Schicht (bzw die nächsten Schichten) das In L5 (p. 26), in developing a ‘thought experi- Bewusstsein der Körperlichkeit repräsentieren ment’ Wernicke writes ‘Sensations would, as würden )’ (L5, p. 30). We also read ‘the most before, reach consciousness, but with a slight superfi cial cortical lamina, that which Meynert delay caused by the longer pathway.’ He was thus identifi ed as the fi rst, purely grey lamina’ (L37, aware of conduction time in axons as a signifi - p. 290), presumably lamina II, in modern cant variable, but could not use this in explana- terminology. tory reasoning. Nothing was known of the The French edition of Cajal’s Histologie du physical basis of axonal conduction. The all-or- Système Nerveux de L’Homme et des Vertébrés none law was known to hold for cardiac contrac- was published in 1909–1911, and was already tion from work of Bowditch at Harvard Medical known in its Spanish version in 1905 (Textura del School in 1871, but that it applied to axonal con- sistema nervioso del hombre y de los vertebra- duction was accepted only in 1909, from results dos, vol. 1, published in Madrid in 1899; com- of Keith Lucas [ 27 ]. This indicates that signal plete in 1904). These works do not use the transmission in axons is independent of the ener- modern 6-layer terminology. Later in L37 getics for generating signals. Wernicke’s igno- (p. 290) we read ‘Cell loss in these cases did not rance of this was part of the context which extend continuously over the cortex, but came in enabled him to develop the imaginative (but irregularly distributed patches, and involved incorrect) sejunction hypothesis. Chemical trans- mainly layers of densely arranged, small pyra- mission was a completely unknown principle. mids, arranged in rows, and increasing in size Basic neuroanatomy of the brain had advanced inwards, in other words, Meynert’s second and in decades before Grundriss. In L1 a term used third layer’: This refers to laminae now known to by Wernicke (after Meynert) was the projection be major origins of cortico-cortical axons system, a metaphor derived from optics. We read (although some descending axons were identi- of ‘the fact of physiological continuity, if not fi ed). This point is relevant to Wernicke’s view of anatomical continuity’ in such pathways. This the cortex as the ‘organ of association’, and of refers to cytological fi ndings of Cajal. Knowledge mental disorder involving disruption in such about cranial nerves went back a long way, but connections. there were still uncertainties, even over their In 1905, it was unclear whether taste and smell exact number, and details such as the exact inner- had their own cortical projection area (L5, p. 26). vation of the tongue for touch and taste. At the Wernicke occasionally refers to the basal ganglia time of writing much was known about ciliary (although terms he uses leave doubt about which Editorial Commentary 355 structures he means). Karl Friedrich Burdach excitability of cutaneous capillaries’: This probably (1776–1847) provided the fi rst account of the refers to the cutaneous ‘fl are response’ or ‘axon anatomy of the basal ganglia [29 ]. Nothing was fl are refl ex’, responding to sharp mechanical stim- known of their function, but there were many uli such as scratching. That it was an involved ideas, including Meynert’s (L5, p. 29), that the local axonal conduction, but no central trans- ‘corpus striatum’ (Ganglien des Streifen ) repre- mission or integration was known since 1889, as sented intestinal sensation. It is unlikely that described by Sokovnin and Rozhansky, and appar- uncertain whether this refers either to ‘the stria- ently discovered as early as 1873 [34 ]. tum’ (part of the basal ganglia) or to the ‘nucleus Early in his career Wernicke made major con- basalis of Meynert’. Meynert was also the fi rst to tributions to the concept of cerebral localization suggest that Parkinson’s disease might arise due of function. Orderly representation of sensory to abnormality there [30 ]. In the 1880s, Hermann surfaces and motor control in the cerebral cortex Nothnagel (1841–1905) named the striatum (somatotopy, retinotopy’, etc) was well under- nodus cursorius, implying a role in locomotion. stood, although in a simpler way than today. Motor functions of the basal ganglia became Larger principles of organization linked basic known early in twentieth century, and wider neuroscience to clinical topics. In L5 (p. 27), aspects of their function were revealed later. writing on protective refl exes, he compares Wernicke refers to several issues about central humans to lower vertebrates: ‘Where a large nervous function. In L3, in analyzing the differ- cerebral hemisphere is present, as in mammals, ence between perceptual and memory images he and more so in humans, we see similar mecha- mentions visual after-images as a model of the nisms of movement transferred to central projec- former. His statement that after-images arise in tion fi elds of the cerebral cortex (as shown retinal ganglion cells is incorrect: Classical after- experimentally by Munk for eye movements)’ images, such as seeing an orange spot after star- This is similar to ideas of Hughlings Jackson ing at a blue light, or a black (sometimes white) (1835–1911), and before him, of Herbert Spencer, spot after staring at white light is due to satura- who, in 1855 had published ‘The Principles of tion of pigments in photoreceptors [31 ]. In L5 Psychology’ [35 ]. Their view, based on evolu- (p. 29) he assumes that the ability to locate the tionary doctrine, was that the central nervous sys- source of a sound refl ects processes in the inner tem has a hierarchy of levels, refl ex activity being ear (‘organ of Corti’), but we now know this to the lowest. Related ideas were promoted by depend on comparison in the brainstem of timing Meynert [22 ], for whom mental illness arose due of sounds from the two ears. to confl ict between cerebral cortex and sub-corti- Important principles of functional organization cal regions (a view still widely held today). were well known. The concept of refl ex action was important for both neuroscientists and clinicians, Bacteriology and Infectious Disease: Advances but the emphasis was different from today: in bacteriology in years immediately prior to Supposedly automatic refl ex action was easily publication of Grundriss provided a new model extended to include psychic processes, for instance of disease. Researchers in psychiatry saw a by Russian physiologists Ivan Sechenov, and potential cause for disorders in their own fi eld. I.P.Pavlov, and in Austria, by a young Sigmund ‘Phthisis’ is mentioned several times in Grundriss , Freud. This was easier then than now, because it a term implying no more than a ‘wasting disease’ was less clear that refl ex action was independent (as did ‘consumption’), qualifi ed, in English, as of conscious awareness (with support from the ‘pulmonary phthisis’. The name tuberculosis was philosophy of psycho-physical parallelism). In given by Schoenlein (1793–1864), based on psychiatry, Kahlbaum [ 32] formalized this with characteristic lesions—tubercles—seen in the terms such as ‘centripetal’, ‘intracentral’, and lungs post mortem. The term ‘phthisis’ was used ‘centrifugal’ for the stages of ‘psychic functions’ well into the twentieth century, and was used by [33 ]. In L34 (p. 236) Wernicke refers to ‘refl ex Wernicke (pp. 294, 296), but sometimes he used 356 Editorial Commentary the German term Lungenschwindsucht . Discovery Moritz Heinrich Romberg (1795–1873), to diag- by Robert Koch of the corresponding micro- nose Tabes dorsalis (L36, p. 280), an aspect of organism, Mycobacterium tuberculosis , dated neurosyphilis in which axons in the dorsal col- from 1882. umns of spinal cord are lost, leading to differen- Knowledge of the symptoms of tetanus after tial loss of discriminative somatic sensation. wounds went back to antiquity. That it was caused Tabes had been named as early as 1836 and given by a bacterial toxin was proven in 1884 by Arthur a full description by Duchenne in 1858 . It was Nicolaier (1862–1942). The bacterium responsible shown to be late-stage syphilis in 1885 by Jean ( Clostridium tetani ), its transmissibility, and its Alfred Fournier (1832–1914), who suggested role in producing symptoms of tetanus were dis- that GPI (‘Progressive Paralysis’ in Wernicke’s covered in the 1890s; and by 1897, an antitoxin had terms) was syphilitic in origin. However, when been produced, giving immunity. In L34 (p. 296) Wernicke was writing, this appears not to have catatonic rigidity is compared to tetanus. The diph- been fully accepted [ 38 ]. Another test involved theria toxin was discovered in 1890 by Emil Adolf pupillary refl exes and Wernicke refers (L37, von Behring (fi rst Nobel laureate for physiology p. 280), to ‘rigidity’ of pupillary refl exes, termed and medicine) working in Marburg [ 36]. The idea ‘Argyll Robertson pupil’ in the English-speaking that bacterial toxins could cause mental illnesses world [ 39]: The accommodation refl ex was appears often in writings of Wernicke and intact, while the light refl ex was lost. Argyll Kraepelin. Discovery of the spirochete in 1903, in Robertson, a Scottish-trained physician studied experiments on monkeys by Metchnikoff and in Prague and Berlin, and identifi ed the syndrome Roux, and the development of the Wassermann test in 1863, calling it ‘spinal miosis’. In fact, none of in 1906 clarifi ed the fact that syphilitic disease the pupillary refl exes (light refl ex, accommoda- could take many forms. Prior to this, diagnosis had tion refl ex, and papillary dilatation) involve spi- been based solely on clinical evidence, as in most nal pathways. Wernicke’s qualifying phrase—‘the of psychiatry to this day. Epidemics of ‘dengue so-called column disease’—suggests he was fever’, mentioned in L28 (p. 190) were long known referring to a named syndrome, rather than to to occur in tropical and subtropical regions. Its symptoms arising strictly in the spinal cord. Only transmission by mosquitoes was known from 1906, later was it found to be an early sign of general and its viral aetiology from 1907. CNS involvement in neurosyphilis. It is now rare in the developed world. Neurology : There are several references to A major issue, mentioned throughout advances in neurology in Grundriss. Wernicke Grundriss, was what was called ‘Progressive mentions ‘degenerative neuritis’. In L1 he refers Paralysis’ (‘of the Insane’: [ 40 ]). (Today to the fact, already known, that peripheral neu- ‘Progressive Paralysis’ has a different meaning, ropathies can lead to differential loss of sensory referring to several clearly defi ned neurological vs. motor function, or of specifi c types of somatic conditions.) Mainly, progressive paralysis is sensation. Many manifestations of syphilis were another manifestation of neurosyphilis. In 1894 well-known to neurologists; but at the time of Wernicke was unlikely to have known that it was revising Grundriss , it was not clear that GPI was part of a sexually transmitted disease, caused by syphilitic; it was seen as a mental rather than a an identifi able micro-organism. When revising neurological disorder (in so far as the two were the 1906 edition he could have known of the 1903 distinguished) [37 ]. Several clinical tests were fi nding, but detailed discussion of Progressive devised in the context of syphilis: In one, the Paralysis occurs in one of the last lectures (L37), Romberg test (L37, p. 229), a standing patient is so any revision he may have intended was fore- asked to close his or her eyes. Loss of balance stalled by his death. There is however no hint of indicates that the contribution of proprioception the fi nding in earlier lectures. Indeed, in L17 to balance is compromised. The test was devised (p. 103) he separates syphilis from Progressive as early as 1840 by the Berlin-based neurologist Paralysis, referring to ‘… disease of the posterior Editorial Commentary 357 columns [attacked] by alcoholism and syphilis Guillain–Barré–Stohl syndrome, after a publica- and, fi nally, the most famous type, of progressive tion in 1916 by Georges Guillain and Jean paralysis …’. In L36 (p. 280) he draws a contrast Alexande Barré. In modern defi nition it is an between Tabes and syphilis and in L37 (p. 286) autoimmune condition of myelin sheaths, limited discusses the differential diagnosis between to peripheral nerves, often triggered by infection. Progressive Paralysis and syphilis. However, he In Wernicke’s day, it was not separated from seems to have suspected some relationship, since other polyneuropathies; and those due to thia- this lecture, focusing on paralytic disorders, mine defi ciency could also affect the CNS. In makes reference to syphilis, and sometimes L27 (p. 182), he refers to fl accid paralysis, absent implies sexual transmission. Likewise, in L35 tendon refl exes, and muscles sensitized to pres- (p. 262) he writes ‘When a mild degree of somno- sure. These symptoms are found in polyneuritis lence is mixed in, a special subgroup among such due to in thiamine defi ciency. However, he writes: cases [of paralysis] seems to be defi ned, which, to ‘Oddly enough, I have never seen such severe judge by the results of specifi c therapy, should be cases of polyneuritis accompanied by polyneu- grouped among the luetic brain diseases’ ritic psychosis’. The latter term, refers to CNS (‘Luetic’: venereal—sexually transmitted). He involvement; he hints at his suspicion of differ- also mentions that paralytic attacks were some- ences between the two syndromes. times accompanied by fever (although that might Epileptic seizures are fi rst mentioned occa- have been due to another infection impacting on sionally in early lectures, and are dealt with in the CNS, or simply to the mental disorder itself— greater depth in L24 and L38. The full range of as mentioned in L41). In L36 (p. 280) he applies epileptic phenomena was not well documented in the word ‘bacterial’ to syphilis, implying perhaps the 1890s. Hughlings Jackson’s classifi cation sep- that symptoms were caused by a bacterial toxin. arated Petit-mal from Grand-mal, but included Despite his not understanding the origin of Vertigo [42 , 43]. In L37 (p. 284) we read ‘… a Progressive Paralysis from syphilitic infection, he specifi c muscle area such as the faciolingual clearly recognized that it was a chronic, progres- region is affected, the onslaught then spreading sive illness, with many mental symptoms (L36, further with familiar regularity’. This reminds one p. 285). He may have suspected it to have a bacte- of Jackson’s report of 1863, on the ‘march of epi- rial in origin, involving a different agent, but lepsy’, from which he inferred orderly representa- could not have known that overt syphilis, progres- tion of body parts in the brain; and the cortical sive paralysis, and other manifestations of syphi- region involved was known by 1875 [44 ]. Notably, lis had a common aetiology. After 1906, it might Wernicke, who inferred this principle from other have been too easy to dismiss unexplained symp- evidence, does not cite Jackson. He may have toms as syphilitic: Other neuropsychiatric syn- been unaware of his work, given that Jackson’s dromes are described in Grundriss which were most important papers on it were in journals not otherwise recognized for many decades, when which were probably inaccessible in Germany there could be no confusion with syphilis. [45 , 46 ]. The Asylum reports in which the later Reference to specifi c brain disorders includes publication appeared became the journal Brain. In Parkinson’s disease and its festinating gait (L34 European centres, differentiation of epilepsy from [p. 245]: ‘This movement accelerates in a manner hysteria was much-debated [16 ] and the word similar to propulsion in Paralysis agitans ’). ‘seizure’ was used for both. Charcot was the fi rst Dyskinesias—involuntary movements of mouth to attempt to distinguish the two, but differentia- and tongue—are described (L19, p. 120) although tion was not easy in Wernicke’s time. For instance, Wernicke attributes them to vivid taste hallucina- in L28, the so-called ‘second state’ could arise tions in patients with general paralysis. Landry’s equally from hysterical or epileptic attacks. paralysis (L27, p. 182) fi rst described in 1859 by Wernicke’s term ‘hystero-epileptics’ (L19, p. 122) the French physician, Jean Baptiste Octave presumably refers to what are now called ‘pseu- Landry de Thézillat [41 ], was known later as the doseizures’ or ‘psychogenic convulsions’. 358 Editorial Commentary

Wernicke mentions ‘general weakness of Separation of positive from negative symptoms in memory’ in L7 (p. 40; and in L8) where he psychiatry developed before Wernicke’s day, describes early stages of a disorder akin to what being fi rst proposed, in the context of childhood came to be called Alzheimer’s disease. In 1907, convulsions, by John Russell Reynolds in 1861 2 years after Wernicke’s death, Alois Alzheimer, [ 48], and extended by Hughlings Jackson in 1881 of Kraepelin’s institute in Munich, published the to apply to neurological symptoms more gener- fi rst description of the disorder, with details of ally. For Jackson, following the distinction was neuropathology, after the patient he had studied based on the hierarchical concept of brain organi- for 5 years had died, and been subjected to zation, so that positive symptoms refl ected autopsy. Clearly clinical aspects of Alzheimer’s release from inhibition coming from higher lev- disease were known at the time of Wernicke’s els. In psychiatry, the same concept goes back to death; and the ‘plaques’ had also been described Meynert: (L33, p. 240): ‘You can judge how far already by Marinesco [ 25 ], but not linked to Meynert approximates the standpoint that I have dementia. always advocated in these demonstrations, from In L14 (p. 87) Wernicke refers to confabula- the fact that he always places in the foreground tion as ‘… the positive form of falsifi cation of symptoms of functional defi cit, that is the differ- memory’, described as ‘incoherence in contents ent grades of weakening of associations, and he of consciousness’, linked to “memory distur- considers symptoms of irritation to be a conse- bance”’. A reference to Kraepelin is dated 1887, quence of these.’ These ideas appear as early as also the year of the doctoral thesis of L2, where we read: ‘absence of reactive move- S.S.Korsakoff in Moscow, defi ning what came to ments is often just as characteristic and as valu- be called ‘Korsakoff’s psychosis’. This is related able a symptom as their pathological to chronic alcoholism and vitamin defi ciency, modifi cation’; and in L11 (p. 67) ‘… all changes prominent features of which are loss of memory in content of consciousness can then be likened for recent events and confabulation, with intact to focal symptoms, and will behave just as do long-term memory. Since the vitamin defi ciency more familiar focal symptoms of brain diseases; caused both this and peripheral nerve problems, but these naturally, will have a different clinical the syndrome was also called Polyneuritic psy- “weighting” depending on whether they corre- chosis in Grundriss (e.g. L26, p. 174). Regardless spond with the stimulus state or the paralysis of whether Kraepelin or Korsakoff claims prior- state’; in L12 (p. 72) ‘defi cit symptoms’ are con- ity, Kraepelin’s major contribution to the concept trasted with ‘irritant symptoms’; in L14 positive came later (1913), when it was identifi ed as a and negative ‘falsifi cations of memory’ are sepa- feature of paraphrenia (see [47 ]). rated (confabulation, vs. ‘quasi-amnesia’). In L19 (p. 123) the idea is mentioned that the cere- Clinical Psychiatry: A phrase in L25 (p. 168); bral cortex can suppress subcortical activity, (‘… if you follow the practical advice for clinical notably in the basal ganglia; and symptoms arise analysis …’), may imply that guidelines were as release phenomena when such inhibition fails. taught in medical schools on ways to advance The idea has been used often since then in clinical knowledge. It is not clear whether this accounts of symptomatology; yet we now know refers to psychiatry or more widely. It implies that, with minor exceptions, long-axons cortical recognition that research and routine practice, for neurones projecting to the basal ganglia are many practitioners were inseparable endeavours, excitatory. unlike today. In any event, in Wernicke’s day psy- Another concept which Wernicke took from chiatry was seen as an advancing frontier. With the past was that there are ‘times of special vul- regard to then-current knowledge of clinical psy- nerability for development of various diseases of chiatry, we start with general concepts, moving consciousness’ (L5, p. 30). This derives from on to specifi c disease entities or prototype Kahlbaum, who proposed [49 ], in 1863 that cer- diagnoses. tain psychiatric disorders tend to occur during Editorial Commentary 359 transitional periods of life. The idea is developed p. 195; L31, p. 211), the exact meaning of which in most detail in L38 where we read (p. 294) that for him is unclear. ‘times of normal physical change, such as On genetics, clinicians routinely asked about puberty, menopause, and fi nally senescence, are family history. So, in L14 (p. 88) we read ‘… a particularly likely to predispose to onset of strong family predisposition to mental illness psychoses’. was established in this middle-aged man’. The concept of ‘degeneration’ loomed large in Founding principles of genetics based on Gregor social and psychiatric thought in late nineteenth Mendel’s work in the 1860s were not well known, century. The term (German: Entartete ) was intro- and systematic study of the inheritance of mental duced by Griesinger, but its persistence had sev- disorders was some way in the future. Wernicke eral origins; harmful effects of urbanization considered hereditary tendencies in most detail in during the industrial revolution, concepts of L38 (p. 297 seq. ). There is not so much as a hint social Darwinism and then biological evolution of eugenicist notions, although such ideas had more generally, greater awareness of historical roots going back some years earlier, at least in change of societies (as in Edward Gibbons’ Britain; and in Switzerland, Auguste Forel advo- Decline and Fall of the Roman Empire ), in psy- cated such ideas [ 50 ]. On one occasion (L38, chiatry Benedict Morel’s Treatise on p. 297) he ventures on the diffi cult area where Degeneration, and in forensic areas, Cesare genetics and (social) environmental infl uences Lombroso’s writings on criminality in relation to interact, and where the degeneration held sway anthropology. Valentin Mangan (1835–1916) (when he suggests that suicidal acts are attributed developed the degeneration concept in a sup- to effects of suggestion, even when they are posed evolutionary and genetic context, and pub- familial traits). In L38 he also seems to give way lished with Paul Sérieux, in 1892, Le délire to surrounding prejudices, when he makes pass- chronique a évolution systématique (‘Chronic ing comments on the social class of some patients delirium with systematic evolution’). The con- with familial mental disorders. cept was losing currency by the outbreak of Terms for classes of disorder, syndromes, and World War I, but can yet be seen as a precursor to symptoms, used in Wernicke’s day, are mentioned both Kraepelin’s Dementia praecox (for which here. Use of Latin terms, with upper case initial by defi nition, full recovery was not possible), and letter for the fi rst, was the style of Carl Linnaeus in later of eugenicist ideology adopted in Germany his eighteenth century botanical taxonomy, and in and elsewhere (with the word ‘degenerate’ the parallel taxonomy for diseases which he also [ entartete ] fi guring prominently in propaganda of developed in 1763 [ 51 ]. Named classes were then the Third Reich, especially in relation to art and taken to be ‘natural types’, an implicit assumption music). Wernicke is scathing about the glib way adopted for diseases in the nineteenth century. in which the concept was sometimes used, as in The old term ‘melancholy ’ appears fi rst in L1, L17 (p. 104) where we read of how other authors then in L17 (p. 81), and is discussed in detail in regarded ‘chronic paranoia … separate from all L30 as Affective melancholia . Two specifi c con- other mental illnesses, and the so-called degen- cepts come from Kahlbaum: Hebephrenia , was eration, acknowledging the latter to have only taken to be a form of adolescent insanity, men- one aetiology. He does sometimes use the term in tioned several times in Grundriss (L14 [p. 87]; a stricter sense, for instance in the context of L17 [p. 107], and in detail in L39 and L40). The alcoholism, or documented degeneration of nerve concept was elaborated by Ewald Hecker (1871) fi bres. Only once does he use the word in a more (assistant to Kahlbaum) as an offshoot from the prejudicial sense, when he hints that it occurs then-new idea that adolescence could be conceptu- across generations in families, for instance, in alized as a distinct developmental stage. The term L38 (p. 294): ‘Appearance of degeneration, rapidly gained acceptance, to be incorporated into which can be followed in many families …’ He Kraepelin’s concept of Dementia praecox (follow- also refers to ‘neurotic degeneration’ (L30, ing Heinrich Schüle [1880] and Arnold Pick 360 Editorial Commentary

[1891]) [52 , 53 ] . Today it survives as the ‘disorga- signifying voluntary muteness in mentally ill nized’ subtype of schizophrenia, or the ‘disorgani- people, often selective according to circum- zation’ dimension of symptoms (although such stance, especially in catatonia. sub-typing was abandoned in DSM-5). Kraam and In L23, under Anxiety psychosis , we are given a Phillips [ 54], who review the concept, never men- vivid description of what might also have been tion confabulation, although this was widely seen termed ‘conversion hysteria’ by Freud. Wernicke as characteristic of hebephrenic schizophrenia. does not use this term, although the phenomenol- Presbyophrenia (L14; p. 87), a type of ‘paraphre- ogy is described clearly—severe hysterical anxi- nia’ (psychosis with onset during a period of tran- ety leading to distinctive quasi-neurological sition in elderly people), a concept whose history symptoms (paralysis, sensory losses, etc.), whose is reviewed by Berrios [ 55], is long-abandoned, detail fi ts no known neurological pattern. ‘Blind but is mentioned several times by Wernicke. thrashing behaviour’ (L38, p. 164), seen in patients Paranoia is a very old concept, with a com- under extreme stress, is also discussed by plex history [56 , 57], complicated by popular Kretschmer [61 ] using the term ‘instinctive motor misunderstandings. While broadly signifying fl urry’, which removes an animal from a danger ‘delusional’, variants focus on whether it is zone only by chance. He hardly regarded it as ‘monodelusional’ as believed today for ‘delu- defensive, but likened it to behaviour of a cornered sional disorder’ and advocated by Kraepelin [58 ]; animal, as did Wernicke. In addition, in L24 and on the subject of delusions. Popular under- (p. 158 seq. ), Wernicke recalls a case from the late standing today stresses persecutory content. It 1870s, which—whatever else might have been was divided by Theodor Ziehen ( [ 17]; p. 210), present—included major components of delayed assistant to Otto Binswanger at Jena, Paranoia war neurosis (‘shell-shock’, as it came to be called chronica simplex being one of his four types, held in England), from the Franco-Prussian war. Images to be a distinct disease. Wernicke disliked the of bodily dismemberment probably derived from term as referring to any disorder, but defi ned par- what he saw as a soldier ( névrose traumatique and anoid states as ‘all those chronic mental disor- hystérie traumatique, according to Charcot). The ders where we encounter falsifi cation of content framework in which Wernicke understood such of consciousness’ (L11, p. 65). syndromes would have been quite different from The term neurasthenia originated in New that of clinicians such as Freud (who had debated England [ 59], to become part of medical vocabu- in 1886 in Vienna whether hysteria could occur in lary (as ‘nervous exhaustion’; L17, p. 106) in men.) History of the term ‘conversion hysteria’ Wernicke’s time, for instance in L37 (p. 280) when since then has been complex. DSM-III abandoned he mentions that tendon refl exes may be increased ‘hysteria’ but kept ‘conversion’, which, in DSM 5, in neurasthenia. (This was reported by others, for became ‘Functional Neurological Symptom instance by Dejerine and Gauckler [60 ]). The term Disorder’. Three ideas may need to be defi ned is seldom used now in the West, but appears in (Conversion, Dissociation, Somatization), with some Western classifi cation systems, and has but two terms usually recognized in diagnostic greater currency in East Asian medicine. systems. DSM- III and DSM-IV separate dissocia- Two terms appear in Wernicke’s footnote (L1, tion from the others; ICD-10 splits somatization p. 6), and later. Verbigeration —the monotonous, from dissociation/conversion. usually rhythmical, repetition of one or several words—and Mutism: ‘By mutism we defi ne the temporary speechlessness of the mentally ill.’ VI. Wernicke’s Underlying These two were subsequently classed as cata- Philosophical Views tonic symptoms, aspects of Kraepelin’s Dementia praecox . However, Kretschmer, [61 ] argued that We come now to unique aspects of Wernicke’s catatonic symptoms—or at least some of them— thought. In Grundriss, our eventual focus, of may be aspects of conversion hysteria. course, is on clinical issues for psychiatry, which Mutacismus is also mentioned in L24 (p. 164), have their own philosophical underpinnings; but Editorial Commentary 361 underlying these are Wernicke’s unique ideas on ally mathematical; but it need not be mathemati- brain theory, and deeper than this his singular cal, as in Wernicke’s case. The contrast with approach to methods and philosophy of science biomedicine is that (with notable exceptions) itself. To give a good account of his system of relations between variables is established by sta- thought it is necessary to start with the latter top- tistical inference, which eventually becomes a ics fi rst, and then work towards his special proxy for causality. approach in psychiatry. Second, Wernicke is more willing than most biomedical scientists to base arguments on hypotheses about hidden variables, which, at the VI,(a). Wernicke’s Adoption time, cannot be directly validated, and thus lack of the European Style of Natural direct empirical proof. This is typical of physics, Philosophy where many hypotheses or variables arose from their value in providing explanations, rather than Throughout Grundriss, we see a distinct contrast from direct proof that the variables existed with to pre-existing medical traditions. Wernicke’s properties ascribed to them. The archetype for approach as a psychiatrist probably was unique, the die-hard medical empiricism is the apostle St. but as a scientist, it seems he drew lessons from Thomas—a physician—who could not believe in outside medicine, from the most fundamental sci- the Resurrection without feeling the holes in ence, namely physics, or, to give it its original Christ’s hands. In contrast, Wernicke writes often name, natural philosophy. Similarities in both of ‘internal connections’ in the brain (informa- content and method are to be found between tion connections, not anatomical ones), which he much of Wernicke’s thought and prevailing tradi- could never observe directly, but inferred from tions of natural philosophy. Striking similarity is their effects. So, in L11 (p. 66), we read of the also evident, especially in L1–8, with the thought ‘indisputable connection’, between active mental of Ernst Mach, placing Wernicke clearly within disturbance and chronic mental disorder in which European traditions going back to Leibniz, rather the active process has subsided; and in L12 than English ones tracing back to Newton. How (p. 73) we read of ‘internal relationship between the similarities with Mach were conveyed to hallucinations and autochthonous ideas.’ In both Wernicke we do not know. In any case they sup- cases, plausible inferences are made, as a physi- port the view that if psychiatry is to be rational, it cist might argue without directly observing the must be based on concepts as fundamental as process, or intervening variables. Likewise in those from which natural philosophy itself arose; L20 (p. 127), he writes: ‘Gentlemen! You can see and psychiatry then differs from most medical that just by getting to know all the internally con- disciplines, whose basic concepts are ‘givens’, nected symptoms puts the signifi cance of the fi rst derived from elsewhere, requiring no original left temporal convolution in the right light, as the philosophical or metaphysical thought. (A caveat site of ‘phonemes’, the most common—and you is needed here: Ernst Mach was avowedly anti- could almost say, the most important—of all the metaphysical; but this may have been in reaction psychotic symptoms’. The same phrase is used in to the emptiness of German idealist philosophy L29 (p. 198) for the relation between autochtho- of the time, rather than a denial of centuries of nous ideas and phonemes; and in L30 (p. 208) for metaphysical debate preceding and accompany- Affective melancholia and a variety of symp- ing the birth of the natural sciences.) toms; and similarly elsewhere. Occasionally, the At the methodological level, there are four inference of hidden connections with explanatory striking features about Wernicke’s thought. First, power is applied to individual symptomatology, the author was a fi rm advocate of reasoning in rather than a generic process, as in L38 (p. 283), science, as much in psychiatry as elsewhere. where we read ‘… the entire clinical picture Systematically, he sought reasons for relation- could be understood only as a circumscribed ships between observations. This is typical of autopsychosis based on an overvalued idea’: physics from its outset, where reasoning was usu- Reliance on unobserved internal processes is 362 Editorial Commentary linked to his important concept of ‘elementary be deduced from familiar features of the diseased symptoms’ (see below), since links between organ’. By aiming to deduce symptoms from such symptoms and secondary ones involve more basic knowledge (the only occasion on internal links. which the word abzug is used in Grundriss ) he A third related feature, is Wernicke’s willing- clearly sought explanations as understood in tra- ness to postulate ideal situations, far removed from ditions of natural philosophy. There are of course any empirical demonstration as ‘thought experi- many ways in which subjective experiences can ments’, which aid clarity of thought. This way of be grouped as named symptoms. His statement thinking connects Wernicke directly to Mach. It appears to state that the groupings he recognized was a concept gaining currency in the Germanic were those which could be deduced from actual world at the time, as Gedankenexperiment , about or potential brain mechanisms, the neurosciences which Mach wrote (‘On thought experiments’) in of his day, a procedure closer to that of physicists 1905 [62 ]. It is different from medical traditions than of typical medical researchers. This makes where strict empiricism tends to rule, and is espe- him different from most psychiatrists, before or cially different from modern insistence that every since, and possibly unique. Examples follow statement be ‘evidence-based’. As an example, in later; but as a general statement, he states (L11; L2 he writes: ‘If we do not expect a speaker to p. 69) that ‘only as an exception do you fi nd an lead us astray, then we must recognize that in this “objective” observer who experiences just the case, in a normal person, answers will arise in a “foreignness” of emerging thoughts without totally determined manner, to be predicted with attaching to them any far-fetched interpretation’. approximate accuracy.’ He acknowledges that One may ask if, even in principle, description ‘total determination’ is not reality, but uses the (and therefore classifi cation) of experience can conjecture to advance an argument, just as a ever be wholly separated from interpretation, as physicist postulates a ‘frictionless surface’. In Kraepelin wanted: All description uses pre- L5, to bring to life the idea that a person’s body existing forms, analogies, or vocabulary. (and brain) are also part of the observable exter- We can now recognize what were the found- nal world, he invites the reader to join in such a ing clinical concepts for Wernicke. The state- ‘thought experiment’, and in L6 to compare ment just quoted indicates that primary concepts humans with molluscs. Other examples are evoc- for him were not any supposed disease entity ative analogies. (defi ned by a range of symptoms, accepted with The Fourth, and perhaps most fundamental little deeper analysis, as in Kraepelin’s system), similarity to the natural philosophy tradition is but symptoms themselves, as primary experi- Wernicke’s approach to validating concepts: ences, from which any disease entity is derived When pioneers of the sixteenth and seventeenth secondarily. However, with symptoms taken as century struggled to make rational the study of the starting point, one should rely not on surface Nature, their struggle was, in part, to defi ne con- appearance, but on deeper understanding, to cepts in a way which supported precise reasoning reveal commonalities, despite surface differ- [ 63 ]. Defi nition and explanation are then interde- ences. Here we see interdependence of defi nition pendent. Proto-scientifi c pioneers in psychiatry, (or descriptive form) and explanation, allowing such as Pinel and Esquirol saw their role as being symptoms to be grouped together and named. We to describe what they saw, not to explain it. see striking parallels here with the thought of Gradually the emphasis shifted: For Kraepelin, Ernst Mach. Mach’s fi rst university experience classifi cation (that is defi nition of concepts) had was teaching medical students (in which he to come fi rst, presumably on the basis of some excelled), and he was to make major contribu- sort of authority, and only then could explanation tions to analysis of sensory systems, especially be attempted. Wernicke’s approach was different the visual system. In important ways, he antici- from both. Rather than laying claim to personal pated ideas which blossomed in the twentieth authority, he states, early in L1: ‘symptoms must century as Gestalt psychology [64 ]. For Mach the Editorial Commentary 363 foundation for natural philosophy could not be necessary to relate the position of each point of a derived concepts—mass or force—but primary sensory surface such as the retina, to a frame of experience, that is sensation . His integration of reference such as the visual axis. However, the physics with perceptual psychology is made clear term was used in various ways, sometimes incor- in the title of his book fi rst published in 1886, and porating practical actions which helped defi ne a extensively revised in 1905: ‘The analysis of sen- position with respect to a frame of reference, and sations and the relation of the physical to the psy- for Wernicke incorporating both ‘emotional’ chical’ [65 ]. His maxim was: ‘The world consists quality of sensation at each sensitive point, and of sensations, for the scientist and for the com- motor behaviour such as defensive movements mon man’ ([3 ]; p. 126). He knew well that, when associated with the ‘emotion’. In discussing the sensory systems register reality they impose their spatial sense in the retina, with fi xed orientation, own biases and distortions of that reality, an arguments used are nevertheless reminiscent of insight stated centuries earlier by Francis Bacon, those of Lotze, Helmholtz and Mach. There are who wrote: ‘It is a false assertion that the sense of many further similarities between Wernicke and man is the measure of things. On the contrary, all Mach in their respective treatment of sensory perceptions as well of the sense as of the mind are systems, such as the role of motor systems in according to the measure of the individual and elaborating perception (L3, L6) ([65 ]; p. 127), not according to the measure of the universe. And terms such as ‘sensation of movement’ (L6) human understanding is like a false mirror, ([65 ]; p. 137), the importance for perception of which, receiving rays irregularly, distorts and constantly dealing with solid bodies (L4, L6, discolours the nature of things by mingling its etc.) ([65 ]; p. 232), and even highly technical own nature with it’ [ 66 ]. Cohen ([3 ]; p. 131) detail such as retinal after-images (L3) ([3 ]; comments that ‘Mach’s theory of science is a p. 131). new and better version of Bacon’s counsel of Not only did Wernicke recognize distortion modesty, and warning against hubris.’ It is in any imposed by sensory systems on our perception of case striking that Mach and Wernicke both based space, he also hints at distortion in perception of their science on primary experience rather than time. In L4, he suggests that two percepts are derived concepts. never experienced simultaneously: ‘… simulta- Given that our sensory systems are akin to a neity of sensory perception is not possible, on distorting mirror, it follow that notions of abso- account of the property designated as the “one- lute space, assumed in Newtonian physics, might ness” or perhaps as the “unity of consciousness”. be part of the distortion. Here again, we see strik- In truth, we always experience only one sensory ing kinship between Wernicke and Mach. In L5, percept at once; any second, apparently simulta- when discussing the brain’s representation of neous percept happens either earlier or later. corporeality and the ‘tone of a sensation’, Association by simultaneity therefore appears to Wernicke bases our concept of space as having be but a special case of generic association been acquired from association between adjacent through succession.’ Simultaneity may be sub- points on a sensory surface, which are then cap- jectively valid, yet, as Wernicke appears to tured within cortical connectivity. This principle accept, a unitary subjective percept arises objec- is straightforward for the retina, more complex tively by association of more elementary compo- for cutaneous sensation, albeit similar in princi- nents (although for elementary perception this is ple. The phrase ‘local sign’ is used already in L3. scarcely available to consciousness). These state- The phrase was not Wernicke’s, but originated ments are not very precise indicators of with Hermann Lotze in 1852 [67 ], and was later Wernicke’s thoughts, but later, in dealing with used by Hermann Helmholtz, Mach, and William clinical matters he refers to defi nite distortions of James (who probably took it from Mach, whom sense of time in some of his patients. Thus, in he had visited in Prague). For Lotze and L14 (p. 89), he describes how, normally ‘… Helmholtz, local signs were learned associations, memories are strung so close together that alien 364 Editorial Commentary elements fi nd no place between them. This tem- premise of Spinoza’s was that entities with noth- poral association must therefore be broken if the ing in common, could not engage in causal inter- pseudo-experiences of confabulation are to be action [69 ]. So, things which are extended in taken as true.’ Again, in L18 (p. 219), he describes space might engage in their form of causal inter- a patient who ‘on one occasion … expressed his action, and things in the realm of thought (ideas) astonishment that the head warder had disap- followed their own sequences; but since there is peared through one door of the hospital and nothing in common between extension and simultaneously entered through another door. On thought, neither could there be causal interaction another, food suddenly stood before him without in either direction between ‘body’ and ‘mind’. any delay … Both events seemed supernatural Instead, there was continual parallelism between and magical to him at the time. Now the patient the two, necessarily so, since the two were differ- gives us the explanation that he made errors of ent aspects of a single entity. observation due to a lapses in attention.’ Such Mach adapted this parallelism to physical distortions are no cause for surprise if our con- ‘causality’ as a whole, and wrote: ‘the old- cepts of space and time arise from the associa- fashioned idea of causality, is a little clumsy: A tions of spatial or temporal data points, rather dose of cause is followed by a dose of effect. This than the geometric absoluteness of space and represents a kind of primitive, pharmaceutical time; and they match contemporary views: Weltanschauung, like in the doctrine of the four Subjective time is not a geometrically regular elements … connections in nature are rarely ever dimension. These ideas also appear to connect so simple that one can identify one cause and one Grundriss with debates about distortion of space effect. Consequently, I have tried for a long time and time occurring in physics in the same era: to replace the concept of cause by the mathemati- Even before Einstein’s special theory of relativity cal concept of the functional relation: depen- cast doubt that absolute simultaneity could ever dency of the appearances from each other’ [65 , exist, simultaneity was being discussed by Henri 70]. Such reasoning is likely to be a source which Poincaré and Hendrik Lorentz. was to lead the physicist, Niels Bohr [71 ] to ques- Beyond such parallels with physics, in one section the validity of any ‘claim of causality’. In tion, Wernicke questions the validity of the con- L4, Wernicke sometimes uses the word ‘function’ cept of causality, replacing it with something akin unmistakably in a mathematical sense, implying to a ‘mathematical function’ relating variables. no causal relationships, merely a systematic Thus, in L4 (p. 23), he refers to ‘causality’, as an description of events (albeit non-quantitative). inbuilt error or bias in how we view the world. For instance he writes (p. 23): ‘Perhaps by now it Admittedly he is not consistent, because in L5 is obvious that consciousness of the outside (p. 30), now fully convinced of the validity of cau- world has defi nite dependence on the outside sality, he writes: ‘Movement without any kind of world, or, we might say, is a function of it.’ In the cause, is inconceivable’. Nonetheless, we see same lecture he writes: ‘Always, when a certain echoed what David Hume had written in 1740 sequence of events recurs without exception, we [68 ]: ‘’Tis not therefore reason which is the guide believe that a law is operating, and are particu- of life but custom. That alone determines the larly encouraged in this belief when we succeed mind in all instances to suppose the future con- in arbitrarily evoking the initial event, and then formable to the past. However easy this step may observe the subsequent one. Such an experiment seem, reason would never, to all eternity, be able has an irresistible persuasive power over us. to make it’. In a more recent precedent, when However, clearly, this reveals no deeper connec- Fechner developed his strict psychophysical par- tion between the two events—it proves merely allelism, he denied causation between mind and the presence of that pathway which was claimed brain in either direction. In this, he followed a line earlier in the same processes. Our need to infer taken two centuries earlier by another proponent causality, in short, is an inborn error or a bias of of parallelism, Baruch Spinoza. A fundamental our brain.’ Editorial Commentary 365

These ideas come in early sections of insights into reality) is central to Western philos- Grundriss. In clinical sections, Wernicke does ophy, and can be traced back to Plato, even to not follow through on these ideas, and happily Pythagoras. Wernicke’s ‘credo’ announced in L1, uses ‘aetiology’ as a synonym for biomedical that mental disorders are diseases of the brain, cause. In L38 (p. 293), we read ‘Every specialist was adopted by most psychiatrists in Germany is forced to some general notion: Very often we since Wilhelm Griesinger, this being central to fi nd some debilitating event being specifi ed as a debates between ‘Psychikers’ and ‘Somatikers’. proximate cause’. In L26 (p. 174) he uses the The Somatikers were clear about the materialism phrase ‘an unconditional cause-and-effect rela- on which they based their views, although they tionship’. It is possible that he was hinting here at often had sympathy for some views of the a defi nition of ‘cause’ provided by John Stuart Psychikers, while rejecting less helpful notions, Mill a few years earlier [72 ]: ‘the antecedent or such as remaining ideas of demon possession and combination of antecedents upon which an effect various types of quackery. Wernicke is caught is invariably and unconditionally consequent’. between two opposed infl uences, the materialism ‘Cause’ itself is very hard, perhaps impossible, to of the ‘Somatiker’ ascendency in psychiatry, and defi ne rigorously. the more metaphysical tendencies of Gustav A view made clear in Mach’s writings, prob- Fechner and followers. It would be a mistake to ably shared by Fechner, possibly also by take Wernicke’s materialism as implying lack of Wernicke, is that a scientist’s task is to provide subtlety or sensitivity to subjective realities (a the most economical description of nature, not charge often made later against behaviourists). to explain it (if that implies ‘fi nding its cause’; We read, for instance in discussing cerebral rep- although ‘explain’ could encompass exact quan- resentation of language (L2, p. 10): ‘We need not titative descriptions, and the reasoning leading assume that the entire process normally follows a to them). Here Mach’s views probably coin- set pattern, virtually in preformed pathways, so cided with those of Newton two centuries ear- that the result is predictable.’ Far from the deter- lier, but defi nitely differ from ones prevailing in minism, which might be implied by refl ex con- biomedicine, then and now. cepts of Wernicke’s times, here he anticipates Overall, there are numerous similarities Chomsky on the creative aspects of language. between Fechner, Mach and Wernicke, on under- Overall his stance became a curious mix, avoid- lying methodology, the primacy of subjective ing many implications of Fechner’s strict psycho- experience, the conditional nature of reality con- physical parallelism. Thus, for Wernicke, veyed by such experience, and the concept of parallelism applies to some brain structures but causality. The similarities give strong support to not others, and not consistently. His ambivalence the idea that it was Mach to whom Wernicke surfaces in L19 (p. 124) in terms of opinions of made his cryptic acknowledgement in the his former colleagues: He discusses the views of Foreword to the 1894 edition of Grundriss; and Meynert and Neumann that hallucinations might they connect this work with Einstein’s approach- arise due to release from inhibition. The former, ing revolutionary ideas, where mass, length and his earlier mentor, was clearly of the Somatiker time were all subject to distortion. persuasion, the latter, one of the few remaining Psychikers. The logic of their respective positions is similar—only the words differ—and VI,(b). Wernicke on Mind/Brain while Wernicke suggests that Meynert’s version Relationships might be strengthened by experiments on localized function, he prefers the impartiality of The debate about the relationship between mind Neumann’s views. and brain (otherwise expressed as that between In more detail, in L2 (p. 11) we encounter the mind and body, mind and matter, meaning versus phrase ‘the organ of consciousness, in other mechanism, or subjective versus objective words, the organ of association’. The important 366 Editorial Commentary point is that consciousness is defi ned by the act of Fechner. His parallelism is sometimes expansive, association. This equation comes more easily in sometimes more restrictive. German than in English, since the German word Nonetheless, the infl uence of parallelism has a for consciousness, Bewusstsein , contains the past major impact on his whole approach to psychia- participle of wissen , the verb ‘to know’, which try. Wernicke, like Meynert, had no qualms about knowledge, is, in some sense acquired by associa- using subjective intuitions about how his own tion. The phrase sich bewusst sein , could then be mind worked, in order to draw inferences about translated as ‘to be aware of’ or ‘to be conscious how the brain operated. Examples are his subtle, of’. In L3 it becomes clear that Wernicke departs yet consistent distinction between ‘feeling’ from classical ‘two substance’ dualism, suggest- ( Gefühl ), ‘sensation’ (Sinnes ), and ‘perception’ ing instead the inseparable union of two different ( Wahrnehmung), and his grasp of Plato’s point aspects of cerebral activity. However, this seems (see next) of the subjective difference between mainly limited to the cerebral cortex, when he our perception of an object, and that of the gener- writes (p. 17): ‘Consciousness is a function of the ality or idea of the class of objects. Such intu- central projection fi elds. If the assumption—that itions are of course fallible, yet nonetheless a projection fi elds occupy the entire cortical man- fruitful source of ideas for exploration. tle—is confi rmed, then the corollary follows: Consciousness is a function of the cortical mantle.’ His argument for the role of the cerebral cor- VI,(c). Wernicke on Theory tex is based partly on comparison with animals, of Knowledge where both cortical structure and apparent perceptual capacity (as inferred from behaviour) differ Just as old as the debate about the relation from humans in corresponding ways. In L3 it is between mind and body is Plato’s theory of ideas, also implied that consciousness depends on neu- central to epistemology. In L4 (and note, L2), ronal perikarya in the cortex (the presumed site of Wernicke considers the relation between repre- association), not on axons or glial cells, when he sentation of immediate perception of an object writes (p. 16): ‘… when a memory … reaches a and that of the generalized concept of the object. person’s awareness via nerve pathways, it occurs He recognizes the distinction made by Plato 2000 specifi cally in nerve cell bodies.’ Wernicke is thus years earlier. Subjectively, it arises from the far short of the fully fl edged parallelism of Spinoza everyday fact that we generalize from individual or Fechner, essentially more materialistic in tone. cases of an object to its generic form, which latter Inconsistency in his proposed matching may have some vividness in our minds. The dis- between mind and brain comes again in L6 tinction was implicit, 50 years later, when Donald (p. 33), where we read: ‘The fi rst spontaneous Hebb [73 ] formulated the ‘neural assembly’ con- movements a child makes are apparently under cept. In Wernicke’s original, letter-spacing of his control of organ sensations’, in the newborn, with preferred term is widened—k o n k r e t e n B e g no continuity of retrievable memory with child or r i f f e—(‘concrete concepts’), clearly his own adult. Where he uses phrases such as ‘sensations special term. However, the conclusion implied by of movement’ or ‘representations of movement’, Wernicke, and made explicit by Hebb was very the inference is that, even for simple refl exes in different from that of Plato: In contemporary molluscs, sensory stimuli produce sensations. In thinking, we ascribe the origin of generalized L8 he writes (p. 49): ‘Feelings of pleasure and concepts, as distinct from objects themselves not pain in the spinal cord also seem to confer Affect to the other-worldly realm of Plato’s ideas, but to to the organ of consciousness, except that here their manner of representation in the cerebral we cannot specify the grey matter as the sole cortex, as captured by associative processes. bearer of the phenomenon’. He thus appears to be On other aspects of the theory of knowledge guided by Fechner’s parallelism, although his there are frequent indications of the infl uence of views are not worked out so consistently as by Immanuel Kant, and hints at that of John Locke. Editorial Commentary 367

The main debt to Kant is separation of ‘form’ In Wernicke’s clinical lectures, notably when from ‘content’ of experience. This appears fi rst in writing on delusions, he makes further assump- L2 (p. 13): ‘If the presenting symptom is an urge tions on epistemology. In L9, the fi rst clinical lec- to talk, then by the same token this is a circum- ture, he explicitly identifi es symptoms, which we scribed form of hyperkinesia. If, on the other call ‘delusions’, as ‘falsifi cation of contents of hand, his response is nonsensical speech, we consciousness’. This raises the unanswerable could rightly regard this as a symptom of paraki- question, attributed in the Gospels to Pontius nesia. Here, however, one would need a more Pilate ‘What is truth?’, a question which is tau- detailed account for each of these, because mis- tologous, since any answer has to be framed in understanding is to be expected. We will always terms of an assumption about the very matter at be forced, on practical grounds, to distinguish issue. Baruch Spinoza grasped the tautology two totally different aspects of speech: active well, when he wrote ‘He who would distinguish movement as such, and the content of the spoken the true from the false must have an adequate words.’ (emphasis added). In psychiatry, this sep- idea of what is true and false’ [69 ]. aration became central to writings of both Karl The notion that delusions refl ect error in think- Jaspers and Kurt Schneider. In L3, Wernicke ana- ing has a long history [76 , 77 ]. Modern psychiatric lyzes the difference between sensation and per- thought usually identifi es a delusion (as far as pos- ception, perception involving coordination of sible) by the manner in which a belief is held and many items of sensation, which conferred ‘form’ expressed, and by how it was formed (if evidence on them. This had been emphasized by Ernst on this is available). Wernicke, no doubt aware of Mach [64 ], and later was central to Gestalt psy- diffi cult issues in epistemology raised by delu- chology. The hint at John Locke comes in L4 sions, has prepared the ground well: In earlier lec- (p. 22), when Wernicke distinguishes essential tures he emphasized how, based on current and non-essential features of a concept. Locke knowledge, the brain comes to represent individual [74 ] had separated ‘primary’ from ‘secondary’ stimuli, and their integral, refl ecting the outside qualities (a split which, while not identical to world in its entirety. In L4 (p. 22), he is quite Wernicke’s, has some relation to it). explicit: ‘We can also identify the sum of such con- A different debt to Kant comes in L8 (p. 44), cepts as consciousness of the outside world , for in where he writes: ‘Sensory perception that has these concepts we in fact possess a true picture of never occurred previously … remains not only the outer world’ (ein getreues Bild der Außenwelt ). misunderstood, but also very-imprecisely per- The brain also acquires consciousness of the ceived’. This is supported by modern realization person’s own body, and the updated sum, of all that, even for the most basic visual perception, his/her life experiences so far. Altogether these we ‘learn, by experience, how to see’. However, three comprise, to a degree, an individual’s con- this sentence is followed by: ‘… complex thought cept of themselves as an integrated person. processes usually take place along prescribed However, the brain’s representation is not abso- paths’, and ‘Overall, mental activity shows itself lute, just an approximation, as Francis Bacon to depend on a long history of acquiring ideas, asserted. Given that the brain’s representation is and arranging them in special ways’. This appears potentially fallible, it may become more seri- to be a close parallel (albeit a special case) to ously deceptive. Nevertheless, Wernicke’s strong ideas presented in the opening of Kant’s Critique defi nition of truth and its separation from false- of Pure Reason , [ 75 ] where it is argued that syl- hood, based on understanding brain mechanisms logistic logic, as previously conceived is always implies that philosophical notions of truth depend incomplete, strictly a non sequitur, because it on, and in a sense, ‘bend the knee to’ what is relies on unstated, background notions (‘syn- known, or inferred about brain processes. This thetic a priori’ statements, for Kant). Wernicke reasoning also links with Mach’s view, that our (but not Kant) implies that such knowledge is not view of external reality is a distortion, although a priori, but acquired. sensation is primary. 368 Editorial Commentary

One specifi c aspect of distortion is introduced early lectures as in later clinical ones. Wernicke in L15 (p. 96), where Wernicke writes about is not entirely consistent in his treatment of them. ‘overvalued ideas’: ‘In this lady there was no In L7 (also L12), following Meynert, the view is psychopathic basis from which the overvalued expressed that an individual’s unchanging sense idea would have grown. However, you will not of ‘corporeality’ gives him his ‘primary Ego’, go far wrong if you take note of the “critical” age which also assimilates his knowledge of the out- she had reached, combined with an excess of side world, and personal life story. However, by mental energy, and resulting improper lifestyle, L14 (p. 86) he writes: ‘Normally, in a complex as suffi cient reason for occurrence of a sexually brain mechanism, there should not exist the coloured, overvalued idea’. These sentences sum remotest corner that is in discord with all other up his notions of ‘overvalued ideas’, and spell parts, and which does not function under their out with crystal clarity, a profound problem. Our infl uence’: This view of normality is perhaps the evaluation of ideas, persons or events inevitably dream of a philosopher, for whom rationality recruits basic functions of association, imple- comes easily, who does try systematically to mented by the cerebral cortex. Any mechanism erase all inconsistency in his thought, and who designed to detect and register associations, must (incorrectly) takes this as a universal norm. Such contain a ‘set point’ or ‘threshold’ above which a philosopher may be over-infl uenced by Western the link becomes credible, and below which it is religious thought which took rationality as the rejected as coincidental, and then forgotten. As in norm for human nature. However, deduction, and any statistical inference, conclusions are reached the quest to eliminate logical inconsistencies are ‘to degrees of probability’, not as certainties. not universal human endowments (whatever phi- Thus, without any inference of psychopathology , losophers of earlier centuries had said): They are we are all prone to error. Depending on where the products of education, training honed by experi- threshold is set—which varies from person to ence, and practice. The example given in L14, of person—we may be more, or less error-prone. a patient with a doctoral degree, is exactly the Overvaluation of ideas then refl ects normal cere- sort of person to have acquired this facility; but bral mechanisms in persons who are intrinsically most unlettered people, however effi cient and error-prone, as are we all. For some of us, cul- agile their minds, lack this facility, and operate tural traditions have given us an alternative fac- on the basis of memory and inductive inference ulty, that of deduction, which, when deployed (which are universal cerebral processes) rather systematically, can at least correct inconsistency, than by deduction. In L16, Wernicke, in effect, if not preventing error. L15 (also L14) deals with accepts this, when he compares recovery in two such corrective strategies. However, deduction is patients. In one, completely lacking insight when not a natural ability, but an artifi ce developed in ill, and complaining about his illegal detention, some cultures. Even in the most sophisticated recovered in an uneventful way; in another hypo- cultures, only a minority of the populace has suf- thetical but plausible patient, with extensive legal fi cient ability and faith in the method for it to training, there is a persisting focus on legal injus- overrule their associationist instincts. Therein tice, with continued accretion of far-fetched lies our problem! explanatory delusions. However, subsequent helpful corrective explanations might also develop in those who have acquired a facility in VI,(d). Wernicke on Personhood, reasoning. Unity of a Person, and The insight that the supposedly ‘indivisible’ ‘Self-Consciousness’ Ego has a complex, ever-shifting structure, and can become overtly fragmented, is clear in some The concept of personhood, the ‘unity of a per- of Wernicke’s lectures. In L12 (where he intro- son’, and—‘mystery-of-all-mysteries’—‘self- duces the sejunction concept) he discusses patient consciousness’, are topics which arise as much in Rother, and writes (p. 72): ‘This individual Editorial Commentary 369 consists simultaneously, as it were, of a number defi nition of fugue—a rare condition, usually of different personalities’, and that there is ‘a dis- related to psychic stress—has as exclusion crite- integration of individuality’. Likewise in L28 ria physical trauma, other medical conditions, (p. 193) he uses the phrase ‘split personality’ and various psychiatric diagnoses. The case (Spaltung der Persönlichkeit). The composite reported by Max Naef [79 ] (a doctoral thesis pro- nature of personhood is also found in writings of duced while working under Auguste Forel) which Ernst Mach who wrote that, although ‘psychol- Wernicke describes in detail (L28, p. 190 seq. ) ogy and psycho-pathology teach us that the Ego would be excluded according to such criteria: is the bond which holds all my experience This patient’s problems probably combined con- together, and the source of all my activity’, it can sequences of hyperthermia-heat stroke and den- ‘grow and be enriched, can be impoverished and gue fever, given the high air temperature in inland shrink, can become alien to itself, and can split Australia, and railway carriages with no air con- up—in a word can change in important respects, ditioning in the 1890s (see [ 80 ]; on neuropsychi- in the course of its life’ ([65 ]; p. 356). Quotations atric effects of hyperthermia). like this show that Mach—polymath that he In L7, the topic of ‘ self- consciousness’— was—could offer deep insights into psychiatry, ‘riddle of all riddles’ is Wernicke’s phrase—is from which Wernicke may have benefi ted. When discussed, and Wernicke’s scepticism about phi- we get to L28, and discussion of the ‘second losophy is interesting. He does not dismiss it out state’ in some of his patients, the fragmentation of hand, which would have been simplistic, given of personality is explicit. A vivid personal account that the natural science tradition grew out of hard is given by a patient, of her experience of this debates in past centuries on essentially philo- state, its authenticity ensured by apparent lack of sophical issues; and Wernicke was clearly distortion by her awareness of any popularized indebted to philosophers, especially Kant. concepts of ‘multiple personality’. Wernicke However, he ends by pointing out that the seem- clearly regarded the topic as very signifi cant, ingly ‘indivisible unchanging ego’ (implied by because, after describing this case, he starts his much of our language, culture and history), is comments with the words: ‘To leave no doubt actually a complex dynamic structure. This point about the importance of this case …’ The so- can be made from many perspectives, suggesting called ‘multiple personality’ had occasionally that different parts, with different functions can been described in the previous century, in France ‘cast their eye’ over other parts, by looking back especially by Charcot, who described a transient in time (Wernicke’s point), or by looking around condition with disorder of consciousness: There at the other parts of this complex entity. Such was dissociation between automatic activities ideas were becoming accepted by clinicians, (which were coordinated, if sometimes outland- from work of Pierre Janet in Paris. By the time of ish or bizarre) and personality, to which these the 1906 edition of Grundriss , more sophisti- activities were foreign, or contrasted with educa- cated views on this had been formulated across tion received. Pierre Janet described splitting of the Atlantic, by J. Royce and J.M.Baldwin (see identity, in relation to psychic trauma. Wernicke’s ref [16 ]), whose work Wernicke is unlikely to emphasis is different, with little stress on psychic have read. The line of thought was developed in trauma, and more on other ways in which such the 1930s by George Herbert Mead [81 ] and a states might be precipitated, including epileptic modern addition is found in a section of the doc- seizures, and alcoholic binge drinking. Hysteria toral thesis of Kate L. Ball [ 82]. The non -unifi ed is mentioned in this context, and it is clear that nature of the Ego was accepted by Mach, who Wernicke accepted it as a condition not limited to writes of ‘the instinctive, but untenable splitting women. Some states of dissociation described by up of the Ego into an object experienced and an Wernicke fi t the defi nition of ‘fugue’, a condition active or observing subject—a problem which which, according to Ian Hacking [78 ] was, in has tormented everybody long enough’ ([ 65 ]; part, a male equivalent of hysteria. The modern p. 332). Again: ‘Whoever cannot get rid of the 370 Editorial Commentary conception of the Ego as a reality which underlies visible. Here, rather than seeing personhood as everything, will also not be able to avoid drawing the integral of many parts of consciousness, we a fundamental distinction between my sensation fall back on older notions, perhaps related to an and your sensation’ ([65 ]; p. 356). Apart from ‘indivisible soul’. K.L.Ball, in her doctoral thesis anything else, this shows continuity between the [82 ] suggests that personhood is twofold, the thorough parallelism of Spinoza and Fechner, right hemisphere characterized as ‘the self expe- and the thought of Mach. riencing, and acting now ’; the left, as ‘conceptualizing the self, the will, and controlling at least some thoughts’. VI,(e). Wernicke on ‘Will’, Hegel’s concept of ‘will’ is pure teleology. In and on Teleology L8, Wernicke apologetically admits that his defi - nition of Affect is also teleological. Teleological In L30 (p. 204), we read: ‘For anyone to “will” a reasoning has a long history. The birth of the natu- certain action presumes making a decision, ral sciences depended (inter alia) on abandoning unquestionably an action of pure thought … In Aristotle’s notion of ‘fi nal cause’ (a cosmic form content, this implies that two or more possibilities of teleology) in favour of ‘antecedent cause’. For have been weighed against each other’. The Freud teleological arguments were used widely, German word for ‘will’—Das Wille— resonates in without restraint, this being a major criticism of German history. In combining ‘ Das Wille’ with his work. However, the behaviour of living things ‘pure thought’ a link is made to earlier idealist phi- clearly often does work towards an end goal, and losophers such as G.F.W.Hegel (1770–1831) Ernst Mach himself argued that teleology was which belies the materialist tone with which sometimes a valid account of nature, although not Grundriss began. For Hegel, ‘Will’ is not ‘free’ as Aristotle’s ‘fi nal purpose’, or with any overall until it is actualized, apparently unlimited by purpose for living things. (Here he might be at physical realities in the brain. Later, the monthly odds with Richard Dawkins, and his concept of magazine of the Hitler Youth was to be entitled the ‘selfi sh gene’). Today, no apology is needed Wille und Macht (‘Will and Power’). In discussion for teleology, if a correct approach is adopted: of freedom (or otherwise) of will by philosophers, Rigorous ways were devised to establish the teleo- the process of ‘getting out of bed’ is a widely used logical nature of behaviour, in work of ethologists metaphor, as here (L30, p. 207). It appears in such as Nikolaas Tinbergen and Konrad Lorenz, William James’ ( The Will to Believe; and other work that is highly relevant to psychiatry. essays in popular philosophy , published in 1897 [83 ]), and may have started its life there. Wernicke side-steps the challenge to determinism-in-princi- VII. Wernicke’s Contribution ple, based on overemphasizing ‘Das Wille’ , when to Neuroscience, Psychology he writes (L30, p. 207) ‘… of the error … that a and Overall Medical Knowledge person can control his thoughts and feelings, whereas actually the thoughts control the person’. In the English-speaking world, Wernicke’s name Possibly neither of these is right. Perhaps a is linked with two ideas: cerebral localization of person (or at least ‘one side’ of a person) is his or function, and—almost as strongly—a supposed her thoughts. Descartes, after all, asserted ‘I think ‘associationist school’ of thought. Less well therefore I am’. Referring back to the ‘unity of known, yet fundamental to Grundriss, are his personhood’, Wernicke is not consistent in dis- ideas on basic brain science. Here we deal with cussion of ‘will’. He writes (L35, p. 267) ‘To his additions to science and medical knowledge, assume a unilateral condition of the will would and with important gaps in his understanding, be nonsense’: Why nonsense, to assume that ‘the which shaped some of his mistakes. His major will’ resides in one hemisphere? Many clinical contributions to thought about mental disorders fi ndings have shown that personhood is not indi- come later. Editorial Commentary 371

VII,(a). Basic Neuroscience transfers to such intercortical pathways, and then seems very well suited, just as in the speech area, At least in early lectures, Wernicke assumes that to produce the paraphasia’. interactions between nerve cells were solely Sherrington is acknowledged as the fi rst to excitatory. In L8 (p. 43) he writes: ‘We can demonstrate neural inhibition clearly, inferred demand no more from it [the brain] than the rather than proven, in the spinal cord. There were sequence of certain excitatory processes’. Later, however a number of forerunners, such as the he contradicts this, implying that inhibitory inter- Edinburgh-based physiologists Charles and John actions might occur between cortical neurones. Bell early in the nineteenth century, and others in Sometimes this is ambiguous, when he mixes Russia and Germany in the nineteenth century, psychological and biological language. Thus, in cited by Sherrington in his Nobel Lecture of L8 (p. 48), when introducing the topic of emo- 1932. It is therefore interesting that the work of tions he writes of ‘a set of phenomena … which Hering in 1897, apparently denying the existence very often have effects of slowing down [hem- of inhibitory effects, and which Wernicke cites, menden] the course of mental activity, which are has, as its co-author CS Sherrrington, who had both decisive and disruptive, in equal measure.’ travelled in Germany (where he met, and worked In L19 (p. 123) he attributes the idea of ‘mutual with Goltz [see biographic comments, below]). inhibition’ to Meynert, whom he quotes in L33 In Refl ex activity of the spinal cord of 1933, (p. 236): ‘The association intensity corresponds Sherrington and colleagues [84 ] often used the to the molecular tissue attraction as a source of phrase ‘reciprocal innervation’, and ‘reciprocal strength. The mass of arching fi bres, within inhibition’ is used occasionally, stating (p. 67) which two sources of force, that of the idea of an ‘There is as yet no experimental evidence for the “objective” and that of the initial idea, tend existence of inhibition with neurones other than towards each other, as it were, in the act of think- motoneurones’. Direct proof came in 1942, when ing, always attaining vital force for elevation spinal inhibition by the eponymously named above the threshold of consciousness from two Renshaw cell was discovered [85 ]. Overall ideally centralized cortical areas, but the second- Duchenne (and Meynert) were proved correct in ary association from only one of these areas: this debate. Hering was proven incorrect, but either that of the “objective” or that of the initial may have infl uenced Wernicke. idea, according to whether for example the rhyme Of great interest is that, as early as 1894, fi ts its word picture. The functional attraction is Wernicke had clear ideas for what is now called the weaker here, and is inhibited by the stronger’. ‘synaptic plasticity’ as the physical basis of mem- In L35 (p. 235) he uses the curious phrase ‘inhib- ory. This is mentioned in L3 (p. 16), where he itory thought’ [hemmende Gedanke ]. ‘Inhibition’ writes: ‘Pathways that are initially hard to access is mentioned again in L35 (p. 236) where we become more fi rmly trodden-in with each new read: ‘maintenance of certain abnormal positions training experience—you could say that they are may reveal only subjective sensations of changed “molded by experience”’. There are references to balance between the motor impulse and its col- early German experiments (dated 1880 [Ward], lateral and antagonistic activation of defi nite and 1882 [Jarisch and Schiff]), showing the con- muscle areas, which cooperate in the normal cept as a basis for memory to have been clear in position’. He adds (note): ‘This representation is his mind in 1894, and to be much older than its based on Duchenne’s theory. The more recent current reincarnation. (Other early references on works of Hering, Jr. have meanwhile proven that synaptic plasticity are found to be in John [[86 ]; the assumption of an antagonistic muscle coordi- p. 198]). What is more, in discussing ‘falsifi ca- nation is not tenable.’ However, shortly after tion of memory’ (L14, p. 89), he shows aware- (L35, p. 269), he explicitly refers to inhibition at ness that there must be a complementary process: a neuronal level ‘The same inhibition [Hemmung ], ‘… memory falsifi cation requires a preceding which is responsible for immobility of the patient, break-up of associations.’ Today, dissipation of 372 Editorial Commentary associative memories is the subject of experi- More fundamentally, associations in the cortex mental study as ‘long-term synaptic depression’, are potentially so ambiguous, that they need a complement to ‘long-term potentiation’ which some sort of supervision or constraint to ‘disam- establishes them. Related to this, the temporal biguate’ them. A recent theory [88 ] attempts to precision of association at a neuronal level, is give an account of this process: By interplay mentioned in L3 (pp. 17, 18): ‘I agree entirely between hippocampus and cerebral neo-cortex, with Sachs and Goldscheider, that only by assum- the inherent ambiguity of associations in the lat- ing that functional links are acquired between ter structure could be resolved. It was also argued simultaneously excited perceptual elements using that such interplay sets up lasting confi gurations existing connections can one explain the specifi c which represent contexts for cortical operations memory for respective forms of retinal images, in specifi c situations, serving to disambiguate defi ned by patterned stimulation of retinal points’ activity circulating in the ‘organ of association’. (emphasis added). The modern slogan is ‘cells These contexts, it was proposed, correspond to which fi re together, wire together’. Kant’s ‘synthetic a priori notions’, which Wernicke describes as the ‘long history of acquiring ideas, and arranging them in special ways’ VII,(b). Wernicke (p. 44). There is one further major shortcoming in and ‘Associationism’ the view of the cortex as an ‘organ of association’: The motor region of the cortex, directly It is incorrect to regard ‘Associationism’ as a infl uencing lower motoneurones of brainstem ‘school of thought’. It is now fully accepted as a and spinal cord, and the decision-making pro- major bridge between neurobiology and psychol- cesses by which motor outfl ow is determined, do ogy. Wernicke’s view that the cerebral cortex was not fi t the concept. Wernicke gets near to this in (above all other brain regions), the organ of asso- L35 (p. 267): ‘From such arguments, it seems ciation, is basically correct, as a three-word syn- that in motility psychoses, consciousness of per- opsis. In L33 (p. 236) the assumption behind this sonality—in our sense, that “grand complex of is stated in simplest form: ‘If such functional dif- ideas” which makes up the Ego—is to a certain ferences of excitability are disregarded in the degree detached from motor mechanisms of the organ of association, the primordial condition of body, over which “the Ego” has become used to the childlike brain (Meynert’s “genetic confu- exert control. As a witness, the “Ego” is consion”), in which any given association is possible, fronted with motor processes, and also with the reappears to some extent, and may be retained for failure of this machine, and in turn, is initially a while, because anatomically preformed combi- affected by this’. By analysis at a psychological nations exist between any given two cortical level, this appears to reach a conclusion which areas’. Miller [87 ] developed a similar starting can now be put on a stronger footing: Operations point as a basic substrate for forming associa- of the motor system are not a natural component tions, that all neurones are connected with all oth- of the cortex, seen as the ‘organ of association’. ers in the organ of association—the The motor cortex is anomalous, having a place in ‘omniconnecton principle’—although, of course, the parcellation of the cerebral cortex only this does not—and cannot—occur in practice. because of other styles of processing imposed on One can of course point out that other princi- it by the basal ganglia, and elsewhere. ples of organization need to be added. As men- Many implications of the concept of associa- tioned above, for Wernicke, associations were tion are pursued in early lectures. Much of L3 is not only spatial (between data represented simul- devoted to distinguishing perceptual images from taneously), but to a degree, temporal. However, memory images. In the tactile sense, he separates he had no idea of the brain mechanisms by which sensitivity—‘ability to detect’ a tactile stimu- temporal associations might be formed, nor the lus—from what he terms Tastvermögen —using temporal limits within which they might apply. such stimuli for object recognition. In modern Editorial Commentary 373 terms this is the distinction between sensation as ‘positive feedback’: A ‘suspicion’ that ‘some- and perception, the former implying ‘awareness’ thing is the case’ leads to a ‘search backwards’ for arising direct from sensory input, the latter imply- relevant evidence, and if it is found, it is fed for- ing added processes of interpretation or analysis wards again, to strengthen the initial suspicion. In of that input. We translate this as ‘tactile percep- this way we arrive at sharp categorical judg- tion’. Likewise, later in L3, he often uses the ments—‘identifi cations’ in Wernicke’s terms— word optische and occasionally visuell . At one which go beyond objective assessment of the point he writes of ‘visual impressions that attract evidence. Wernicke is speaking of what we would our attention’ using the word Gesichtseindrücke. now call ‘pattern completion’, a process which In modern terms both this and visuell imply ‘per- Braitenberg [89 ] calls ‘ignition’—of representa- ception’ as distinct from ‘sensation’. Later (L20, tion of a whole, when only parts of are detected. p. 129) with a slightly different sense, he is at Wernicke’s associationism is based on ‘associ- pains to separate perceptual images from ation based on signal continuity’, a concept pur- ‘thoughts’ with no perceptual connotation (men- sued by Pavlov and others in somewhat different tal images devoid of perceptual imagery). The contexts. Not long after Wernicke’s death ideas German word Empfi ndungen implies sensation emerged that there was another major type of asso- itself rather than perception ( Wahrnehmung ) or ciation: North American psychologists developed remembered images of sensation, a subtle subjec- the idea of association between an item of emitted tive distinction, discussed in relation to both behaviour and the subsequent effect of that behav- visual and auditory sense. In translation we try to iour. From this so-called law of effect , the concept make the distinction as consistently as possible of reinforcement was developed, along with asso- (for instance using ‘visual’ as opposed to ‘visual ciated lines of theory and experiment. This con- perceptual’, and avoiding the word optische ). cept was mainly missing in Wernicke’s thought, as Despite separating perception from memory far as it infl uenced behaviour. images, Wernicke argues that similar associative processes apply at each level: He sees an exact parallel between formation of memory images in VII,(c). Cerebral Localization primary visual areas by linkage of ‘perceptual of Function elements’, and those higher in the hierarchy which generalize from percepts to concepts. The The concept of cerebral localisation followed arguments are another prescient forerunner of naturally from the ruling paradigm of general Hebb [73 ] in advancing the ‘neural assembly’ medicine, to relate symptoms to diseases in spe- concept: Most representation is via networks of cifi c organs or body systems, defi ned by anatomy widely distributed, but connected nerve cells. In and pathology. This was inevitable when, with L3 and L4 his arguments amount to setting up a few objective markers of disease, symptoms were ‘straw man’, such that ‘perception’ and ‘memory’ the prime source of evidence of disease processes are separate processes, represented in different in the living. The relation with general medicine groups of nerve cells; and he then proceeds to is seen in L24, where Wernicke employs the demolish the hypothesis, where he writes (p. 24): localization concept to refer to bodily symptoms, ‘But as soon as you go beyond this initial physi- bodily ‘localization of function’ being common ological unit, the memory image, and envisage clinical thinking at the time. Interestingly, just the next higher level of visual images or even throughout this lecture he refers to localization in association between visual images and remem- the body of feelings of anxiety. Just as much as bered images from another projection fi eld, the asking a patient ‘where does it hurt?’ he is at ease diffi culty of conceiving the process increases asking ‘where does your anxiety come from?’ enormously.’ This may seem strange today, but is logical, and In L4 (p. 22) he refers to ‘simple circuit opera- has precedents from classical times, when the tions’. He probably means what we now refer to heart rather than the brain was held to be the seat 374 Editorial Commentary of emotions. Similarly, a word root for ‘schizo- iour, carried out mainly on dogs, with some on phrenia’ (and other terms in psychiatry) is that for monkeys. The same principle assuredly applied the ‘phrenic nerve’ supplying the diaphragm. in humans. Wernicke writes ‘There can no longer Curiously, yet logically, the word ‘hypochondria’ be any doubt that each region represents the total (literally, ‘below the ribs’) is occasionally applied sensibility and motility of the designated body to unusual states of happiness as well as to those part, the arm region, which thus constitutes the of anxiety (p. 107; L29, p. 198). central projection fi eld for sensibility and motil- The concept of cerebral localization arose in ity or, in other words, the entire nervous system Wernicke’s earliest work defi ning the brain region of the arm.’ This comment would not be held representing speech sounds, but had become more valid today: A ‘second somatosensory area’ was nuanced by the time Grundriss was written, defi ned by Adrian in 1940 [90 ], spatially separate although missing some points we accept today. from the primary area, and now known to deal Sometimes he presents localization as a hypothe- with aspects of somatic sensation different from sis, without evidence, as in L1, when he suggests those dealt with by the primary area. In L1 he that semantic organization of speech uses brain refers to Broca’s area as the ‘motor speech path- regions different from those for phonetics. way’. Modern neuroanatomists would avoid such Sometimes he infers topographic mapping a statement, knowing the relation to motor out- between connected regions, in absence of evi- fl ow to be less direct. In one respect, however, his dence, simply because it seems necessary. localization is quite modern: In L36 (p. 274) he Sometimes his use of the concept is an analogy writes ‘Affi liation of motility symptoms with (‘For purposes of this analysis, all changes in con- changed body awareness is thus illustrated tent of consciousness can then be likened to focal again’: This view, iterated several times in this symptoms, and will behave just as do more famil- lecture, corresponds to a view which avoids sepa- iar focal symptoms of brain diseases’ [L11, rating functions of primary motor and somato- p. 66]). Sometimes he refers to the concept in a sensory areas of cortex (for instance in the notion quite metaphorical way. Sometimes he makes it of ‘active touch’: [91 ]). clear that it is no more than a hope for the future In L3, Wernicke discusses the difference that precise location can be found for symptoms between perceptual and memory images, and he describes, as when he writes (L33, p. 236): ‘the writes (p. 18): ‘only those elements in the cortical closed train of thought is a functional acquisition projection area serving perception should corre- pointing towards a most minute localization in spond to points in the retina’: He appears to defi nite anatomical elements’. In stricter scientifi c assume one-to-one relations between neural ele- vein, he concedes that much representation is dif- ments in the retina and those in the visual cortex, fuse, an insight closely connected to his ideas on a view which modern neuroanatomists would modifi able connections between members of question. Likewise, in L6, there is reference to a widely dispersed nerve cell networks. conjecture that there be orderly connections Nonetheless, in describing akinesia, hyperkinesia between points on the cortical map of the retina and parakinesia, which can occur independently and locations controlling activity of combina- in different muscle blocks (L35, p. 260), the infer- tions of eye muscles, corresponding to these ence that there is localized abnormality is strong, points; some empirical evidence for this is cited although the brain structure in which this exists from Munk’s experiments. However, empirical (cortex, or perhaps basal ganglia) is unclear. proof is lacking. This conjecture is intended to In early lectures (e.g. L2) the evidence he cites address a major problem for representation in the is clinical, either relating symptoms to identifi ed brain: How can object recognition generalize lesions, or studies in animals using lesions and over different sizes of retinal image, different electrical stimulation. In L5 he cites experiments directions of viewing etc. We read (p. 18): ‘An conducted by Munk, involving cortical lesions, equilateral triangle or a cross can be recognized with long-term follow-up, and study of behav- whether the triangle is standing on its base or its Editorial Commentary 375 apex, or whether the cross is standing, lying, or which neuropathological evidence was available, standing at an angle. How could the same mem- and other psychoses for which it was not, lent ory image be derived?’ The explanation proposed weight to localizationist views which he might seems far-fetched today. Moreover, given his have wanted to apply generally to psychoses more plausible account of concept formation in (L37, p. 274). We now know that pathological L4, which might also apply to percept generaliza- changes in progressive paralysis/tertiary syphilis tion, it is unnecessary. are greater than ever seen in endogenous psycho- Diffuse representation is raised as early as L1, ses, so the analogy may be false. Even so, in clos- when the supposed Conceptualization Centre is ing pages of L41 (p. 328), he rejects this hope: mentioned. ‘In truth, this supposed ‘Do the few cases I have in mind allow us to con- Conceptualization Centre is distributed to cortical clude that all acute psychoses, as well as the less sites far removed from one another’. In L2, any severe cases would reveal similar anatomical ambiguity is resolved, by asking whether this cen- fi ndings, were they to reach autopsy? . . In my tre has a defi nite physical location, or is it more opinion this question cannot be supported.’ diffusely localized, perhaps ‘localized’ more exactly but more abstractly in a logical structure? In L7, when discussing the cerebral basis of per- VII,(d). ‘Psychic Refl exes’ sonhood, he asks (p. 39): ‘What spatial sense can we make of a personalized consciousness?’ In The notion of ‘psychic refl exes’ was common talk answer, he refers to several types of disorder. at the time. Wernicke formalizes the concept, with Amongst those listed, it is unclear if they include distinctive italicized abbreviations: sAZm, signi- what is now call ‘mental illness’, to which cerebral fying the various stages in the ‘psychic refl ex arc’. localization seldom applies, or to neurological con- s and m are sensory and motor fi elds respectively, ditions, where it often does apply. Overall, while, presumably in the cortex, while A and Z , are as a neurologist, Wernicke’s name is rightly linked hypothetical staging posts where higher lever per- to the concept of cerebral localization of function, ceptual analysis and output planning are accom- this concept is not central to Grundriss. At times he plished. This model is fi rst described in L2 (p. 12), pulls away from localizationism in a fundamental for instance in the following lines: ‘Nervous exci- way. Thus, in L36 (p. 274), he writes: ‘There seems tation, which takes place along the pathway sAZm to be no compelling case for drawing an analogy can be likened to a refl ex process, and we can des- between the differentiation amongst these cases [of ignate this pathway as a “psychic refl ex arc”. The akinetic motility psychosis’] and the quite circum- movement activated from m then appears as the scribed nature of direct focal symptoms in brain result—a discernible consequence—of this acti- diseases’. Thus, he recognized that localizationist vation.’ The model is used throughout Grundriss , approaches, whatever their value in neurology, had for instance in L8 (p. 44), though expressed less limits as applied to realities of mental disorders. clearly than in L2 ‘… [mental] activity triggered At times cerebral localization is raised as a by the question as “registration”; and the result of possible basis for future classifi cation: ‘… I can- mental activity included in the answer as “execu- not emphasize strongly enough that the forth- tion”’. An example is the symptom of negativism coming principle of classifi cation must be that of ‘possibly having a signifi cance similar to that of a anatomical arrangement, giving a natural group- “modifi ed cortical refl ex”’ (L35, p. 266). ing and sequence of substantial changes’ (L17, Comparison with a monosynaptic ‘stretch refl ex’ p. 104). Here he is fl ying his favourite kite, that is hinted at, and the differential susceptibility he correlations will one day be found between the site describes, to rapid as opposed to slow stretch, of brain pathology and symptoms exhibited by implies selectivity to ‘phasic’ as opposed to ‘tonic’ patients, not only in neurology (where this was well stretch, a distinction well-known for stretch supported) but also in psychiatry. The relation refl exes. However, the two effects must have very between symptoms of progressive paralysis, for different mechanisms. 376 Editorial Commentary

Jackson’s hierarchical concept of brain orga- today) that the cerebral cortex has an inhibitory nization has already been mentioned. In L20, action on activity in the basal ganglia. He was Wernicke deals with levels of coordinated motor aware in a general way, of issues raised today behaviour, generated by the brain under different for understanding these structures. Thus, the conditions. These were to be explored later by fascinating lecture on melancholia (L30, Kretschmer [61 ] in Hysteria, Refl ex and Instinct. p. 204 seq. ), gives an incisive psychological Curiously, in L20 (p. 131), he accounts for com- account of decision- making, but referring to plex, but more-or-less automatic actions, as using the cerebral cortex. This is incompatible with a a ‘short-circuit’ within cortical networks, as view of the cortex as the ‘organ of association’, derived from the ‘psychic refl ex’ concept. He which can include neither ‘decision making’, uses the concept again in L24 (p. 157), to account nor competition between rival programs— for eruptions of ‘senseless rage’: ‘These motor implying inhibitory as well as excitatory pro- expressions bear the stamp of senseless rage, and cesses. However, mutatis mutandis, it is a fi ne would be correctly understood as a type of refl ex account of processes now thought to occur in response to violently increased organ sensations, the basal ganglia, where separate paths exist to and thus as hyperkinesia induced by psychosen- initiate and to veto any possible action, the so- sory means, via a short-circuit’. An alternative called ‘direct’ and ‘indirect’ pathways from view was possible, following Jackson’s claim, striatum to motor thalamus and motor cortex; that organization of motor responses shifts from and within each of these—under most circum- cortex to subcortex. Something like this is sug- stances—for resolution of competition between gested in L32 (p. 225): What appears to be ‘body rival courses of action [ 92]. In the process, language’ which is quite complex, is nonetheless Wernicke insists that at least one competitor instinctive, more-or-less automatic. should have access to motor outfl ow pathways. The psychic refl ex perspective leads to other Today, that condition is not needed: conclusions on voluntary actions, which are Competition can occur entirely between intra- strange for modern readers. Wernicke writes psychic ideas. He actually had evidence for (L35, p. 266): ‘… persisting contractions and this: Thus, in L29, where patients are discussed those independent of passive movements are so in whom the veto faculty is impaired, symp- invariably combined with states of unconscious- toms occur in one patient as unconstrained ness or marked stupor, that one might be com- motor outfl ow , and in another as unconstrained pelled to relate them to some form of volitional thoughts . action. I confi ne myself to suggesting that there Closely related to functions of the basal gan- are suffi cient clinical and experimental data to glia, Wernicke had little awareness of the rein- prove that central projection motor fi elds are the forcement principle, either (as soon to be defi ned) origin of tonic spasms and contractures’: There is in learning theory, or, following the Olds/Milner a disjunction here, in that evidence for involve- experiment of 1954 [93 ], at the biological level. ment of primary motor cortex is taken as equiva- He does imply a reinforcement process in L22 lent to voluntary action, even in patients who are (p. 140), when he writes: ‘we must attribute to unconscious or stuporous. Affective states the capacity to alter the normal value of ideas, in such a way that certain ideas are overvalued …’ This principle could clearly infl u- VII,(e). Wernicke on the Basal ence the representation of ideas and perceptions ; Ganglia its role in reinforcing behaviour is hard to fi nd in Grundriss. In any case, with no explicit knowl- Wernicke has little to say about the basal gan- edge, he sought elsewhere for processes by which glia. In L11 (p. 67) he does refer to a specifi c abnormal excessive (not epileptic) neural activa- structure, the lentiform nucleus (Linsenkern ); tion could occur. This was one aim of the ‘sejunc- and in L19 (p. 123) to the idea (still current tion theory’ (see below). Editorial Commentary 377

VII,(f). Higher Levels of Functional and dreams is so great that it breaks through, Organization even during apparent wakefulness. In this context, in L27 (p. 179), Wernicke refers to ‘falsifi - At a higher level of organization, Wernicke cation of consciousness, and [the] belief in the makes an important distinction as early as L8, lived reality of the dream experiences’, and thus between content of consciousness (produced by appears to imply this theory. It can now be based permanent change) and activity of consciousness on solid evidence—the so-called REM dissocia- (its ever-fl uctuating dynamics). This becomes a tion [94 ]—for which there is some EEG evidence recurring theme throughout Grundriss . In terms [95 ]. This idea is supported by a further similarity of activity, he compares ‘psychophysical motion’ reported in L14 (p. 87) ‘the total loss of memory between sleep and waking (L8, p. 46), and seems during epileptic twilight states, alleged experi- aware that sleep is an active process (an issue ence of Delirium tremens , or any other delirium resolved many years later). At times, he draws from severe intoxication, hysteria, or lastly, dur- parallels, as many have done, between distortions ing normal dreaming’. Amnesia for dreams is of reality in dreaming, and in mental illnesses. In well known, and normal. There are however two L9 (p. 55), he writes: ‘Lack of insight into illness differences between the state Wernicke describes is, in effect, the same as an increase in the sum of and normal REM sleep, that in the latter, there is a person’s memories by a body of data not cor- deep muscle relaxation, with no possibility of responding to reality, as we might gain from mental imagery infl uencing outward behaviour; experiences in a dream. If we were to string these and in the aftermath of delirium, after a period of often highly adventurous dream experiences onto sleep, imagery from the period of delirium is our store of memories, what incalculable conse- remembered for a while (L27, p. 179). quences for our actions, or our judgment of people might it lead to!’ More scientifi c issues about sleep are raised in L26, when discussing Delirium VIII. Wernicke’s Distinctive Clinical tremens , a severely abnormal state following Concepts in Psychiatry withdrawal, after prolonged excess of alcohol consumption. We now know that similar states VIII,(a). Is Clinical Science Even can be produced by withdrawal from other seda- Possible in Psychiatry? tive/hypnotic drugs, such a benzodiazepines. He writes (p. 172): ‘we are entitled to attribute Wernicke was aware of this as a signifi cant ques- another main symptom of Delirium tremens — tion. In the eighteenth century, when botanical total insomnia—to the stimulating effect of the classifi cation was high on the scientifi c agenda, dream-like hallucinations’. Today, insomnia is the acknowledged pioneer, Carl Linnaeus (1707– generally regarded as a sign of an impending or 1778), was a Platonist (philosophically speak- actual psychotic state (defi ned more narrowly ing), who believed in ‘natural types’. A rival than in Wernicke’s day), rather than being pre- Frenchman, George Buffon (1707–1788) cipitated by the hallucinations. Admittedly, hal- asserted, in contrast ‘Nature knows only the lucinations in other situations (effects of drugs, individual’. Just the same issue arose as psychia- their withdrawal, or toxicity, brain injuries, gen- try invented itself. In L8 Wernicke writes: eral medical crises), which are often visual rather ‘Despite all differences in social milieu, and the than auditory, may lead to, rather than follow epoch in which we live, all individuals in full insomnia. possession of their senses, have fi rmly laid down An alternative view of Delirium tremens is in their store of apperceptions, combinations of possible, now we know of a specifi c ‘pressure’ identical thoughts. In this regard therefore, we for dreaming (rapid eye-movement) sleep: must guard against overestimating the diversity Insomnia could be a precursor to dream-like hal- of individuals. This is defi nitely an advantage for lucinations, where the pressure for REM sleep psychiatry, making clinical observation possible’. 378 Editorial Commentary

This basic step moves the researcher from what ium, and soon of megalomania.’ Again (L35, seems endless variety and uniqueness of persons, p. 260) we read: ‘As we have seen above, it is in to their being somehow brought within a generic the nature of akinetic symptoms, that it is often scheme. After this step, he implies, psychiatrists totally impossible to decide how far they are may be within reach of scientifi c study, even of intermingled with other identifi cation disorders, diagnoses, rather than being limited to endless and at other times this is possible only after the unfocused description in the style of the natural akinetic stage is over. So we must then take into historian. Wernicke does this through a set of account the possibility that the above clinical pic- well-analyzed psychological processes, usually ture of akinetic motility psychosis, derived applicable as much to healthy as to disturbed entirely empirically, is too broad, and still con- individuals. Emil Kraepelin had the same basic tains cases in which the motor symptom complex objective, but approached it in a very different is merely grafted onto another syndrome, which way. is just as signifi cant, and encompasses it’: We see here his keen awareness of a methodological issue, that grouping of symptoms to form clinical VIII,(b). Role of Theory in Wernicke’s entities is sometimes guided by theory, but, in its Psychiatry absence, by empirical associations; and we see his discipline in separating the two. Less explic- Theory plays a crucial role in Grundriss, espe- itly, the same point is made in L34 (p. 256): cially in the fi rst eight lectures. This is empha- ‘Although this result is based on a statistical sized again in his closing sentence of L41: ‘In review of cases, it also confi rms what we might conclusion, I want to draw your attention to one already have expected’. point, and that is that these, my last comments, The balancing act between theory and empiri- should serve to remind you of the need for those cal data was crucial to the birth of the natural sci- theoretical considerations which occupied us in ences. The main difference from natural the fi rst half of our clinical studies, but, for you, philosophy is that psychiatry is much more com- perhaps often quite diffi cult to understand.’ At plex, and a would-be theoretician needs far more times he states explicitly that there are two roads facts at their fi nger tips before venturing an to scientifi c truth—theory and empirical data; explanation. This is hinted at in a comment on and that such truth is most secure when the two Kahlbaum (L34, p. 254) who ‘… has not escaped agree. In L28 (p. 188), commenting on the ‘sec- the fate of all authors who have laboured on ond state’, he writes: ‘Although I do not deny the monographs in a designated domain’: He implies theoretical interest in these most enigmatic states, that his own more comprehensive approach, cov- this should not affect their factual status’. This ering the whole fi eld of mental disorders, as well distinction is most clear in comments on melan- as their basis in neuroscience allows him to sug- cholia, a disorder defi ned by him most strongly in gest conceptualizations superior to those offered theoretical terms. So, in L35 (p. 261), we read: by those limited to single areas of psychological ‘Affective melancholia presented us with an abnormality. This also underpins his profoundly example where symptoms derived from a hypo- holistic approach to the brain and his understand- thetical scheme, and these alone, make up a clini- ing of each patient as an individual. cal picture which, in reality, is met very often’; In his fi nal lecture, Wernicke gives us some and yet shortly after, empirical demands prevail clues to his methods in analyzing and distilling (L35, p. 262): ‘sooner or later in their course, the wealth of clinical data at his disposal. ‘My they give further signs, in that delusions of relat- presentation is based on approximately 5,000 edness join in, this being entirely foreign to mel- carefully kept medical records that have been ancholia. Cessation of melancholia, which may prepared over the course of 15 years, under my last for a year or more, then usually gives way to direction and supervision’ (L41, p. 325), one pre- a further, worsening stage of persecutory delir- sumes between 1885 and 1900, his years at Editorial Commentary 379

Breslau. ‘Unceasing study of these case histories, In drawing attention to Wernicke’s strategy, their monitoring by continuous observation, the we should however be aware that conditions comparison of similar cases with one another, in which, to modern clinicians, are clearly neuro- addition to special study of individual symptoms logical, fell easily within his area of practice. The in these patients, required such an expenditure of fi rst example (L1) is a patient with abnormality in time that it was impossible for me also to evalu- semantic rather than phonetic organization of ate studies of other authors in the literature to the language. He draws an analogy between nonsen- extent that would have been necessary for my sical speech and transcortical aphasia, a concept purposes. The individual cases gave me the already defi ned. Other examples of ‘crossover’ advantage that they were very fully examined for are patients who turn continually in circles (L12, my purposes, especially since, through my p. 74), ones with impaired speech but intact sing- photographs, which form an integral part of our ing (L12, p. 75), or compulsive speech after a medical records, I usually managed to call to temporal lobe lesion (L20, p. 127). In L29 mind the entire personality’ (L41, p. 325). This (p. 199) his description corresponds well to mod- paragraph, and the preceding one, gives us insight ern descriptions of obsessive-compulsive disor- not only into his method, but also his into utter der (OCD, now a psychiatric disorder) or to the dedication to the task he had set himself. closely related Tourette’s syndrome (now a disorder in neurology). Giles de la Tourette (1857– 1904) described the latter syndrome in 1884, VIII,(c). Relation Between Neurology while working under Charcot. In these two syn- and Psychiatry in Grundriss dromes, the balance between the ability to initiate and to veto actions is shifted to the former and Despite his opening assertion that mental disor- away from the latter. Wernicke’s comment about ders are brain disorders, Wernicke does under- actions being ‘softened by concomitant anxiety’ stand (L1) that they are generally different, a is interesting, since OCD is often co-morbid with different sort of brain disorder—Geistes- anxiety disorders, or occurs along with anxiety. krankheit as opposed to Hirnkrankheit. He also The specifi c symptom of Coprolalia [from sometimes makes a distinction between ‘psycho- kopros = faeces] (L32, p. 232), with inability to logical’ and ‘organic’ (i.e. neurological) drivers suppress undesirable speech is discussed in an of abnormality, for instance of abnormal move- apparent case of Tourette’s syndrome, as in L29 ments (L23, p. 148; L24, p. 154). Nonetheless, (p. 200). as a didactic method, he sometimes uses disor- Some disorders described by Wernicke strad- ders from neurology as a spring-board from dle with ease the divide between today’s neurol- which to understand psychiatric conditions, ogy and psychiatry: In stroke patients we see the when the two have similar symptoms. Examples symptom of confabulation, or a patient (L39, include the case of transcortical aphasia in L1; p. 200), who ‘believed the persecutor to be a man ‘hypermetamorphosis’ introduced in L20 in a who lay beside her in bed and had taken posses- neurological context, to be developed in L22 in a sion of the paralyzed half of her body’. The com- psychiatric context; and mania after temporal monality of processes of forming explanatory lobe lesions, to lead into mania with no such delusions between the latter case and many cases lesion. (The only basis upon which he could we now identify as mental disorders is striking. have made this comparison is to have seen mania In L37 (p. 305) he states that ‘… bouts of cortical in a patient whose brain was subsequently exam- epilepsy tend to leave focal symptoms in their ined post-mortem , referring to his own Lehrbuch wake, including, quite remarkably even those of der Gehirn Krankheiten [ 96]). Modern studies of a sensory nature, such as sensory aphasia or secondary mania after brain injury do attribute it hemiopia, and often also combined sensory most often to damage in temporal basal polar symptoms right up to the level of asymbolia’. regions [ 97]). Presumably he implies that areas of association 380 Editorial Commentary cortex as well as primary areas were affected. In easiest translation of the German word Krankheit, L20 (p. 131) a recognizable symptom is given an which was Wernicke’s usual word, used either accurate description—now called ‘akathisia’, a narrowly or broadly. In English it might be term introduced in 1902 by the Czech physician extended to include effects of injury (although Ladislav Haskovec (1866–1904), working in this is unusual). In L5 he does use the word to Prague [98 ]. Wernicke does not use the term, and refer to brain injury, which is odd to English may not have known the latter’s account. In L32 speakers. However, in English, there are several (p. 230) disturbing sensations are described by alternative words to chose from, with different two patients, with either akathisia or what might shades of meaning (‘disease’, ‘illness’, ‘ailment’ now be called ‘restless legs syndrome’, and ‘disorder’, ‘sickness’, ‘condition’, ‘syndrome’, which were driving their unusual movements. etc.), with fewer alternatives in German. Some The former is usually now seen as a side effect of physicians separate ‘disease’ (a generic concept) therapy with neuroleptic medicines; the latter, from ‘illness’ (that is, how a generic disease has mainly during sleep periods. The phenomenol- unique effects at an individual level). In German, ogy is nevertheless similar. Overall, it is refresh- Krankheit serves most purposes. In English, ing to see so many conditions described with so despite available alternatives, the restricted little awareness of today’s frontier between neu- vocabulary of German has tended to prevail. rology and psychiatry. Thus, one of the oldest anglophile psychiatry journals, founded in Wernicke’s lifetime, followed German tradition by calling itself Journal VIII,(d). Wernicke’s Concept for Nervous and Mental Disease . of Mental Illness/Disease Today, the debate is opening up again, part of a larger debate on use of medical models for In L1 Wernicke’s ‘credo’, that mental illnesses mental disorders. Medical terms for mental disor- are brain diseases, was in part a continuation of ders are now increasingly challenged by some of an ancient debate, between those who viewed today’s consumer activists. This is not new. One diseases as imbalances of factors intrinsic to each of Wernicke’s critics, Karl Jaspers, based his crit- organism (a view fi tting the doctrine of ‘four icism in part on exactly this—the use of medical- humours’), and those who proposed that there ized ‘disease’ terms for mental disorders [100 ], were essential concepts of disease, to be classi- this being the basis for his sharp line against fi ed in ways akin to botanical classifi cation [99 ]. Wernicke, as a purveyor of Hirnmythologie Essentialist notions grew, over the whole of med- [ 101]. It is therefore indeed ironic that Wernicke icine, as symptoms came to be correlated with never once uses the word Psychopathologie in pathology in specifi c organs or organ systems. Grundriss , while Jaspers is best known for his This was the tradition Wernicke grew up with, magnum opus entitled Allgemeine and in L5 (p. 28), he refers to cases in neurology Psychopathologie [ 102 ] . (The original 1913 ver- (presumably with lesions of known location) as sion of this work ran to only 332 pages; the ‘cortical diseases’. Such ideas reached their peak English translation which is now read, comes in the late nineteenth century when infectious from the 7th edition of 1959, with 748 pages.) diseases were identifi ed with specifi c micro- There are hints that Wernicke was aware of organisms. Extension to mental disorders was the alternative view, although he could not break (and still is) less convincing. free from medical terms. In L5 and later (L9), he Wernicke’s ambivalence on this large issue is uses the plural form, Krankheiten , when he has discussed later in this essay. Here we limit com- not yet mentioned any generic illness by name or ments to aspects which might have been ‘lost in given any diagnostic term. Sometimes he uses translation’. Psychiatry in the English-speaking Geistesstörungen, rather than Geisteskrankheiten world in the last century drew heavily on earlier (in L9, apparently introduced to Grundriss in the German work. The English term ‘disease’, is the 1900 revision of 1894 text [[ 52 ]; pp. 121]). In Editorial Commentary 381

L24 (p. 162) he applies the term to chronic men- sided, for which he prefers ‘chronic mental distal disorders); and in L33 (p. 242) he uses the turbance’. The term also spans anxiety psychosis term Zustandsbild, literally, ‘picture of an exist- (L22, p. 143) alcoholic psychosis (L38, p. 295) ing condition’ He writes ‘To demarcate such and hysterical psychosis (L39, p. 301). A section cases it would be well to remember the old dif- in L24 (p. 162) gives important clues about how, ferentiation between habitual forms and actual operationally, he used the terms ‘psychosis’ and illnesses advocated especially by Kahlbaum. The ‘neurosis’, and, indeed what ‘mental illness’ was state of exhaustion described above is evidently for him. It reads: ‘For paralytic and hebephrenic not to be regarded as an actual illness, but shows somatopsychosis, severe organic loading is taken us asthenic confusion as a habitual form or, as to be prognostically unfavourable when the lim- recently termed, a disorder [ Zustandsbild ]’ . Such its of hypochondrial neurosis are exceeded and details might indicate that Wernicke intended to an undoubted mental illness is present’. convey the English concept of mental illness or ‘Psychosis’ becomes virtually synonymous with disturbance, as distinct from disease. However, ‘mental illness’, requiring obvious distortion of a in L9 and L16, he uses Geistesstörungen to make person’s sense of reality (in any of the three another precise distinction (also made by Miller domains of consciousness), while ‘neurosis’ is [[103 ]; p. 99]), between ‘active psychosis’ and separate from both these terms. Overall, the best ‘psychotic symptoms persisting as a hangover , or rendition of psychosis for Wernicke was proba- memory effect ’ from past episodes. bly ‘a state leading at least transiently to loss of It is worth summarizing the history of the insight (loss of the sense of personal wholeness)’. word ‘psychosis’ here, and what it meant for However, he was probably still formulating the Wernicke. According to Beer [52 ], Feuchtersleben concept at the time of his death. was the fi rst to use it in print, in 1847, but it may have been current for some time before that. He intended to stress mental concomitants of ner- VIII,(e). Wernicke’s Concept vous disorders, in contrast to the word ‘neurosis’ of Psychopathology which originally referred to objective signs of brain disorder. In any case, the word was not used Wernicke never uses the word Psychopathologie to differentiate classes of mental disorder in in Grundriss, although the word had been in com- Wernicke’s day. At the time of the 1906 edition of mon use in the Germanic world for some decades. Grundriss, Wernicke often used ‘psychosis’ as This is a fact of critical importance in deciding ‘falsifi cation of content of consciousness’, with how far he accepted the medical notion of mental ‘hallucinations’ and ‘delusions’ as the main illness. The words Pathologie or pathologische examples, a usage similar to today’s prevailing are used frequently, but refer almost entirely to meaning, but rather wider. (In today’s parlance, actual or potential fi ndings in the brain, while a ‘psychosis’ is often evidenced by limited forms different word, krankhafte, is used to describe of delusions and hallucinations. Thus, in today’s experiential or behavioural abnormality. Thus, in terms, falsifi cation of body perception in anorexia English, for the former (‘pathology’), we translate nervosa, or dissociation leading to falsifi cation of here with words which are directly equivalent, personal identity are not classed as psychotic.) and for the latter we use words such as ‘abnormal- However, Wernicke also used ‘psychosis’ with a ity’, ‘aberrant’ or occasionally ‘unhealthy’. His much wider range of meanings. Already in L1, he habitual usage might imply that, for him, experi- uses the phrase ‘motility psychosis’, and classes ential or behavioural features for which he used mutism and verbigeration as ‘psychotic symp- krankhafte might be statistically quite abnormal, toms’. Some clarifi cation is offered in the next but were not pathology sensu stricto. We identi- paragraph where he explains that ‘psychosis’ fi ed just two exceptions, where pathologie (not refers to an active mental illness, to distinguish it psychopathologie) is linked to behavioural or from residual states after an active phase has sub- experiential abnormality (see ‘Psychopathology’ 382 Editorial Commentary in section XVI. ‘Terminology’), and a third refer- cine’ in a strict sense. Sometimes the reasoning is ring to ‘sexual pathology’ (p. 326). We also found exact and prescient. For instance, in L20 (p. 129) two examples of tautology (such as krankhafte he discusses the idea that representation of some Symptome). The issue here is part of an older verbal thoughts—those ‘which are mainly con- debate, on whether ‘symptoms’ of mental disor- crete, with a somewhat simplifi ed thought con- ders are in continuity with normal experiences, or tent’—does not involve the left temporal lobe. are qualitatively different in nature [104 ]. Clearly, This intriguing idea receives support from recent in his sejunction theory, and in symptoms he research on representation of language in Chinese thought to be derived from sejunction, he did have script. In this case, the sequence from visual rep- a clear concept of neuropathology underlying psy- resentation of symbols to that of their meaning chiatric symptoms; yet that theory could not with- can be direct, not (as in alphabetic script) medi- stand scrutiny (see below). For most other ated via initial acoustic coding [105 ]. symptoms, our impression is that Wernicke mainly Wernicke, defi ned and grouped symptoms in thought in terms of the ‘continuity’ alternative, so far as he understood them on the basis of more although he never explicitly addresses the issue. basic scientifi c principles. In contrast, Jaspers took the basic categories of Kant as irreducible qualities [106 , 107], but could not validate them VIII,(f). Wernicke’s Attitude in a fundamentally scientifi c way. His categories to ‘Symptoms’ therefore had no link to any possible physical basis, and were thus independent of the common Despite never using the term Psychopathologie, language of science. Wernicke like Jaspers, uses Wernicke often used the medical term Symptome. Kant’s philosophy in emphasizing the distinction We have already seen how, like Mach, he based between content and form, yet drew on Mach’s his reasoning on primary experiences. In L1–L8, philosophy of science, to take primary experi- this reasoning links neurobiology to psychology ence as the key to the language of the natural sci- quite directly. In psychiatry reasoning from pri- ences. In psychiatry, this meant that symptoms, mary experiences meant that symptoms as albeit linked only indirectly to their physical sub- reported by patients were the starting point. Like strate, were by no means independent of that sub- Jaspers, he tried to grasp the subjective experi- strate. Wernicke thus did succeed (in principle if ence of his patients, rather than relying only on not always in practice), in bringing the common objective manifestations. He rejected grouping language of science to bear on psychiatry. That by aetiology (by which he meant ‘proximate was a huge achievement. cause’), because any one aetiology could lead to For Wernicke symptoms were by no means a wide variety of syndromes. He preferred fi xed entities, as they may be in general medi- grouping based on reasoning from more imme- cine. In L15, he argues that the class of symptom diate data; and he suggested that analysis of which emerges can depend on immediate events each case may lead to conclusions at various in a person’s life: What starts as an overvalued levels of organization: as psychological formu- idea, may subside, or be amplifi ed to delusional lations, as specifi ed pathways or regions, and proportions, depending on whether immediate potentially as cellular or molecular pathology at events and the social environment are benign or such locations. malevolent. Likewise (L18; p. 114) the symptom- Much of his reasoning is about psychological picture in a patient (not just its content, but the mechanisms underlying symptoms. (Reasoning class of symptoms) depends on his pre-existing at other levels, if attempted, was usually hypo- intellectual endowment (namely his capacity for thetical.) Thus links between symptoms and neu- ‘well-ordered thinking’), whether it be intrinsic, robiology were indirect; but they did exist, or developed through education. In addition he plausible if indirect. Most of his psychiatric prac- recognized that the underlying driver of a symp- tice appears to have been ‘psychological medi- tom complex might show up as a variety of Editorial Commentary 383 symptoms, depending on individual characteris- the basis of Wernicke’s extant conference presen- tics of each patient. Thus, in L13 (p. 81), we read: tations. His analysis of melancholia exemplifi es ‘For a single form of illness (such as acute “anxi- the concept. According to this, disorder of mood ety psychosis”), which entails an essential mental is not primary; ‘disorder of will’ is primary. It is content, one individual might portray that con- only a patient’s awareness of how impaired he or tent itself, while another produces phonemes rep- she is that leads secondarily to lowered mood. resenting the same content’. Major symptoms Whether or not Wernicke’s reasoning is robust, such as hallucinations and delusions can occur in few other psychiatrists even made the attempt. It many conditions, and do not defi ne any such con- is however part and parcel of his essential holism: dition in absence of other contextual detail; they As each person constructs his sense of whole- are indications of signifi cant mental disorder— ness, all parts of the mind (approximately) might no more—whose true nature must then be be in interaction with every other, continually defi ned. changing their mutual relation in response to life The primary aim of Grundriss was to teach events. It follows that a single abnormal experi- about psychiatry and the abnormalities he called ence can infl uence all aspects of psychology, thus symptoms. There are just a few references to producing many secondary symptoms. what is now called ‘personality theory’. In L7 we ‘Symptoms’ are thus not isolated, documented read some of Wernicke’s ideas about human indi- one-by-one, regardless of concurrent abnormal viduality, the emphasis being on acquired rather experiences, individual context, personal facul- than innate personality traits. This emphasis also ties, and life events. Wernicke appears to use the features in the clinical lectures, sometimes in ref- same concept for somatic symptoms, for instance erence to habits of behaviour, but occasionally to when (L24, p. 156), he suggests that a variety of personality as formed by habit. For instance, in secondary symptoms can start with abnormal L20 (p. 128), the term ‘brain habits’ is used, laryngeal sensation. A later psychiatrist, Eugen implying emphasis on acquired personality Bleuler, was infl uenced by Wernicke, and did dis- traits, rather than ones built into a person’s brain tinguish primary from secondary symptoms of processes ab initio . His comments on how basic schizophrenia, apparently following Wernicke’s processes appear as different symptoms accord- lead. ing to each individual’s traits suggests that he A fl aw in this approach is that abnormality at was aware of more fundamental differences. the neuropathological level (such as decreased However, research studies on personality were myelination) might have impact on many path- not well developed at the time of writing. ways in the brain, giving rise to diverse psychological changes. The correlation between concurrent symptoms is then due to their com- VIII,(g). Wernicke’s Concept mon biological origin, not to interactions at the of ‘Elementary’ Symptoms level of information. Moreover, at times Wernicke admits failure to derive all symptoms in a patient In L13 (note) and L14 (p. 87) Wernicke intro- from a single ‘elementary symptom’. Thus in duces the term ‘elementary symptom’, L21 (p. 135) he writes: ‘We will not be able to (Elementarsymptome ), an important concept in derive the fact of disorientation from experiences his attempt to bring reasoning to bear on psychia- that you have just heard about, and they must be try. It implied that, for each patient, a single viewed as independent phenomena’; or in L28 symptom was usually fundamental, one from (p. 149), in discussing a case of acute autopsy- which all others were derived. The concept is not chosis: ‘Manifold abnormal sensations of which well presented in Grundriss , but is implicit she complained belong here only in part; in other throughout. Krahl and Schifferdecker [1 ] explore ways their importance is probably that of inde- the idea, its origins, implications, and differences pendent, hysterical concomitants’. In other lec- from ideas of other psychiatrists of the time, on tures (e.g. L23, p. 149) he is at pains to point out 384 Editorial Commentary that in the disorder he describes, symptoms occur symptoms. He states ‘… more complex circum- ‘in isolation’, these being exceptions to his usual stances underlie pathological processes of activa- thesis. tion, and in some way must be seen to depend on The logic of interaction between symptoms is symptoms of defi cit’ (L14, p. 85). In other words, usually ignored in today’s psychiatry in docu- defi cit (‘negative’) symptoms had more direct ments which operationalize detection of symp- explanations than symptoms of activation (‘posi- toms, as if they were independent entities. The tive’ ones), which were usually secondary to the concept of ‘elementary symptoms’ has much to former. This assumption may have grown from the recommend it in a fi eld where scientifi c reasoning fact that, as a neurologist, he was mainly concerned is rare. The history of the transition from with functional loss after discrete lesions. In his Wernicke’s style to today’s, moves inexorably sejunction hypothesis, he sees positive symptoms from Jasper’s fl exible approach to description as a bi- product of defi cits. However, this rule is by [108 ]; to Schneider’s fi rst rank symptoms of no means absolute. In L33, in introducing ‘con- schizophrenia, later codifi ed, probably against the fused mania’ (p. 236), he is clear that the picture of author’s intention [109 ]; to the emphasis of Erwin positive symptoms ‘as a symptom of stimulation— Stengel, working for the World Health Organization that is, one connected to fl ight of ideas and loquac- in the 1950s, on standardized nomenclature [110 ]; ity—is separated in principal from the and then to DSM III. This is largely the story of corresponding state of defi cit’. Moreover, in dis- tension between gifted and imaginative clinicians cussing states where hyperkinetic and akinetic who, above all, needed fl exibility, and administra- phases are combined (L35), ‘the hyperkinetic stage tors requiring precision and replicability, whatever always comes fi rst.’ This issue was addressed by the validity of the concepts used. Miller [111 ], suggesting that, at least for schizo- Krahl and Schifferdecker [1 ] suggest reasons phrenia, negative symptoms arise from activation (other than his premature death) why Wernicke underlying positive ones; repeated excess of ner- never developed the idea more fully. One such vous activity produces progressive cellular destruc- reason is that he preferred to focus on sejunction tion (However, the author no longer accepts this theory. However, in the opening paragraph of inference). Many views are viable here. L15, sejunction and supposed ‘elementary symptoms’ are closely related, the former as a neuropathological process, generating the latter as VIII,(h). Affective Impact of Mental primary symptoms. So, in showing how one ele- Illnesses mentary symptom leads to others, he refers to: ‘the remaining content of consciousness, appear- As part of Wernicke’s thoroughly holistic ing, to a degree, to have disintegrated into frag- approach, he gives considerable thought to the ments, a fact to which we gave the name emotional impact of mental disorders. For this, he “sejunction”, in other words, detachment of indi- uses several terms—Affekt , Gefühl and Emotionen vidual components one from another. Such com- being the main ones—used carefully in different ponents initially form tight-knit structures, as senses, and often using the word Färbung (color- complete experiences, but their sejunction is ation). A fourth word used occasionally is shown by the fact that memories which fl atly Gemütsbewegungen (literally ‘movements of contradict each other can co-exist. The sejunction temper or disposition’). Affekt refers to an inner hypothesis then led us to a closer understanding experiential reaction or state, learned about of certain symptoms of activation, fi rst, of mani- mainly from a patient’s words. Gefühl is more of festations of disturbed conscious activity itself, a ‘visceral’ feeling, an ‘organ sensation’, but not and then of self-generated ideas and obsessions, identifi ed with any particular sensory modality, then of hallucinations.’ and closely linked to an automatic refl ex reaction Brief discussion is also needed on how Wernicke (often found in the compound noun Organgefühl ); saw the relationship between positive and negative while Emotionen refers to objective manifesta- Editorial Commentary 385 tions of Affekt , a state with visible, non-verbal, In all psychoses, abnormal mental content autonomic or somatic signs of emotion, typical of appears in the context of the Affective state hysteria (as becomes clear in L39). In L39 (p. 303) termed Ratlosigkeit , an insight probably based we also read an interesting line: ‘Almost always on Griesinger’s concept of ‘primordial delirium’ in these cases, phrenic nerve insuffi ciency can be (L18, p. 113). The word Ratlosigkeit requires demonstrated as the basis for the fear’. This some discussion. Its use predates Wernicke, for appears to refer to the theory of emotions pro- instance in writings of Kahlbaum [32 ], allied to posed independently by William James [112 ] in the term ‘confusion’. Wernicke knew it to be 1884 and Carl Lange [113 ] in 1887: Emotions as used sometimes by his patients to describe their experiential states originate as subjective state of mind; and he is also aware that it is dis- responses to automatic autonomic and other ste- tinctive to the German language (L21; p. 134). reotyped bodily reactions. How should it be rendered in English? The usual This is a diffi cult area for translation, where translation has been ‘perplexity’, or ‘helpless- there may be more words in German than in ness’. Neither word is a correct rendition. It is English. In English ‘emotion’ is the term used in different from ‘disorientation’, since, in L21 general speech, ‘Affect’ is a specialist term, (p. 134), we read that sensory deception alone although its use goes far back in history; and need not produce disorientation, but can lead to another word ‘passion’ is archaic, but with simi- Ratlosigkeit; and in L27, a patient is described lar meaning. In our translation we use ‘Affect’ or without Ratlosigkeit, but with prominent allo- ‘Affective state’ when Wernicke uses Affekt psychic disorientation, (p. 181), contrasted with (retaining the upper case ‘A’, to avoid confusion another in whom allopsychic disorientation is with the English verb—‘to affect’); and Emotion accompanied by Ratlosigkeit (p. 183). The dif- is used when he uses Emotionen. Gefühl is usu- ference appears to be that a person in a state of ally rendered as ‘feeling’. Ratlosigkeit knows that he/she is in this state; a In L25 (p. 169) Wernicke suggests that in disoriented person may lack such self-knowl- acute psychosis (Acute hallucinosis , in his edge (presumably of an Affective state). The terms) disturbed Affect recovers fi rst, followed relation between disorientation and Ratlosigkeit by hallucinations, while delusions persist lon- is not entirely clear, but may depend on whether gest. In addition, quite generally, he designates the disorientation is in the allo-, auto-, or the Affective impact of mental disorders in somato-psychic domains: Intense emotional acute mental illnesses, especially if they ‘irrupt reactions to auto- or somato-psychic symptoms acutely’ (p. 190), by the distinctive German may exist, while allopsychic orientation is word Ratlosigkeit. However, the impact is itself maintained. a product of another state, identifi ed as Ratlosigkeit, is itself an abstract noun indicat- Desorientierung (disorientation). Wernicke ing loss of Rat—a German noun most often used admits that he cannot defi ne the latter properly, as a ‘counsel’ or ‘advisory body’—a group of it being a matter for future work. It is presum- people, such as a city or regional government, ably not in the realm of Affect or emotion itself, ‘taking counsel’, or ‘providing advice’. Implicitly, but possibly a precursor of these at a cognitive then, Ratlosigkeit, suggests ‘loss of the inner level. Ratlosigkeit appears to be the Affective counsel’ or ‘deliberation amongst our various state produced by awareness of confl ict or faculties’, a meaning quite different from and incongruity between contents of the mind, pro- more specifi c than either ‘perplexity’, or ‘help- duced by mental illness, as in L28, where we lessness’ (the latter implying ‘loss of control’). read (p. 190): ‘It was only the newspaper article There appears to be no equivalent word with the [reminding a patient of a former place of work] same sense in English. Most discussion of it in that awakened in him the Affective state of psychopathology appears to have occurred well autopsychic disarray [Ratlosigkeit], and which after Wernicke’s days, for instance in a mono- caused him to seek medical help.’ graph from 1939 by G.E. Störring (see unsigned 386 Editorial Commentary review in Journal of Nervous and Mental Disease, dence. This theory also led him to view negative in 1940 [ 114 ]). The two English words we feel symptoms as primary, positive ones as second- get nearest to Ratlosigkeit are ‘confound’, usually ary: ‘I have represented sejunction as the funda- as a verb, and ‘disarray’, as a noun. The former mental process, and derived symptoms of has shifted in meaning but its older meaning is irritation from this’ (L33, p. 240). The German captured in a line from the English national word for ‘symptom of irritation’, Reizsymptome , anthem ‘confound their politics’; and in this older could also be translated as ‘stimulation meaning sometimes meant ‘to confuse, fail to dis- symptom’. tinguish, mix up’. While there is no satisfactory In no way does this theory stand the test of translation of this word, we choose ‘disarray’ to time, or could it ever have done so. It is a weak- render Ratlosigkeit. This word captures the sense ness, which in his day, fuelled the charge of ‘neu- of lost coordination, sometimes of a social group, romythology’. It is nevertheless instructive to but not that of coordination of separate faculties. examine the origins of the theory, the clinical The usage should be read in conjunction with this facts which it purported to explain, and the facts explanatory paragraph. Occasionally we do use he did not know, which had he known, might the word ‘perplex’ in a non-technical sense, and have held him back from this notion. In Grundriss, when we use ‘helplessness’, it is to translate a it is presented in L9 in connection with a patient word other than Ratlosigkeit. Occasionally, our named Rother (who is representative of many word ‘disarray’ is used to translate another long-stay patients in his institution). There were German word (e.g. Unordnung : p. 86). also various accessory notions, to deal with other clinical facts. Here we deal with the core concept. Other detail, especially on the second aim of the VIII,(i). Wernicke’s Sejunction theory, follows later in relation to specifi c Theory symptoms. Details of Rother, a gardener by trade, are as A central conjecture in Wernicke’s account of follows: Wernicke has known him since 1871, mental disorder, apparently a process at the cel- only one year after he graduated in medicine. He lular level, is his Sejunction Theory, supposed to has been a stable, reliable member of the institu- account for two striking observations. The fi rst is tion for many years, with little outward sign of the apparent illogical nature of utterances in abnormality, coherent in carrying out many daily many patients, blind to logical inconsistencies tasks, interested in current affairs, capable of all between different expressed beliefs. The second, normal courtesies, with a seemingly rational atti- as stated in the summary heading to L12 is ‘to tude to his being in the institution. However, explain pathological excitatory symptoms’. when questioned, his answers are astonishing. Already in L2 he has given a breakdown of pos- Once we gain complete trust , in the chatting sible neuropathological bases for mental disor- stage, he regales us unreservedly with his experi- ders: Three things could go wrong at a cellular ences. At fi rst we are struck by the fact that he level: Reduced, increased, or aberrant excitabil- knows nothing about having overcome a mental ity. In this context, he refers to ‘pathways’ and to illness; for his part he might have come into hos- ‘conduction’ therein. His inclusion of causes pital only because of an acute febrile illness, and other than frank lesions sounds modern, but gives he actually considers it wrong—a mistake—that no detail. The chief experiences which made him he has been held for so long, even though he raise the topic of pathological excitation were admits that the doctors had always been kind to probably symptoms of progressive paralysis, him. Then he tells of a confl ict with one of his some of which he interpreted as abnormal exces- gardener’s boys shortly before his admission to sive excitation at specifi c locations; his explana- the institution. During the struggle he had been tion of hallucinations in terms of the sejunction thrown down the stairs by this man, and had bro- theory may have grown directly from such evi- ken his neck. Editorial Commentary 387

I ask : “Who?” confi ned in an abnormal situation, a semblance of “Well, me”. normality as a ‘reconstructed persona’. A fourth, Question: “But aren’t you alive and sitting here?” and most likely possibility, recently expounded “Well, yes, but the other one is probably still by Ball [82 ] is that, in a chronic stage of schizo- there.” phrenia, there is failure to unite two aspects of the Question : “What other one?” ‘self’—the ‘self experiencing now’, and the “Well, Rother.” ‘conceptualized objectivized self’, normally rep- Question: “So, once you have been dead; is this resented (respectively) in right and left hemi- possible?” spheres. If the two are poorly integrated, a strong “Of course, everyone has a double.” conceptualized self may see a weak ‘self experiencing now’ as an alter ego, sometimes referred He then recounts how he had experienced to in the third person (see: L21, p. 135; L22, other quite different things that no-one would p. 143; L24, p. 159)—or here, using the patient’s believe: he had once been a bull and, as such, had own surname. This is different from ‘dissociative been tortured in a quite inhumane manner and identity’, where each identity, while to a degree then been slaughtered. He describes how they separate, itself remains coherent. had drawn a ring through his nose and dragged Succinct statements of the core of the sejunc- him along. He had also been crucifi ed once, tion idea come in L14 (‘the uncoupling of asso- together with two robbers. ciations’) and early in L15 ‘… “sejunction”, in other words, detachment of individual compo- Question : “Like Jesus Christ?” nents one from another’: This phrase is reminis- “Yes, exactly like that.” cent of that to be used by Eugen Bleuler in his Question : “Then you are probably Jesus Christ?” 1911 work ‘ Dementia praecox or the group of “Yes, I am Jesus Christ.” schizophrenias ’ [115 ] who wrote: ‘In this malady the associations lose their continuity. Of the thou- In L12 (p. 72) where the term ‘sejunction’ is sands of associative threads which guide our fi rst introduced, Wernicke discusses Rother’s thinking, this disease seems to interrupt, quite state of mind. This section is more controversial haphazardly, sometimes such single threads, than most of his writing in Grundriss ; yet his sometimes a whole group, and sometimes even insight, to our mind accurate, is that there is large segments of them. In this way, thinking something important to be explained. In part, becomes illogical and often bizarre’. The similar- ‘sejunction’ is intended to account for suppos- ity is no coincidence: Wernicke’s Grundriss, and edly abnormal co-existence of incompatible specifi cally the sejunction concept, did infl uence notions. Different interpretations of such distor- Bleuler [116 ]. ‘Sejunction’ (literally a breaking tions of personal identity are possible. Literally, of associations, or a state of broken associations) Rother’s words refer to the Doppelgänger (in is a better term than ‘disjunction’, or ‘dissocia- English: ‘alter ego’), a familiar concept through tion’, both of which imply separation of inter- most of the nineteenth century. A second internally coherent entities. There may also have been pretation is a true multiple (as opposed to double) older origins to the concept, coming from personality, a concept recognized after work of Meynert, since Wernicke writes (L33, p. 241): ‘I Pierre Janet in France, and today given the name might assign such cases to the highest grade of Dissociative Identity Disorder in DSM-IV (still weakened association [in confused mania] controversial). This may be revealed as multiple described by Meynert, which he compares to voices in conversation (three are referred to in genetic confusion.’ Meynert’s concept was that L29, p. 198), a symptom now known to be more in the childlike brain, associative connections common in Dissociative Identity Disorder than in are already very weak, which was probably what is called schizophrenia. A third possibility is linked to Kahlbaum’s idea current in Meynert’s that an attempt is made to recreate for a person day that adolescence was a time of vulnerability 388 Editorial Commentary to psychosis. Implicitly, Wernicke believed the such interplay sets up lasting confi gurations rep- ‘breaking’ to have a clear basis, at a micro-ana- resenting contexts for operating in specifi c situa- tomical level, rather than any gross lesion. As tions. In those humans who operate via deduction such, sejunction laid claim to be a fundamental and logical consistency, such contexts encom- and new neuropathological process underlying pass the operations needed for deduction, setting most major mental disorders. However, it lacked up hidden assumptions as the ‘framework’ any supporting evidence at the neuronal level. needed for the system to operate. In those who do Part of the context for ‘sejunction’ is what not operate in this way, likely to be those with Wernicke did not know, but which we know now. little education such as patient Rother, contexts He had no idea, or did not use, the idea that active can still be established by interplay between neo- inhibition existed in the brain at neuronal levels, cortex and hippocampus, but serve other roles in which, at psychological levels, could suppress the day-to-day lives of such people. In expres- one or more of a set of incompatible notions. sions of belief, inconsistencies may then exist, Failure of inhibition might then give a better but since these are between relatively unremark- account of Rother’s state. Even given his igno- able notions, they attract little attention, although rance of neuronal inhibition, a major fl aw in his it may be hard to get such persons to grasp the reasoning is apparent: He confuses statistical incompatibility of co-existing beliefs. If how- incompatibility (‘negative association’) which ever, such persons experience periods of active could recruit inhibitory processes now under- illness which introduce bizarre notions into their stood, with logical incompatibility (whose physi- beliefs, there is again no way in which the incom- cal basis would be quite different). Further gaps patibility can be resolved; yet the bizarreness of in Wernicke’s knowledge which made possible their beliefs now makes it clear in social settings the sejunction theory are mentioned below. that they have been mentally ill. The more bizarre However, one might ask what could be the the beliefs acquired during periods of active ill- basis of the apparent loss of logical consistency ness, the more outlandish is the residue of strange in patient Rother? As pointed out in section beliefs outlasting the active phase; yet, with no VI,(c). “Wernicke, on Theory of Knowledge”, ability in rational analysis, resolution of confl icts the facility for deductive inference, and with it, of beliefs is diffi cult, and may be impossible. awareness of logical inconsistencies and the need For Wernicke, primary abnormalities could be to eliminate them, is not a natural human endow- defi ned at either a biological, cellular level, or at ment, but one in which some people excel, while a psychological level. Sejunction was supposed others think in more natural ways, dependent on to be the primary biological abnormality. At the memory and association. Wernicke’s assumption psychological level ‘elementary’ symptoms that personal identity is synonymous with logical emerge, as in patient Rother. Some such symp- consistency of information within an individual’s toms are distorted perceptions (hallucinations); mind is unrealistic, and would not separate nor- others are beliefs whose abnormality falls short mal persons from his patients. Regardless of this, of being delusional. With regard to beliefs, he to operate via deduction in the quest for consis- introduced two terms, autochthonous ideas (L11, tency requires that ‘ground rules’ for a system of p. 68) and overvalued ideas (L15, p. 92), both logic be in place, as a ‘framework’ for reasoning linked to delusions. within which premises and conclusions can be ‘located’. In terms of Immanuel Kant’s Critique of Pure Reason, these are the ‘synthetic a priori VIII,(j). Hallucinations and Related statements’, needed (for instance) for numerical Phenomena for Wernicke or spatial reasoning. In another work [88 ] a theory was developed to show how, by interplay For Wernicke, hallucinations are important symp- between hippocampus and neo-cortex, the inher- toms, more primary than delusions (which are seen ent ambiguity of associations in the latter struc- mainly as secondary attempts to explain), and, as ture could be resolved; and it was also argued that such, a major class of ‘elementary symptom’. This Editorial Commentary 389 theme, which went back to Griesinger, may understood in the sense that the patient recog- explain why, for Wernicke, a major subdivision nizes these as their own thoughts, sounded out of psychoses is ‘hallucinosis’ (with separate loud on certain occasions, such as, for example, acute and chronic subtypes) a term which proba- when the patient is reading or writing. Cramer bly originated with him, and not widely used himself, and all his successors, left the symptom until after his death. He recognized the heteroge- so broad, that it has lost its original value as an neity in both the clinical aspects of hallucina- elementary symptom, and now still requires an tions, and their origin. His views on hallucinations explanation of its various routes of development’ appear in L13, L19, and L20. Although covering (L13, p. 80, note): Here he probably refers to a hallucinations in all modalities, as well as multi- comment made in L6, that muscle sensation had modal ones, he clearly states that ‘… for all hal- previously been given undue emphasis for posi- lucinations—with few exceptions—hallucinated tion sense. speech sounds predominate’ (L13; p. 80). Visual hallucinations are discussed in L19 Exceptions included psychoses of intoxication. (p. 120) ‘… patients themselves refer to them as On the ‘incorrigibility’ of hallucinations, he “images”, and … as shadows, or even as “ghosts”, writes: ‘The reality of a sensory deception is a term implying some form of explanatory delu- maintained against the testimony of all other sion.’ Whatever the perceptual component of a senses and most fantastic attempts are made to hallucination, the words with which it is explain it, leaving no room for doubt, or the pos- described, such as ‘poison’, often imply explana- sibility of their sense being deceptive’ (L13, tion. Visual hallucinations, like auditory ones, p. 80). Such an emphatic statement might not be capture the full focus of attention, but have a made today, when many lay people know of the greater sense of unreality than phonemes, and are symptom, some of whom, when they themselves thus less compelling and ‘incorrigible’. Tactile experience it, know immediately the experience hallucinations, sometimes called ‘delusions of to be deceptive, not a faithful refl ection of exter- infestation’ today, leave open the idea that they nal reality. In L21 (p. 134) in discussing patient originate from genuine disturbance of sensory K., Wernicke appears to accept this possibility. input. A fi ne account is given (L19, p. 121) of Wernicke refers to the usual auditory halluci- multimodal (‘combined’) hallucinations, a topic nations, which are verbal, as ‘phonemes’ (L13; rarely discussed today. These often combine p. 80), although he mentions non-verbal auditory senses with natural kinship (such as taste and hallucinations, (L19) which merge or transform smell). For such combinations, Wernicke uses the into verbal ones. The word ‘phoneme’ came from term ‘dreamlike’, etymologically similar to Dufriche-Desgenettes in 1873. Use of the term today’s ‘hypnogogic’ but probably a separate for an abstract concept in linguistics started with experience. An issue of increasing relevance Polish researchers, Jan Niecislaw Baudoiuin de today, is whether these are re-enactments of past Courtenay and Mokiloj Kruszewski, working at trauma. the University of Kazan in Russia between 1875 Many suggestions are made on the origin of and 1895. Wernicke’s use of the term has a differ- hallucinations. In L19, the possibility of abnor- ent sense, indicating inner experiences of speech mal sensory input is implied in both auditory and sounds, which might be projected as external tactile sense. Somatization, a modern term, is not voices (including dialogues [L13, p. 81]), or pro- used, but the concept features prominently (L10, jected upon identifi ed people in the vicinity (L13, L24) especially in relation to intestinal sensa- p. 81), a manifestation with less favourable tion. Then (as today), patient complaints might implications. He is strict in what he identities as be based on lay conceptualizations of the body, hallucinated speech: ‘In my opinion there is no and current fads of the day. In L10 (p. 62) a reason to refer to hallucinations of the muscle patient is described for whom ‘the suspicion we sense, as Cramer (1889) does, in order to explain therefore had, that he was still suffering physical “hearing voices”. The symptom of “thought sensations, was confi rmed when we examined echo” should be as restricted as possible, and him; for it revealed that the patient still felt an 390 Editorial Commentary obstruction and constriction of the bowel imme- much of the description in L24 combines what diately proximal to the anus, complained about might now be called somatization disorders, extreme discomfort and all sorts of abnormal along with eating disorders, especially anorexia sensations during defaecation, albeit conveyed nervosa, which posed a threat to life, then as now with a sense of hopelessness, and requested med- (L24, p. 162). ical treatment for his actual suffering’. In L24 In so far as some hallucinations arise from (p. 162) we hear of ‘unbearable tickling sensation genuine amplifi cation of sensory input to the cor- in the intestine’. L24 also contains descriptions tex, with no change of stimulus parameters, they of what might now be called ‘Irritable Bowel may signify an unrecognized, but general class of Syndrome’ a ‘functional disorder’ not otherwise disorders, found in many, perhaps all sensory sys- recognized until the 1950s, and usually dealt with tems, dealt with sometimes in psychiatry as in gastroenterology. Prominence given to intesti- ‘somatization’, sometimes in various other spe- nal sensation (see also L5) may seem strange to a cialties, as functional disorders in corresponding modern reader. However, the idea that ‘autoin- body systems. Their brain mechanisms may be toxication’ from gut bacteria might cause mental the background for some types of hallucination— disturbance was becoming popular at the time. It indeed, also for some delusions. Today, such sen- built on the germ theory of disease, starting with sory abnormalities are an active area of research, a paper in 1868 by Hermann Senator (1835– not yet assimilated into broad generalizations (see 1911), professor in Berlin. It developed further, section IX,(d). “Wernicke’s Approach to especially after Wernicke’s time, in France, Classifi cation of Mental Disorders” on theoretical Germany and elsewhere [117 ]. Kraepelin validation of Wernicke’s symptoms groups). With regarded auto-intoxication as a possible cause of such advances nowhere in sight in Wernicke’s Dementia praecox [ 118 ]. In L24 (p. 161) we also day, it is no surprise that his concepts of halluci- read of ‘the old theory of positional changes in nations—and delusions—differ from today’s. the colon as the cause of mental illnesses’, a Apart from unusually amplifi ed sensory input belief whose origin we could not trace. to the cortex, Wernicke argues that sensory per- Another recently named syndrome Persistent ceptions with no external stimuli, must originate genital arousal disorder (L24, p. 156) is also in cortical regions for sensory perceptions; ‘the described. What is now called delusion of infes- difference from actual sensory perception is then tation is mentioned (L24, p. 163). Another pos- limited, in that the origin of the stimulus in one sible case of exaggerated sensory input comes in case lies in the periphery, while for hallucinations L13 (p. 83): ‘It often happened that the father it lies in central, transcortical sites, although the pounded the table which drove him into the most target location is the same in both situations’ powerful sexual arousal.’ ‘The very sight of his (p. 81). In part this statement may have arisen father was apparently associated with a morbid from his encounters with progressive paralysis feeling that in this case was linked to morbid patients in whom striking positive psychotic physical sensations about which he was uncom- symptoms, as well as those of defi cit were seen. fortable. Such examples would probably have On the exact means by which this occurs two been called refl ex hallucinations by Kahlbaum’. quite different accounts are offered. The most Wernicke likens it to what Kahlbaum called ‘sen- plausible account comes towards the end of L19. sory delirium’. In either case it is an exaggerated Starting from early ideas of Müller, that there is sensation, rather than a quasi-perceptual image genuine disturbance of sensory input or process- arising from (or distorted by) meaning con- ing in sensory pathways, he excludes, step by structed at higher levels (as are many of today’s step, each suggestion. As part of this, he rejects ‘psychotic hallucinations’). Alternatively, it may Meynert’s view that hallucinations arise from be a case of what, in psychoanalytic theory, is over-activation of subcortical nuclei (L19; called the ‘electra complex’, unusual only in its p. 123). This is based on the fact that hallucina- being directed from son to father. In any case, tions often convey complex meaningful images, Editorial Commentary 391 along with the anatomical fact that, intrinsic to ual’, and again (L13, p. 79) ‘projection fi elds the cerebral cortex is a massive system of long themselves, regardless of whether these fi elds are and short association connections, while the thal- directly affected by a pathological stimulus, or amus and basal ganglia have no counterparts. are affected only indirectly as a result of a sejunc- Modern evidence supports the argument, in that tion process and the hypothetical backfl ow of ner- principal neurons of the thalamus have no local vous current from complex associative structures’ axon collaterals, and the principal neurones of (emphasis added). the striatum (caudate/putamen in humans), main What is implied is that, when pathways for nucleus of the basal ganglia, are inhibitory, not associative links are somehow broken, nervous excitatory; so neither structure can support mas- activity in pathways lacking onward connection sive associative operations. In the end, he is can build up, like a blocked stream, and propa- forced to conclude that ‘the essence of a halluci- gate backwards (‘hypothetical backfl ow’) to irri- nation [occurs when an] aberrant stimulus tate the site of origin, namely primary sensory extends via the memory image to these carriers of areas. Pent-up nervous energy, so to speak, pro- the organ sensation; and a memory image duces spurious retrograde activation of sensory becomes a visual image, and next, becomes a hal- regions. A specifi c example appears in L35 lucination, as soon as it is makes contact with the (p. 268): ‘For primary auditory hallucinations, associated organ sensation—by excitation of hearing is indeed to be regarded as a stimulation those perception cells.’ This view can incorporate process that arouses not only acoustic patterns, a comment made in L11 (p. 69) of ‘thought but also related organ sensation; and, beyond the becoming sound’: the so-called ‘audible intensity of the original stimulus, it is only the thoughts’, as a hypothesis for auditory verbal hal- presence of a well-worn pathway, which has lucinations, and (L12, p. 73) ‘the fi nding that always served for repetition, that explains irradi- patients themselves do not know exactly whether ation into the motor speech area’. The latter can they hear voices or only experience related only be the well known pathway from Wernicke’s thoughts, corresponds to a transitional state to Broca’s area, perhaps accounting for links between autochthonous thoughts and between verbal hallucinations and uttered speech. hallucinations’. A similar relation is implied in L34 (p. 251): This is Wernicke’s most coherent account of ‘Certain parakinetic symptoms, in hyperkinetic hallucinations. However, at an earlier stage (L12) motility psychosis, about which we have already he offers other views, deriving from the theory of had a chance to learn, give us a better hope of sejunction, which like the theory itself, is prone their being traced back to processes of to diverse criticism. In L12 (p. 74) he writes ‘hal- irritation’. lucinations may occur even without an actual Another statement, of how sejunction could process being in place, merely by accumulation account jointly for broken associations and aber- of nervous current at the point of sejunction’. rant excesses of excitation appears in L26: ‘We Here the ‘sejunction’ concept, based on observa- see in his allopsychic disorientation, a failure tions of haphazard disconnection of ideas, with corresponding with paralysis; and we may scant awareness of their logical incompatibility, assume that those complicated arrangements of has shifted to a different class of events, namely mutually associated memory images which allow subjective reports of hallucinations. The connec- recognition of the immediate situation have tion is not obvious until we read what follows become paralyzed or inexcitable. It is then per- (L12, p. 74) ‘the perceived magnitude of the haps not accidental that the irritant effect becomes stimulus is amplifi ed beyond the norm; conse- so clear, in that analogous arrays of memory quently, excitation of sensory regions of the brain images, corresponding to whole situations and (s ) may be expected to occur, even without an experiences, emerge spontaneously, and with external stimulus, especially if the same process abnormal clarity’. In these two sentences we see, has occurred often, and therefore become habit- in essence the twin processes of the sejunction 392 Editorial Commentary concept—loss of habitual associations, and their probably correct for at least some types of hallu- replacement by spurious excesses. These words cination, the other based on the sejunction theory, are in the context of Delirium tremens . which is quite implausible. Three incorrect assumptions lie hidden here, all refuted by subsequent advances. First, at the anatomical level, it is assumed that primary sen- VIII,(k). Sejunction Used to Account sory regions of cortex receive major inputs only for Phenomena Better Explained from ascending sensory pathways, not from other in Other Ways cortical regions. This is incorrect: The overwhelming numerical majority of synapses on In L12 the sejunction theory is used over- pyramidal neurones in primary sensory cortical inclusively, to account for two clinical manifesta- regions are derived not from thalamic input but tions which we now know to have more plausible from other sources, mainly other cortical regions accounts. One of these (L12, p. 74) was a patient [119 ]. Thus, hallucinations could arise by abnor- turning continually in circles: Apart from explan- mal predominance of ‘top-down’ control, which atory beliefs which a patient might construct, this is usually overridden by sensory input. There are is not psychosis, by modern concepts: Such a precedents for this: When sensory input is greatly movement disorder is well known (and well- reduced, the balance shifts, so that visual halluci- studied in animal models), arising in the basal nations may occur in sight-impaired people ganglia from either asymmetrical damage or (Charles Bonnet syndrome), or when falling asymmetrical activation by drugs or internal pro- asleep. This is implied by Wernicke’s account of cesses. Description of the subjective impact of hallucinations (L12, p. 76): ‘… combined hallu- these motor symptoms is interesting and vivid, cinations are not uncommon in all situations of but the case put forward that these are examples reduced sensation.’ of ‘sejunction’ is implausible. The second patient The second, incorrect assumption is that the (L12, p. 75) is ‘… a female patient [who] began ‘hydraulic’ metaphor which Wernicke uses is to sing, and you may still remember how clearly misapplied to transmission along nervous path- she spoke about the fact that she did this against ways. The mistake arises because he did not her will, and did not feel like doing it … She typi- know that the all-or-none law applied to axonal cally showed a defective pattern of breathing … conduction, making information transmission by When singing however, she suddenly presented a axons largely independent of signal energetics. normal respiratory pattern.’ Wernicke writes: ‘I Without such knowledge, the two could be believe that I have demonstrated conclusively linked, so that the hydraulic metaphor might that the explanation of this phenomenon is pos- apply. sible only based on the sejunction hypothesis’. The third gap which sejunction attempted to This is unnecessary. The fi nding that motor disfi ll, is Wernicke’s lack of awareness of the con- ability disappears during singing is known else- cept of reinforcement. Much of L20 deals with a where in neurology, perhaps related to unusual supposed pathological process by which points motor control, subject to unusual emotional of excessive activation arise in the cerebral cor- infl uences. tex, leading to abnormal added experience (‘positive symptoms’). However, today, we might attribute such excess to overactive neural rein- VIII,(l). Delusions and Related forcement, possibly arising directly in the stria- Phenomena for Wernicke tum, and relayed from there to specifi c cortical foci. Overactive reinforcement is now a major There has long been unresolved debate over hypothesis to explain psychotic symptoms. whether delusions arise by normal interpretation Overall, Wernicke offers two incompatible of experiences which are themselves abnormal, accounts of hallucinations, one plausible and or as interpretations which are themselves abnormal Editorial Commentary 393

(see Miller [120 ], while admitting that alternative time—for compulsive thoughts—we might be views apply for some aberrant beliefs). For dealing with an excitatory process whose conti- Wernicke delusions are ‘falsifi cation of contents nuity is preserved; and at another time—for of consciousness’, and, with few exceptions, he autochthonous ideas—with an excitatory pro- advocates the fi rst of these, mainly denying a role cess, where it is partially lost’. for abnormality of interpretation in forming delu- Wernicke assumes that the organ of conscious- sions. This idea can be traced back to John Locke ness is the organ of association, that association for whom delusions arise not from fl aws in rea- is based on excitatory processes, that it occurs in soning, but from faulty premises [ 77]. Thus in the full focus of consciousness, and is slow L11 (p. 67), he writes: ‘Suffi ce it to say that we enough for us to know of its operation. Therefore, can trace back explanatory delusional ideas to according to him, when a person is not aware every single one of the acute symptoms that we how an idea sprang to mind, that is evidence of a will encounter later’. primary abnormality, and perhaps a loss of excit- Later he clarifi es this in one area: ‘Patients dif- atory processes. However, the premises in the ferentiate quite well between their own thoughts, argument can be questioned: Normally, we often which, in the case of compulsive ideas compel do not know the precursors of ideas arising in our them against their will, and “foreign” thoughts, minds, although they are likely to be the result of in the case of autochthonous ideas ’ (emphasis continuous reverberation in our brains. Wernicke added). The word ‘autochthonous’ appears to be admits as much with the phrase ‘unconscious Wernicke’s special term, with no antecedents. mental activity’, in L12 (p. 73). The phrase ‘par- Outside psychiatry, it refers to something arising tially lost’ again admits this as a possibility. locally (for instance in an indigenous society), Closely related to autochthonous ideas is rather than having wider currency, and intro- Wernicke’s concept of ‘overvalued ideas’, a term duced to a locality from outside. In psychiatry, an similar to the then-popular phrase—‘idéé fi xe autochthonous idea is a strongly perceived (which Wernicke uses occasionally [L15, p. 94; notion, with no links to prior thought activity. It L41, p. 329]). This is developed in L15, where he may be perceived as coming from an external, writes that they ‘… are sharply distinguished alien, perhaps malevolent source. This is confus- from self-generated ideas in that they are evalu- ing in relation to its wider meaning. It might be ated within a patient’s consciousness, and thus, better rendered here as a ‘self-generated idea’ by no means are to be viewed as alien intruders.’ which preserves the wider meaning, but since it Overvalued ideas may remain as isolated symp- is a distinctive part of Wernicke’s vocabulary, we toms, as in a case he describes in L15 (p. 93) of retain ‘autochthonous’. He writes (L11, p. 68) an elderly gentleman who, when outside the ‘Patients notice the emergence of thoughts which institution continually feels harassed by other they consider alien to themselves, not perceived people, especially a certain master carpenter ‘… as normal, that is, probably not created by the everything always came back to the one master usual processes of association’. In L12 (note), we carpenter who, meanwhile, had served up the old read that patients ‘initially have no explanation’ story to other people, and notifi ed the police of for autochthonous ideas. Usually however an their observations of mental illness. Nowhere in explanation is immediately contrived, except the institution has anyone observed even a hint of occasionally (333) where he writes: ‘Nevertheless, a delusion or any other sign of mental illness in there are those like the patient who taught me this patient’. An overvalued idea may lead to only recently. In that particular case autochtho- delusional elaboration, but since this is not a nec- nous ideas were the sole psychotic symptom, and essary feature, the two symptoms are separate, an they subsided again without being related to any overvalued idea being classed as an ‘elementary explanatory delusions.’ In L12 (p. 73) we read: symptom’; yet Wernicke admits that ‘the mecha- ‘We might also be tempted to seek a distinguish- nism of its formation remains unexplained’ ing feature related to sejunction, so that at one (p. 90). 394 Editorial Commentary

Wernicke is clear that delusions themselves Beyond such origins of falsifi ed beliefs, are are acquired by a learning-like process, some- other sources for delusions which need not be times instantaneously, and can then persist as abnormal or pathological. Some involve changed enduring beliefs. In L10, (p. 61) he documents sensory input (L10, p. 61, p. 63), especially in the cases where ‘we have observed . .the time at sense of taste or smell (L11, p. 70), or for hear- which somatopsychic delusional ideas actually ing, symptoms such as tinnitus (L19, p. 117). originate, and can thus provide evidence of their Wernicke attributes some falsifi cations to bodily origin from abnormal physical sensations.’ From changes, including ones due to physical abuse this, the point he often makes in early clinical (L11, p. 67), which need have nothing to do with lectures, follows easily—that there is a differ- mental disorder. Likewise, manifest abnormality ence between active illness, and beliefs that of motor function or behaviour (L12, p. 74), itself endure when the active phase is over (‘stable perhaps due to neurological rather than psychiat- conditions and diseases actually in the process of ric disorders, or recovery of mobility (L12, p. 74) developing’: L9, p. 34). Thus, delusions differ can be the origin for an explanatory delusion. from hallucinations, which, while remembered, Lastly, he mentions instances where awareness of are immediate experiences. In L25 (p. 169) he sudden, loss of attention, not itself abnormal, makes this point for one patient, that ‘recovery becomes a source of delusional of explanation involves elimination of the hallucinations, (L19, p. 114). despite tenacious retention of the system of delu- The classes of delusion for which the above sions’. Recent research also shows that halluci- experiences are a trigger, include delusions of nations are usually eliminated more quickly than reference, grandiosity, persecution or hypochon- delusions during antipsychotic drug therapy. dria. The fi rst two of these are in the autopsychic Experiences which could be classed as abnor- domain, the third in the allopsychic domain, and mal, and from which, in Wernicke’s, view, the last in the somatopsychic domain. It follows delusions arise, have been mentioned already— that these four classes of delusion are not pri- hallucinations (which may be projected into the mary: They are subclasses of the two major types, external world as ‘delusions of relatedness’; L11, delusions of relatedness or explanatory delu- p. 69; L13, p. 80) and autochthonous ideas (often sions . So, for instance in L17 (note, p. 107), on projected on to a doctor; L11, p. 69). He also the subject of grandiosity, he writes: ‘Here, I suggests that lack of insight may itself be a pri- believe that I am in agreement with Snell, who mary abnormality (L9, p. 56), often based on the also denies the primary occurrence of overesti- fact of a patient’s detention in hospital (L10, mation ideas essentially’ [121 ]; and later in this p. 64; L14, p. 88). This is seen as a primary effect lecture he discusses, but rejects Griesinger’s idea of the sejunction process; but this is hard to that delusions of grandiosity or persecution might accept: For a patient with no education about be primary symptoms. psychiatry, what needs to be explained is not so Clarifi cation of the terms we use in translation much lack of insight, which is to be expected, but is needed here, especially with regard to ‘delu- that many patients do have, or do gain insight, sion of reference’. Wernicke often uses the term even, to some degree, when acutely disturbed. Beziehungswahn, which we usually translate in a Other origins are said to be other pre-existing generic, abstract sense as ‘delusion of related- symptoms, for instance when a persecutory delu- ness’. However, that relatedness often involves a sion leads to delusions of grandiosity (L9, patient interpreting an event, an idea, a coinci- p. 56), or when past abnormal experiences are dence, or something else, as referring specifi cally reinterpreted retrospectively (such as when to him- or her-self. For this we use the more spe- knowledge that a person has had some sort of cifi c, less abstract term ‘delusion of reference’, a ‘episode’ leads to the belief that she has acquired term already current, after Neisser [ 122 ] drew a new style of thinking, or expertise in a new attention to ‘morbid self-reference’ (krankhafte topic ; L11, 68). Eigenbeziehung ). It became more precise in 1918 Editorial Commentary 395 with the publication of Ernst Kretschmer’s mono- tion, see above) but often develop further in the graph Der Sensitive Beziehungswahn (‘The sen- most consistent manner, forever giving rise to sitive delusion of reference’). The term is as in new delusions’ (L11, p. 67). Such ‘spread’ is not Grundriss, but Kretschmer allied it to a specially typical of ‘normal’ explanations by healthy peo- sensitive personality type. Wernicke makes a ple. In L10 (p. 61) we read that ‘parables, simil- similar suggestion (L13, p. 170), referring to ies, or analogies are … forced up to conscious Raskolnikov, Dostoievsky’s sensitive hero from levels, in distinctive ways for each patient, and Crime and Punishment: ‘In a brutal habitual are then used as a means of description’, again criminal, the state of mind of a Raskolnikov seldom part of normal explanation. Wernicke would be impossible’. In Wernicke’s terms, such writes (L10, p. 60) of experiences ‘reconfi gured delusions have a strong autopsychic content. For … as is often the case, within just such a religious delusions in the other two domains (allopsychic framework.’ Why, one may ask, ‘often the case’? and somatopsychic) we retain the generic term An answer is provided, in that religious language, ‘delusion of relatedness’. There are other issues rich in parable, simile or metaphor, and necessar- for translation. The German word Wahn, can ily symbolic in nature, offers the best scope for mean either ‘delusion’ or ‘an abnormal state in elaboration by hyperactive association; but he which delusions can occur’ (i.e. ‘madness’). We does not make this point. In L12 he states (p. 77) indicate which meaning is intended, whenever ‘… a pre-existing tendency to delusional inter- Wahn appears. Likewise the terms ‘delusion’ and pretation is also supplied by abundant normal or ‘delirium’ can be confused (more in French than near-normal material for processing and evalua- in German), and we have stuck close to tion’. This admission shows that he felt a need to Wernicke’s words here. qualify his thesis, that delusions are quasi- rational Wernicke repeatedly stresses that the process explanations of abnormal experience, with hints of explanation of experience is usually not abnor- that some personality traits favour delusions. mal. So, ‘explanatory delusions may have no The phrase ‘delusion of relatedness’ itself independent signifi cance’ (L12, p. 77). This almost implies hyperactive association, although emphasis was common in the nineteenth century, Wernicke still attributes misinterpretation to when, for instance, delusions could be conceived faulty perception, in that raw sense impressions as ‘parasitic’ on more primary symptoms such as are given abnormal Affective overtones, often hallucinations [77 ]. If more than one explanatory self-referential. In L18 (p. 115), where he is writ- idea is conceived, a patient may be in honest ing of acute rather than chronic disorders, he is doubt which of several to prefer. He supports his more explicit: ‘I presented this to you as an view with the comment (L16, p. 99) that ‘indi- example of a somatopsychic delusion of related- vidual circumstances can decide the outcome— ness; however, we cannot doubt that here too it another argument supporting our view that the was based on a process of aberrant elaboration of formation of explanatory delusions cannot be new associations. In our patient still other exam- based on an ongoing disease process.’ ples showed up in this connection, with somato- ‘Explanation’ may also take the form of voices psychic delusions of relatedness forming via (‘phonemes’) or be built into ongoing experi- processes of aberrant association. ’ (emphasis ences of voices (L13, p. 81). So, we read: ‘The added; the same phrase—krankhafter Assoziation — content of the phonemes consists overwhelm- occurs in L19, p. 240). In addition, the concept of ingly of “delusions of reference”’ (L13, p. 82). an overvalued idea, which Wernicke admitted he In delusion formation, abnormality of associa- could not explain, is well accounted for as intrin- tion itself, that is the very process by which expe- sic hyperactivity of a kind of association— rience is interpreted, is given less emphasis. between matters of personal value, and Nonetheless, such abnormality is often implied. surrounding events. Beyond this, the list of For instance, ‘delusions only rarely stay limited sources from which explanatory delusions arise, to the initial delusional ideas (usually of persecu- such as abnormal sensations (of taste/smell, or 396 Editorial Commentary tinnitus), bodily change, or loss of attention, are processes, and thus with much elemental power; normal experiences for us all, yet we do not use subsequent corrections, on the other hand, take them to construct delusions. Events which occur place slowly, as real, conscious thought processes from time to time for any of us—unusual motor leading to a conclusion after long brooding.’ performance or behaviour, knowledge of past Likewise, he writes ‘a prerequisite of such delu- mental abnormality (common after excess alco- sions by analogy is a facility for relatively well- hol), the fact of detention (not limited to mentally ordered thinking’ (L18, p. 113). ill people)—are not very abnormal (though per- These determinants of the nature of delusions haps strange for people experiencing them de are in the immediate circumstances in which novo), and are not normally given delusional they form, the personality of the patient, or in interpretations. Thus, his emphasis seems their personal style of thinking. Today, there unconvincing. might be more awareness of how enduring traits, Despite what seem signifi cant shortcomings independent of anything driving a patient’s psy- in his exposition on delusions he makes shrewd chosis might shape a person’s ‘cognitive fl exibil- comments about other infl uences on delusion for- ity’ or ‘rigidity’, and therefore the ease with a mation. On whether delusions persist, we read, of they can change their beliefs. Rigidity would a malcontent with a delusionally overvalued idea tend to make delusional beliefs persist longer. (note, L14): ‘… the repetition of the incapacita- There may be a bias towards evidence which tion decision was rejected by an expert because confi rms rather than refutes beliefs, making the malcontent’s delusion was known to be incur- recovery more protracted. ‘Confi rmation bias’ is able! But the result of this provocation itself, was a topic of recent research, not least in relation to that the patient was actually cured!’ Later in this psychosis [123 ], but it is not yet clear how far it is lecture a lady teacher’s overvalued idea is related an enduring trait, regardless of psychosis. Given in part to her fastidious personality. Again, in that the balance between confi rmation and refuta- L16 (p. 99) we read: ‘If [a former patient] has to tion varies between people, and from time to deal with foolish people who offer support for his time, Wernicke’s sense that ‘logic’ is preserved in misconceptions …he will delve just as injudi- explanatory delusions should be qualifi ed by ciously into newspaper reports about his fellow examining that ‘logic’ (which is not a unitary victims; he will again be excited by these and can skill). hardly escape from delusions, which continue every day and week that passes after his discharge, unless he puts his allegations to the test, VIII,(m). Other Symptoms thinking this to be in his best interests, thus help- of Psychosis According to Wernicke ing the inherently false focus of his attention to fade away’. Today, such factors are rarely dis- Wernicke’s concept of psychosis is broader than cussed. In addition Wernicke offers some views the one usually used today. Hence symptoms on the different manifestations of delusions dealt with below may not be included in today’s according to a person’s habitual style of thinking. ‘psychosis’. In L23, he describes and analyzes In L14 (p. 89), when discussing post hoc correc- ‘anxiety psychosis’, an uncommon term today, tive adjustments to beliefs, he writes: ‘Turning yet clearly associated with delusions and hallu- fi rst to the subsequent correction, you will soon cinations, which may be auto-, allo-, or somato- notice how closely the phenomenon is related to psychic in content. Anxiety itself, he states explanatory delusions… However, the subse- (L36, p. 491), ‘can be regarded as a special quent correction possibly corresponds to a more somatopsychic form of disarray’. In L1 we are refi ned psychological need, while explanatory introduced to ‘motility psychosis’—one of his delusions are driven by a coarser motive. special concepts, a topic expanded in later lec- Explanatory delusions take advantage of con- tures. Many symptoms he describes started with sciousness, usually quickly, through unconscious Kalhbaum. After Wernicke such symptoms were Editorial Commentary 397 commonly incorporated by both Kraepelin and giving regional impairment, rather than impair- Jaspers into the diffuse concept of ‘catatonia’ ment of specifi c movements. (Kahlbaum’s term, meaning no more than Parakinetic symptoms include waxy fl exibility ‘movement’). He is thus ‘delivering the goods’ ( fl exibilitas cerea) described in detail, and what as announced in L2, following Meynert, that appears to be a milder form, sometimes called ‘there is nothing else to fi nd and observe than mitgehen (‘going along with’) in classic German movements, and that the whole pathology of the psychopathology, a symptom ‘… in which any mentally ill consists of nothing more than pecu- joint resistance is lacking’ (L34, p. 252). liarities of their motor behaviour.’ Much later Negativism (L34, p. 250) is motiveless resistance Karl Leonhard [124 ] adopted Wernicke’s term, to any imposed passive movement. In L34 for psychoses which were neither manic bipolar (p. 245) we read ‘akinesia gradually remitted but nor schizophrenic. stereotyped movements appeared’. Stereotypy is Motility symptoms are described in greatest a term used by Kahlbaum, and by Kraepelin from detail in L31–35. Symptoms, classed as ‘hyper- the 1890s. Today it is widely used to identify kinesia’, ‘akinesia’ and ‘parakinesia’, are behavioural pathologies in laboratory animals described. Hyperkinetic symptoms are partly given stimulants and other agents. features of mania (L31, L33); akinetic and para- Many of the movements described here— kinetic ones are described in L34 and L35. aimless, but identifi able as fragments of activity Hyperkinesia includes both motor and speech which in other circumstance might be purpose- excesses (the latter termed verbigeration ). ful—are common enough, though in less obvious Akinesia includes immobility which ‘…varies, as form, amongst most people who never get the our cases show, according to its severity, in that attention of a psychiatrist. We are thus reminded sometimes it is so marked that it leads to cessa- of the title of Freud’s book from 1901 The psy- tion of almost all reactions, and causes a condi- chopathology of everyday life [126 ]. However, if tion apparently similar to death’ (L34, p. 249). such manifestations—the ‘symptoms’ described Kretschmer, called this a ‘death feint’, likening it by Freud—are everyday occurrences, present to to responses in most mammalian species (widely a degree in any of us, this calls into question their studied, and referred to as ‘animal hypnosis’). It being designated as psycho pathology . Rather, could account for cases when people reach the they might be taken to be normal manifestations morgue, and are found still to be alive. Another of a motor system capable of acquiring complex akinetic symptom is rigidity . Akinesia for speech behaviours for specifi c purposes, manifest even is mutism (L34, p. 249; L1, note, and includes when those purposes are not engaged. reactive mutism (L34, p. 253). In L35, (p. 267), The clinical lectures in Grundriss deal with we are given a specifi c example: ‘…failure to psychiatry rather than neurology, yet reveal a answer questions put by a physician’. In L35 world-class pioneer neurologist at work. Today, it (p. 264) we hear of ‘the so-called hypochondria- is often asked why such symptoms are seen so cal palsies’, which ‘provide evidence that elimi- rarely in psychiatric practice. One might rather nation of will can be manifest in localized muscle ask whether such symptoms actually are so rare. areas… Of course they never amount to palsies An alternative view might be that, as psychiatry of individual muscle and nerve areas, but of split from neurology, symptoms which do exist, whole limbs, or at least of whole sections of today as in Wernicke’s day, are not now recog- limbs’. Hughlings Jackson’s had suggested that nized for what they are. So, in L35 (p. 267), we the motor cortex, despite its orderly representa- read: ‘When you encounter a new patient who tion of body parts, did not represent individual responds to your questions with striking silence, muscles, but rather organized movements [125 ]. and thus makes examination diffi cult, do not However, what is described appears to be differ- omit, gentlemen, to move his limbs and arrange ent, a shut-down of a defi nite region of motor them in certain positions’. This hints that symp- cortex (or a connected region of the striatum) toms are not found today, because physicians do 398 Editorial Commentary not know what to look for. However this would secondary, as are fear of the future, feelings of not apply to profound akinesia lasting for weeks, inadequacy, self-accusatory or guilt-ridden ideas, described in L34, which could hardly be missed. world-weariness and suicidal thoughts. This is In L15 we read of the relationship between plausible: A person who regularly experiences obsessions and two easily confused symptoms, periods of depression (in today’s term), and overvalued ideas, and autochthonous (self- learns that these have a predictable time course, generated) ideas. Wernicke (L2, note) writes: and therefore that he or she will soon recover, ‘Obsessions are only exceptionally an essential may ‘sit out the episode’, undoubtedly impaired element of paranoid states, if you consider cases in decision-making, yet without desperate fall in of inveterate habitual infl uence on actions by mood. Conversely, as Wernicke acknowledges, obsessional ideas bordering on mental distur- lowered mood can be brought about in other bance, where they belong in my opinion. On the ways (L28, p. 194), when he refers to a ‘transient other hand I do not deny that between self- fi t of melancholy mood, which could as well be generated ideas, overvalued ideas, and obses- really the impact of insights into [a different] ill- sions, transitions exist, in which it is diffi cult to ness.’ The description is of what Wernicke calls assign the symptom to its correct position. In ‘Affective melancholia’, a concept mainly sepa- general however, the three symptoms are easy to rate from a more severe, but less well-defi ned tell apart. When Friedmann [127 ], recently attrib- concept, ‘depressive melancholia’ (‘the so-called uted obsessional ideas to the overvalued ideas in depressive melancholia’: L34, p. 257), in which his perceptive work, and connected the latter to outward signs of changed mental state are pres- the principal element of delusions, he does me ent (patients stop talking, or doing anything). The too much honour, and moves beyond the bedrock modern word ‘depression’ does not capture this of clinical experience.’ This explores the differ- distinction. ence between paranoid states (with their com- The converse clinical picture, mania (L31) is plex, multifaceted, and at times fast-moving excessive facilitation and acceleration of activity delusions), and what was once ‘paranoia’, now (implicitly in the cortex), and with it, excessive renamed ‘delusional disorder’, in which abnor- ease in making associations. Initially this gives mal beliefs have a single theme, clung to with rise to improved performance in many tasks, and obsessive tenacity, with little wider infl uence on secondarily, to elevated mood. As ideas crowd the rest of mental life, and unaccompanied by for attention, all are pushed to maximum levels, hallucinations. Today there are growing hints that and there is a ‘levelling of ideas’ with excesses of some forms of delusional disorder may be similar association, which may lead at a later stage, to to some types of obsessive compulsive disorder, confusion and severe impairment. Wernicke yet the overlap is ill-defi ned, since both appear to makes interesting comments on the ‘levelling of be heterogeneous. ideas’ (L31, p. 218): ‘We can understand this levelling of ideas, which is one of the most important symptoms of mania, when we take VIII,(n). Melancholia and Mania intrapsychic hyperfunction to be a general increase in excitability of intrapsychic paths. On Wernicke’s brilliant analysis of melancholia the other hand, the normal overvaluation of ideas (L30, p. 206), exemplifi es his concept of an ‘ele- is to be explained by the physiological (function- mentary symptom’, from which all other symp- ally acquired) increase in excitability of specifi c , toms fl ow. Melancholia is not primarily a mood chosen paths’. On the basis of modern knowl- disorder, but a defi cit in ‘will’. Thus the patient edge, the following inferences might be drawn: described at the start of L30 states that ‘she could (a) Mania occurs due to generalized change in feel neither joy nor grief; her heart was turned to cortical neurones, making them more excitable; stone’. Any mood change (which he refers to as (b) Since mania is not permanent, but episodic or deprimierte Stimmung—‘depressed mood’) is transient, such change is also transient—probably Editorial Commentary 399 originating in neuronal biophysics, rather than ideas in mania is not limited to ideas with strong permanent change at the level of neuronal struc- motivational links; any recruitment of Affect- ture; (c) This is different from enhanced excit- laden ideas, with consequent classic delusions, is ability in specifi c pathways, brought about by then secondary. cellular learning mechanisms. A comment on motility disorders is made in The analysis of mania raises two interlocking (L35, p. 260), that ‘more often … the akinetic issues: First , hitherto Wernicke has regarded symptom is an expression of increased intensity’. loss—or breakage—of associations (mediated by In L35, Wernicke discusses the relations between sejunction) as different from hyperactivity of mania and Affective melancholia, including top- association (seen in mania). The fi rst is the direct ics such as ‘cyclic psychosis’, and the same idea forerunner of the ‘disorder of associations’, is raised, as he hints, when he writes (L31, regarded by Eugen Bleuler as a primary charac- p. 220): ‘A mild form of one illness generally teristic of the disorder for which he coined the tends to appear during convalescence from the term ‘schizophrenia’. The metaphor of a ‘knight’s others and signals its termination’. This has an move’ in thought (a modern phrase) has been equivalent in later paper by Court [128 ], advocat- used to describe that disorder. Interpreted liter- ing the view that mania and depression are not ally, this is a move along unorthodox pathways, polar opposites. Rather there is a transition from but still actually existing, if indirect, associative normal, to depressed, to mixed and then to a links. A commonly cited example is the link manic state. between ‘lion’ and ‘stripes’ (with ‘tiger’ as the hidden connecting link). However, the more the associative links become indirect, via hidden VIII,(o). Hebephrenia, Thought stages, the less likely is it that a clinician can Disorder, and Forerunners detect them. Therefore to claim that a sudden of Dementia Praecox shift of topic in a patient’s discourse is ‘incoherent’ rather than a case of ‘hyperactive associa- ‘Hebephrenia’ was a mental disorder defi ned by tion’ is a subjective judgment on the part of a Kalhbaum and Hecker, typical of adolescence, clinician, saying as much about his mental pro- characterized by ‘thought disorder’, that is disor- cesses as about those of his patient. Cases where dered cognition, revealed as silly, foolish, mean- Wernicke makes the strongest statements about ingless talk. Today, thought disorder is evidenced breakage of association are in early lectures, by disordered content of speech. In L25 (p. 170) dealing with patients with very chronic disorders. and L29 (p. 196) cases are mentioned in which This distinction might be made in error more any ‘formal thought disorder’ (formale often in such cases than in most acute cases con- Denkstörung) is absent, the fi rst times in sidered later. One can thus argue that Wernicke’s Grundriss this term is used. (It is to be distin- attempt to separate breakage of associations from guished from ‘thought defi cit’—Gedächtnisde- their hyperactivity is fl awed reasoning. In the dis- fekt —which appears occasionally [e.g.: L27, order we now call schizophrenia, there is evi- p. 180]). The clearest account of thought disorder dence of hyperactive associative processes, is in L40 (p. 325), in adolescents, although there including an excess of indirect associations; but it is called ‘hebephrenic dementia’ not ‘thought this is appears to be an enduring trait, not a tran- disorder’. ‘Hebephrenia’ became part of sient state, as it is in mania. There may however Kraepelin’s Dementia praecox (hebephrenic sub- be a more subtle distinction to be made here: type), and survives now as ‘disorganization’ in Apart from enduring traits leading to excessive the symptomatology of schizophrenia. Dementia ease in association, in the transient psychotic praecox , defi ned in the 1896 edition of phases of schizophrenia, delusions may arise Kraepelin’s textbook, had, by defi nition, a poor because of hyperactive associations based on outlook, ending in dementia, however it started. strong motivational drives. In contrast, fl ight of The most direct reference to this is in L39 400 Editorial Commentary

(p. 304): ‘Thus the unfavourable prediction that being similar to Kraepelin’s Dementia praecox , Kräpelin makes for such cases, does not always the intended meaning is quite different. apply to those during puberty’. This clearly refers In L32 (p. 227 seq.) there is also a long verba- to Dementia praecox; yet Wernicke never uses tim transcript of speech pathology. Such exam- the term, and distances himself from its major ples were used deliberately in literary productions implication, the inevitability of a poor long-term when surrealism took off after World War II, for outcome. instance in the incoherent ‘speech’ of Lucky, in Apart from this, there are statements in Beckett’s Waiting for Godot [ 129]. Such cross- Grundriss where motility disorders present simi- overs from psychiatry were intended to portray larities to what became the catatonic subtype of speech disorganization (‘formal thought disor- Dementia praecox . Thus, in L32, (p. 228) der’) in schizophrenia. Wernicke writes: ‘After a few weeks in this hyperkinetic state, which was sometimes replaced by akinetic phases of apparent exhaustion, he VIII,(p). Dementia became calm, but at the same time with rapid increase of feeble-mindedness, while his greatly Today, dementia is often seen as an end stage, reduced nutritional status gave way to a rapid with little to be done by way of either treatment increase in body weight. At present, you would or prevention, and, at least for Alzheimer’s dis- scarcely recognize this ruddy, apparently pro- ease, defi ned partly by adverse, irreversible foundly demented patient, instantly refusing and change in the brain. However, since Wernicke unbiddable towards any demand to think. The distances himself from Kraepelin’s Dementia contrast is provided by the evidently un inten- praecox, he has to defi ne dementia independent tional movements, reminiscent of the familiar of this. In L34 (p. 256), he maintains that demen- jactation of unconscious states. Common to both tia is not an irreversible end-stage; and he hints is only the monotonous recurrence of the same that at least some forms of dementia are a bi- form of movement’. Later in the same lecture, we product of severely disordered mental process- read: (L32, p. 234): ‘the special aetiology is thor- ing—mental chaos —as opposed to delusions oughly decisive for the prognosis, so that the which are systematized in some way. Likewise, paralytic form here leads to dementia, as it does much of L39 implies that psychoses occurring at in other paralytic psychoses. This is true in cases transitional periods of life refl ect in part the spe- of hyperkinetic motility psychoses, which occur cial stresses and confusion arising during those in the course of a real hebephrenia or other periods. If such suggestions are correct, some chronic, hebephrenic degenerative psychoses’. In forms of dementia represent the unravelling of L34 he writes that akinetic motility psychosis is acquired schemata for understanding the world, most prevalent in young persons, especially girls; the body, and the self, arising not so much from a and in L39 (p. 303) he writes: ‘Next most com- biological disorder, but from disorder of the mon might be motility psychoses of any kind, but ‘information economy’ associated with extreme particularly akinetic motility psychoses, which mental states. If so, the inevitability of transition fi nd their next occasion for occurrence at time of to dementia would be less absolute, and possibili- puberty’. He refers to ‘the familiar tendency for ties for prevention, even reconstitution, would be akinetic motility psychosis to be transformed into more favourable. Sometimes combination of dementia’. There are common points here coinciding stressors (in L39 [p. 306], of men- between Wernicke’s motility psychosis and strual diffi culties and hebephrenic symptoms) is Dementia praecox, yet what he describes does a prerequisite for transition to dementia. Pursuing not match Kraepelin’s concept. Likewise, in L31 this line of thought, L37 focuses on Progressive (p. 219) a phrase occurs which we translate as Paralysis, which, we note, commonly led to ‘early dementia’ (schon zeitig … Demenz: liter- dementia. His criterion of lost insight, supposed ally ‘early-onset dementia’). Despite the phrase to separate it from neurosyphilis (p. 286) raises Editorial Commentary 401 an interesting question, given that most cases of Most of his prognostic indicators refer to psy- progressive paralysis were forms of neurosyphi- chological processes or factors, which are sepa- lis. One might ask whether the loss of insight was rate from any illness. In L15 (p. 94) we a genuine consequence of underlying brain read ‘… when the extent of the disease is limited pathology, or rather of severe psychological reac- just to the fi rst psychotic elements, it is possible tions, including denial (=lack of insight) of for health to be restored through the gradual awareness of a slowly progressing disorder, appearance of more powerful countervailing which was widely feared, publicly stigmatized— arguments’. Whereas today, various forms of psy- more even than other mental disorders—and ulti- chotherapy or CBT might be sought to resolve mately fatal. confl icts of belief set up during periods of psycho- In L40 (p. 314) the more familiar side of sis, Wernicke appears to consider that unaided dementia is prominent. In the nineteenth cen- processes of natural healing will occur, simply by tury, terms for different grades of intellectual a patient’s awareness of contradictions existing defi ciency varied, but usually three grades were amongst his or her beliefs. Later he writes: ‘The recognized. The most severe was idiocy, and clinical presentation of such cases has proved use- terms for other grades varied from one country ful to me several times, as is the process of “inter- to another. Generally the three grades were nalization” itself, that is, a conscious ability to defi ned in terms of mental age (and, in the twen- recognize mental illness’. The notion that, by use tieth century, as I.Q.). The ‘theoretical’ basis was of a person’s powers of introspection, self- often in part racist (with more severe levels sup- knowledge can contribute to recovery, is a posedly correspond to ‘lesser races’), and also modern-sounding, and wise principle, but hard to had some basis in Haeckel’s recapitulation the- support on the basis of strictly biomedical ideas of ory (which was also closely linked to his own mental disorder as diagnosable diseases. Further racial ideas). hints of Wernicke’s approach come in L16 (p. 98) for a patient who ‘can hardly escape from delusions … unless he puts his allegations to the test, VIII,(q). Prognostic Indicators; thinking this to be in his best interests, thus help- Concepts of ‘Cure’, or ‘Return ing the inherently false focus of his attention to to Health’ fade away’. He acknowledges the role of social milieu in resurgence, progression or regression of Wernicke often writes of the degree to which symptoms: ‘Gradually, and in favourable cases, patients can recover from their illnesses, and we patients themselves notice that return of aware- get various clues in Grundriss to the prognostic ness of their period of illness is unhelpful’ (p. 99). indicators he used. The word he usually uses is Here he suggests what is now seen as good prac- Heilung , which might be translated as either tice in ‘early intervention’ programs for psychotic ‘healing’ or ‘curing’. Occasionally he uses disorders, that patients can be assisted to gain Besserung (strictly ‘improvement’; e.g. L23, insight into warning signs of an incipient break- p. 151). Back-translation of the German word down, which may help avert relapse. Sometimes ‘cure’ includes both Heilung , and Kur , while that Wernicke comments on the prognostic signifi - for ‘heal’ is limited to Heilung . We therefore pre- cance of different symptom profi les, for instance, fer to translate Heilung as ‘heal’, ‘restore to for anxiety psychosis in L23, and for psychoses health,’ or sometimes ‘recover’ as more accu- more generally in L40, where complete recovery rate, terms that are less strongly medical, similar can occur (he estimates) in about a third of cases. in implication to ‘recovery’, now widely The word ‘degeneration’ (Entartung ) when used, favoured amongst community mental health a concept already with a long history in the groups. Occasionally (L11, p. 67) the word Germanic world, as in other countries, refers to ‘cure’ is used, and then, in quotation marks, as if the supposed irreversible nature of mental disor- to signify that it is not a wholly valid concept. ders, often related to alcohol abuse. 402 Editorial Commentary

VIII,(r). Holism in Wernicke’s clinical topics in L9 (p. 54), he writes: ‘We can Thought defi ne acute mental illnesses as the process of altering the content of consciousness, which we When dealing with Wernicke’s clinical style (sec- see taking place in a defi ned time period. Such tion IV “Wernicke’s Personal Style in Psychiatric changes are often linked with Affects and emo- Practice, Teaching, Writing, and in Scholarly tions, just as they are under conditions of healthy Disputes”), the following sentence was quoted mental life.’ The latter idea is expanded greatly in (L7): ‘After a person has recovered from a mental L22, where Affective states are taken to be the illness, it is required that we ensure that he has driving force behind illusions, hallucinations and achieved insight into the abnormality of the state other symptoms. he has experienced; for the sum must necessarily In the clinical lectures, he incorporates into be inaccurate if it contains false elements’. We see his account of symptoms a person’s entire trove here an impressive aspect of Wernicke’s thought— of life experiences, their employment, training, his understanding of each individual striving to be and acquired habits of thought (if not so much a coherent whole. The individual’s search for this their intrinsic personality traits). He has little to sense of personal wholeness is found in other say on a topic thought important today, the impact giants of psychiatry in early twentieth century of psychic trauma as a cause of (or at least an (Jung, Kretschmer, and later Victor Frankl); but infl uence on) mental disorders: Nevertheless, in nowhere do we fi nd it rooted so fi rmly in brain L37 (p. 281) we read: ‘Whoever fi nds himself science as in Wernicke. We see the intrinsic holism forced to work beyond his individual strength, at many levels. When referring to fundamental under tight time pressure, taking on responsibili- neural processes, he is never far from the concept ties beyond his capacity, must struggle with of unifi ed personhood: In L3, in discussing the excitement, grief, and sorrow, that can easily relationship of perception to memory, we learn cause damage in purely intellectual work. that, though the two words are separate, the Undoubtedly all-pervading careerism encourages respective functions are inseparable; and on such damage. From this, and similarly from the ‘remembered images’ he writes of their ‘solid increased prevalence of syphilitic infection, we ownership ’ (German: Besitz ), implying that a per- can explain the signifi cant predominance of the son ‘owns’ them. Later, in L11 (p. 67) when com- male sex, particularly amongst educated classes’. menting on normal large-scale patterns of Surprisingly, this is in the lecture on Progressive association, he writes: ‘We would then not be too Paralysis. He alludes to a common myth (which bold were we to conclude that, in this sense, the one of the authors has met in a Chinese context), set of “specifi c energies” of sensory elements may that psychosis occurs ‘because a person thinks be transferred to the entire organ of association.’ too much’. We see here a habit of inference Even more remarkable, in L20 (p. 126) he mixes emerging in other situations, when the true cause this physical metaphor, with another, that of ‘reso- of an ailment is not clearly defi ned: All manner of nance’. The fi rst seems strange today, but the sec- supposed social factors are seen as ‘causes’, or ond is an astonishing forerunner of the modern contributory ones. A modern example is gastric idea (still debated), that the ‘binding problem’ of ulcers, once attributed to ‘stress’, now known to unifying percepts and concepts across dispersed be due to a bacterium which fl ourishes in acid cortical regions is solved by resonance of electro- environments. How far this applies to mental dis- graphic activity shared across regions [130 ]. orders as understood today is unsure. He is at home with the idea that cognitive and All this is underpinned by an account in L7 of Affective processes are in continual interaction how each person constructs their own sense of as parts of the unifi ed whole. We read (L8, p. 49): personhood, by assimilating the three compo- ‘It will not surprise you that the content of apper- nents of their trove of memories—the enduring ceptions in mental activity also exerts infl uence sense of their own bodies, experiences of the on accompanying Affect’; and in introducing external world, and their personal life story—into Editorial Commentary 403 a remarkably unifi ed whole (for most people). approach (for which today’s psychiatry is a better Wernicke had no access to insights we now have, target), is for specialists to over-pathologize such as one made by Geschwind [ 131 ] that in experiences (especially hallucinations and delu- sub-primate animals, where prefrontal areas are sions) which are part of normal human experi- small, multimodal convergence in areas occurs ence. One might mention the transition by mainly in limbic areas, notably the hippocampus; imperceptible steps from normal overvalued while in humans, it occurs extensively in the neo- ideas to frank delusions; or that in many cultures cortex itself. Geschwind suggests that this might ‘hearing voices’ is accepted as normal, even as a be a prerequisite for appearance of language; but ‘gift’. it also allows each of us to construct a sense of personal wholeness, however far this falls short of any ideal. In his grasp of the intrinsic holism of VIII,(s). Wernicke’s Links a human person, Wernicke, in our view, is ahead to the Emerging Dynamic Tradition of where many practitioners in mainstream psy- in Psychiatry chiatry are today, dominated by categorical diagnoses in which a patient’s search for inner unity At the time when Wernicke practised in Breslau, has no place; and where the profession rarely major changes were occurring in European cen- teaches trainees how, as doctors, they could fos- tres in the emerging profession of psychiatry. ter the rebuilding of the sense of wholeness in Three strands of mental health care were in inter- their patients. Other traditions however (such as action—care and administration in institutions; that of Carl Gustav Jung) do retain this emphasis, teaching, research, and practice by academic but are not mainstream. neurologists; and the gradual, uneasy incorpora- These issues are related to one discussed later, tion into orthodox medicine of what had been namely whether medical concepts of disease, folk medicine for centuries, but became the defi ned as disorders in specifi c organs or body dynamic tradition in psychiatry. The last of these systems are adequate as an analogy for mental is analyzed in detail by Henri Ellenberger [16 ]. disorders. In one sense Wernicke’s holism implies The point is that they were in fruitful interaction that personhood arises because of close interac- at the time, and leading physicians crossed from tion of all system (or at least of their cerebral rep- one to the other, apparently with no overwhelm- resentation), which is perhaps a less medical ing sense of ‘cognitive dissonance’ (although conceptualization. However, in another sense, he both Freud and Jung had periods of crisis— might be saying that the ‘system’ which is disor- referred to as ‘creative illness’). In addition there dered in conditions he describes, namely the were many interactions between this emerging brain as a whole, is precisely the system repre- discipline and experimental psychology of the senting, as far as possible, that personhood, uni- day. Key fi gures included Charcot, Freud, Janet, fi ed to whatever degree is possible. In that sense, and later Jung, Kretschmer and many others . he succeeds magnifi cently, and this can then be Meynert can also claim to have crossed some seen to fi t within medical paradigms, albeit ones frontiers. Many clinicians of the time, from which are signifi cantly stretched. respectable academic positions, had experi- Admittedly, our fulsome praise has to be qual- mented with hypnosis, either themselves being ifi ed, because Wernicke apparently entertained hypnotized, or by administering it as physicians; the idea that human beings are entirely ‘rational’ and Wernicke refers to it occasionally (e.g. L14, in their mental operations, this being not just an p. 90). Hypnosis was a ‘bridgehead’ by which ideal, but the expected norm. Departure from this dynamic psychiatry spread within orthodox norm is then, by defi nition, a form of pathology, practice. or mental disorder. This point became central in Wernicke himself was, it appears, also one of the critique of psychiatry by Michel Foucault those intrepid ‘frontiersmen’. Over many years, [132 ]. Another possible criticism of Wernicke’s he had sporadic contacts with Freud, whose fi rst 404 Editorial Commentary independent work, an 1891 monograph on aphasias, However, precisely for that reason, we have not was partly a response to Wernicke’s work. Freud the slightest inclination to examine it more had seven of Wernicke’s works in his library, and closely, for the time being.’ This shows his aware- in 1896 Wernicke referred a patient to Freud. ness of contemporary discussion on subconscious In 1898 Freud's fi rst truly psychoanalytical processing. In L8 (p. 47), he writes of ‘intense study (of the Signorelli parapraxis) appeared in pain, such as violent toothache, [which] immedi- Monatsschrift für Psychiatrie und Neurologie , ately signals to our subconscious to redirect edited by Wernicke and Ziehen [ 133 ]. Wernicke attention to our senses’. This is the fi rst time cites Charcot several times, whose work in Paris Wernicke uses the word ‘subconscious’ (German: started the acceptance of dynamic psychiatry. In Ohnmacht). In a later lecture (L24, p. 162) he any case, he indicates at the start of Grundriss his writes ‘When the functioning of organs which awareness of alternative models for mental disor- usually goes unnoticed, reaches perception…’, der: a footnote (L1, p. 4) to his statement that phraseology which clearly indicates his aware- ‘mental disorders are disorders of the brain’ ness of varying levels of consciousness. In L34 declares: ‘A difference of opinion prevails only (p. 251) he writes ‘… balance evidently cannot over how far they [that is mental illnesses] are of be maintained based on a particular level of men- a functional nature or are determined by palpable tal ability, the only possibility remaining is changes.’ This probably refers to the debate at the unconscious compensation, in other words, time, about psychogenic syndromes studied by adjustment acting exclusively within conscious- pioneers of dynamic psychiatry, such as Charcot, ness of corporeality’. The contradiction between Janet and Freud, where symptom patterns the two last phrases implies that Wernicke unknown in neurology occurred—later to be accepted that that component of ‘contents of con- called ‘conversion symptoms’. sciousness’ which was most familiar to each Apart from these links, much of Wernicke’s patient—consciousness of corporeality—had, by engagement with the emerging dynamic tradition its familiarity, sunk below usual levels for con- is captured by his use of key terms or concepts, scious awareness. usually ones featured in Freud’s works. Perhaps In Freud’s writings, the Ego (German: das the most telling words are unconscious and sub- Ich ) is a term of great importance. As a noun, it conscious. In L2 he writes that ultimately all had currency in German philosophy long before symptoms boil down to movements of one sort or Freud used it (around 1920) in his structural another, a view concordant with the materialism model of the human psyche. For instance, it of the Somatiker school. However, he then appeared in writings of Max Stirner (1806–1856) ‘exclude[s] … intentional movements of which and of Theodor Meynert—mentor to both Freud other people are aware before they reach the con- and Wernicke—who used the term ‘primary Ego’ sciousness of the patient him- or her-self’. In this, in his treatise Psychiatry : Diseases of the he hints at advances in France and Vienna, where Forebrain [134 ]. For Wernicke, like Meynert, but unconscious or subconscious processes (which unlike Freud in the 1920s, the concept was rooted control seemingly deliberate behaviour) were in what was known about sensory and motor sys- recognized. He acknowledges that symptoms tems. It is hard to fi nd in Freud’s extensive writ- arising in the autonomic nervous system may be ings a precise defi nition of what he meant by the relevant, although never in Grundriss , do they term ‘Ego’, and it was probably used in more have the importance implied by dynamic psychi- than one sense. Freud only occasionally cites atrists of his day. On the hinterland between con- Wernicke, although in New Introduction to scious and unconscious (L5; note) we read: ‘We Psychoanalysis [ 135 ], he acknowledges a point will be confronted again and again with the con- which Wernicke stressed, that the Ego (unlike trasts between functioning and latent conscious- Freud’s Id and Superego ) was at the interface ness; they correspond apparently to different with the external world. Wernicke’s usage con- states of one and the same anatomical substrate. trasts with religious or metaphysical ideas of an Editorial Commentary 405 entity defi ning a person’s essence (his/her ‘soul’ the late nineteenth century, with expansion of the in Western tradition) often taken to be immortal. rail network, railway accidents had become com- As the ‘essence’ of personal identity, this entity mon (see also L27, p. 182), and an issue for pub- may be held to be indivisible, but reasons put for- lic debate (depicted in closing sections of ward for quasi-indivisibility of personal identity Tolstoy’s Anna Karenina —published in serial by Wernicke are quite different, in no way sug- form between 1873 and 1878). Related to this gesting immortality. was the question of how far disability was genu- The phrase ‘symptom complex’ is usually inely injury-related, or exaggerated by conscious thought to be intrinsic to psychoanalytic thought, or subconscious processes to obtain insurance but its history is interesting. The noun ‘complex’ payouts, or other secondary benefi ts. (In the now- goes back to the seventeenth century. Wernicke’s unifi ed Germany, national health insurance had 1874 paper on aphasia was actually entitled Der been introduced under Bismarck in 1883.) This aphasische Symptomencomplex; Eine psycholo- debate lay behind one of Freud’s early public pre- gische studie auf anatomische basis . In Grundriss , sentations (in 1886) ([16 ]. Ellenberger, 1970, the phrase ‘symptom complex’ occurs a number p. 438). The term ‘railway neurosis’ could thus of times (pp. 17, 132, 150, 162), and on p. 72 we be used in a Freudian sense. Such a usage is have a reference to the ‘Ego complex’: ‘The fact found in L11 (p. 68), when discussing a patient that, in the brain, different ideas and idea-com- with somatopsychic delusions. Wernicke writes plexes are not merely juxtaposed, but are nor- ‘… with such a round-about description of the mally combined into larger groups, and fi nally change in content of his consciousness, he is seen into unity of the ego, can, in the fi nal analysis, be by many doctors as a hypochondriac, that is, suf- due only to associative processes.’ fering from neurosis’. The term ‘neurosis’ is Neurosis is a term much used by Freud. It orig- sometimes used with hints of the older sense of inated in the eighteenth century with the Scottish William Cullen. So, in L37 (p. 284) we read of physician, William Cullen, meaning an objective ‘epileptic neurosis’, a curious juxtaposition disturbance in the brain. By the time of Freud and which would not be written today, refl ecting the Wernicke its meaning had shifted completely undefi ned border between hysterical and epilep- [52 ]. As the ‘Somatikers’ gained ascendency, tic seizures; and in L41 (p. 329) we read of ‘… ‘psychosis’ took over from the earlier word, while neurosis in a subcortical vascular centre’. ‘neurosis’ became accepted as a term for disor- Conversion symptoms are closely linked to ders arising from emotional confl ict; and ‘psycho- severe anxiety. In L23 (p. 150) Wernicke intro- sis’ by Wernicke’s day was also becoming split duces the term ‘anxiety neurosis’, and asks how into ‘organic’ and ‘functional’ types, the respec- ‘anxiety psychosis’ (perhaps equivalent to con- tive home ground for neurology and psychiatry. version hysteria) differed from ‘anxiety neuro- Wernicke, no doubt aware of these shifts, sis’: ‘In no other area of mental illness are there sometimes ‘fl ags’ the areas of contention. In L29, so many points of contact with the functional dis- in dealing with the relation between obsessions orders of the nervous system.’ ‘Functional disor- and autochthonous ideas, he writes (p. 199): ‘In der’ implies a disorder with no clear structural no other area is it more diffi cult to separate psy- basis [136 ]. Wernicke uses the term only a few chosis from neurosis: Thus, to identify both the times, and not very consistently. In L16 (p. 99) he degenerative aetiology as well as the elementary writes ‘… for such cases one must concede the symptoms as lying within the range of mental possibility that these symptoms persist to some normality, it might be fi tting to speak solely of extent as a purely functional disorder’. In L32, obsessional neurosis. ’ Mainly he uses ‘neurosis’ (p. 231) it is applied to abnormal movements of in the new sense, but sometimes in the older way. chorea, a claim hardly made today. His fi rst use of the term (L8, p. 47), refers to ‘… Both ‘anxiety’ and ‘neurosis’ are terms with neuroses (following head injuries, railway acci- interesting histories, long predating Wernicke. dents and the like)’ has hints of both meanings. In Their combined use became prominent in 1894, 406 Editorial Commentary at a time when the concept of ‘neurasthenia’ was are “right back into” their life, and who are inde- introduced from North America. Freud stated that pendent enough to earn their own bread; yet they ‘anxiety neurosis’ should include: ‘general irrita- are very reluctant to talk about their periods of bility, anxious expectation, anxiety attacks, and illness, even setting up major barriers to clinical [somatic] equivalents such as cardiovascular and probing’. Likewise, in (L16, p. 99) we read: respiratory symptoms, sweating, tremor, shud- ‘Gradually, and in favourable cases, patients dering, ravenous hunger, diarrhoea, vertigo, con- themselves notice that return of awareness of gestion, paraesthesia, awakening in fright, their period illness is unhelpful’. Reticence obsessional symptoms, agoraphobia, and nausea’ about talking of periods of past illness may have [137 ]. Wernicke’s use of the phrase suggests that bases other than fear of reactivating psychosis it already had wide currency, if only in informal (as implied here). It might refl ect fear of some- use. Most specifi cally, he occasionally refers to thing that utterly defi es a patient’s comprehen- symptoms (notably psychogenic amnesia) which sion, for which they have no language or frame other clinicians were calling conversion hysteria . of reference, leading to avoidance of anything In L14 (p. 90) when referring to lapses of mem- linked to the experience, and possibly to genuine ory, he writes that ‘the close relationship between amnesia. These two may be the same, since the content of these memory lapses and the over- retrieval of memory depends on activating the valued idea points to the fact that the associative context or ‘framework’ in which a memory was link is not entirely missing, but is heavily biased embedded. towards and limited to the overvalued idea, without which insight the apparently conscious act could not be explained. So this probably repre- IX. Wernicke’s Approach sents a narrowing of consciousness, as it is known to Classifi cation of Mental Disorders otherwise only from states of high Affect … However, we cannot exploit this moment, IX,(a). Historical Introduction because it remains unexplained why only certain types of mental patient show this symptom’. The No system for classifying anything can be ratio- idea of loss of memory at times of high Affect is nal, until the purpose is specifi ed. Wernicke similar to ‘hysterical amnesia’ which Freud accepted prevailing traditions and concepts, yet attributed to repression; ‘narrowing of conscious- appears to struggle to break free from them. ness’ (also L39, p. 301) at such times was a theme Alternative approaches of Linnaeus and Buffon of Janet, in his exploration of automatism ([16 ]; in the eighteenth century have been mentioned, p. 224). Amnesia described by these writers was and Wernicke tried to reconcile competing claims often more extensive than in cases referred to by for mental disorders. From time to time it is clear Wernicke, whose explanation is quite different. that he, like Linnaeus, sought a ‘natural order’ in In L25 (p. 306), Wernicke does use the term what he saw in the clinic (and debates about the ‘defensive reaction’, but it is not clear that this word ‘nature’ were critical in the seventeenth referred to ‘psychological defence’ as understood century in emergence of the natural sciences— in the emerging dynamic tradition. Today, such not least in writings of Robert Boyle). We read amnesia might be attributed mainly to high selec- (p. 4): ‘However, since in Nature combinations tivity of ‘selective attention’, a concept not well of symptoms are far more diverse and complex, it formulated in Wernicke’s day. Nowadays its has been necessary to construct an artifi cial selectivity is known to vary between people as a framework, sometimes more widely, and some- trait, and (as a state variable), from time to time times more narrowly, accomplished by different in one person. Wernicke hints that he understands observers in very different ways’; and again both. Another hint at evidence from which others ‘Symptoms must be deduced from familiar fea- developed the concept of repression comes in tures of the diseased organ, in order to treat the L16 (p. 99). Wernicke refers to ‘… patients who illness—in our case from features of the brain. Editorial Commentary 407

Only in this way do we have the prospect of well preserved.’ In L17, he is sharply critical of obtaining a classifi cation and overview of symp- Ziehen (and others) for implying that there are toms which is both natural (i.e. based on the defi nite ‘disease conditions’ ( Krankheitszustand ). nature of things) and, at the same time, exhaus- The next step, that there are categorically sepa- tive.’ In L21 (p. 133) we read ‘Disorientation rate ‘diseases’ probably had little currency in disorders included in our schema represent only 1894, but the 1896 edition of Kraepelin’s text- the route by which nature brings about such dis- book promoted this notion, and took hold orientation; but every psychiatric patient is in increasingly, so that, by the time of Wernicke’s some way disoriented’. death it may have prevailed. Gradual emergence Despite his quest for ‘natural types’, he can of the disease concept for psychotic disorders is also focus on the uniqueness of each patient; and discussed by Beer [52 ]. in L20, stands back from any system he might Another issue for classifi cation, which hardly impose, with the following words (p. 131): ‘We applies today, comes in L9. Wernicke contrasts should always remember, simply, that any ‘internal’ and ‘external’ origins of mental disor- schema, ours included, has value merely of a ders, and the phrase ‘external cause’ is used in means of teaching and understanding, and L23 (p. 146), referring to an event in a patient’s becomes superfl uous as soon as a better, simpler, life. This followed Kraepelin’s early (1881) clas- or more correct grouping of the facts is found. sifi cation, separating endogenous from exoge- Rest assured, gentlemen, nobody is more aware nous origins to mental disorder. The latter of this than I, and that respect for the facts when included infectious causes: At the time, there searching for a way to represent mental illness as were several links between infectious disease and seen in the clinic is my primary consideration.’ mental disorder. Quarantine measures for patients Clearly, in his own fi eld, he was aware of coun- with dangerous infections were in places not terarguments, such as a contemporary Buffon unlike those for compulsory detention in psychi- might have urged. atric institutions. Early attempts to defi ne con- The 20-year period after 1890 in Germany cepts of medical ethics applied in both fi elds. At was critical for emergence of what we now take a time when unlettered people understood little for granted, that mental disorders are defi ned as of their own bodies, symptoms of infectious dis- categories; yet Wernicke was unhappy with the orders could be incorporated into psychotic delu- growing trend. He preferred to take as his start- sions (L10; p. 61); and of course, syphilis, whose ing point symptoms and the processes by which late stages include psychiatric syndromes, fi tted they arise, rather than supposed disease entities. Kraepelin’s scheme, especially after the spiro- There are several steps between his position and chete had been discovered (although today, when the notion of mental disorders as categorical syphilis is rare, the dichotomy is less relevant). A ‘diseases’: In his frequent use of the word bacterial toxin was seen as a potential cause of Krankheit he probably implied no more than a mental disorders. ‘process’ (such as sejunction); and occasionally he uses Geistesstörungen as a ‘catch-all’ term, rather than Krankheit (‘disturbance’ rather than IX,(b). Purposes of Taxonomy ‘illness’ or ‘disease’). As early as L11, he writes (p. 66): ‘… let us face the question of nomencla- Wernicke was aware that different systems of ture. According to current labels, all those classifi cation are needed for different purposes. patients would be examples of “chronic insan- In L10 he refers to the issue of how to separate ity” or “paranoia” … We can avoid this misun- ‘curable’ from ‘incurable’ cases, this being an derstanding if we talk of paranoid states , which administrator’s classifi cation. In L11 (p. 66) he include all those chronic mental disorders where sketches his classifi cation of psychoses, using we encounter falsifi cation of content of con- scientifi c-clinical principles—somatopsychic, sciousness, while conscious activity remains allopsychic, and autopsychic classes of psychosis. 408 Editorial Commentary

Clearly he saw the two purposes as separate, add- IX,(c). Broad Versus Narrow Criteria ing (p. 66): ‘… you could emphasize the importance of that group of patients in whom the Wernicke’s critique of then-current categories disease process had apparently run its course, and was not a rejection of categorization of mental the patients have recovered, without their having disorders in principle, and he did have his own gained any insight into their illness’; and contin- distinctive categories: Most of his criticism was ues: ‘The necessity of the latter distinction can, targeted at over-inclusive defi nitions. We see this however, lead us to introduce other, somewhat- as early as L11 (p. 65): ‘… if we wanted to com- simplifi ed terms into the fi eld.’ This second, sim- prehend it in this way—that paranoia was a well- pler, more pragmatic classifi cation serves the characterized clinical form of illness then the interests of institutional administrators in identi- fl oodgates of greatest confusion of concepts fying patients who recovered or were improved would be opened, for the cases show very great suffi ciently to be discharged, and those needing differences one from another.’ In L38 (p. 294) we continued institutional care. A similar purpose also read: ‘Nevertheless, if, by way of example for classifi cation, dealt with in L40, is to defi ne you speak, hear, or read of “exhaustion psycho- severity. In L40 (p. 314), in discussing mental ses” as a specifi c clinical entity, this is the same defi ciency, he writes: ‘Separating these three misunderstanding to which I have already repeat- [types] one from another is of course quite artifi - edly drawn attention. Even more can one say, cial, and in many borderline cases cannot be with some justifi cation, that in the sense just dis- achieved; but otherwise, it is easily applied in cussed, by far the majority of acute psychoses are practice’: Here he accepts both the pragmatic “exhaustion psychoses”’. More broadly, he writes need for, and the limitations of categorical clas- (L17, pp. 101, 102): ‘The “general impression” sifi cation of persons. However, generally, he sometimes relied on even by better-known repre- separates the two purposes. sentatives of our profession, when they fail to In Kraepelin’s system, emerging at the same elicit defi nite psychotic symptoms, is no better time, classifi cation (at least to separate Dementia than everyday parlance and must elicit the deep- praecox from manic depressive illness ) was est suspicion, when used as the basis of diagnosis based jointly on patterns of symptom, and long- of a paranoid state’. Today, in much the same term evolution of each case, especially on way, the ‘cause of psychosis’ is often attributed whether a patient recovered suffi cient to be dis- to ‘trauma’, without either trauma or psychosis charged. The distinction between an administra- being defi ned precisely enough to specify the tor’s and a scientist/clinician’s purposes was thus nature of the relationship, except most vaguely as not so clear: The administrator’s classes became ‘proximate cause’. The positive side of this, part of a supposed scientifi c classifi cation. Wernicke’s preference for narrow defi nitions Granted, classifi cation based on long-term out- (which also applied to symptoms, such as verbal come does have a scientifi c side, and in L17 hallucinations) appears several times, for instance Wernicke does explore how acute syndromes in L34 (p. 254): ‘Only where [motility symp- progress to chronic ones. Merging of classifi ca- toms] constitute the clinical picture, solely or in tion systems, which should be kept separate, greater part … are we justifi ed in accepting a spe- because they serve different purposes still pre- cial illness whose essential symptoms are motor vails. Systems such as DSM-III, DSM-IV and in content. I would particularly emphasize that DSM 5, purportedly serving clinical purposes, “catatonic”—or, in our sense, specifi c motor— are widely used in USA and elsewhere for deci- symptoms, tend to appear in the majority of sions on fi nance, insurance, and medico-legal or chronic progressive psychoses at some phase of forensic matters. Likewise, ICD, though now the illness. We are thereby warned to confi ne our widely used for clinical purposes, started life as clinical picture of akinetic motility psychosis an administrator’s document for collected mor- within the narrowest possible limits.’ Again in tality statistics. L35 (p. 261), he cautions himself: ‘So we must Editorial Commentary 409 then take into account the possibility that the any symptom could occur in various disorders. above clinical picture of akinetic motility psy- Today, especially in DSM, it is habitual to list chosis, derived entirely empirically, is too broad’. collections of symptoms which jointly defi ne The same criterion could be said to apply to each condition. Inevitably, many patients fi t diag- another of his more specifi c entities—Affective nostic criteria for a number of disorders, which is melancholia. Here we get an important clue to almost certainly mainly an artefact of how diag- one of his criteria to determine when, if ever, he noses are defi ned. In an attempt to avoid such could think of specifi c illness or disease entities: high prevalence of co-morbidity, systems such as They should be defi ned as narrowly as possible in DSM often impose by fi a t exclusion as well as terms of symptoms, thus avoiding the conundrum inclusion criteria in their defi nitions; but this has of today’s nosologist—that entities overlap so been criticized. ‘… by defi ning some diagnoses much that spurious co-morbidity, is not just an in terms of exclusion as well as inclusion criteria, exception, but the norm. arbitrary separation is enforced between disor- Occasionally, however, when seeking to ders which are actually closely related, and a pos- defi ne and name ill-defi ned concepts, he recom- sibly arbitrary hierarchy between disorders is mends broader concepts as in L28 (p. 192), where generated’ [ 138]. However, Wernicke’s approach, he refers to ‘the concept of the second state, where, in each patient, one symptom is usually which is unambiguous in itself—yet currently fundamental, the others secondary, related to the always too narrowly defi ned’. fi rst by psychological reasoning, is a stronger way to avoid spurious co-morbidity arising from facile categorization. IX,(d). Psychiatric Taxonomy Separation of acute from chronic disease goes in Practice: Issues of Co-morbidity, back to the fi rst and second centuries CE, in writ- Illness Trajectory, and Severity ings (whose originals are lost) of Soranus of Ephesus [139 , 140 ]. By the nineteenth century, Concepts identifi ed in a scientifi c taxonomy of the distinction was accepted as important in med- disease need not be identical to those recognized ical descriptive writing. In psychiatry, the issue in offi cial systems of diagnosis, although the two was of widespread interest, and central to should be closely related. Whatever his critique Kraepelin’s systematization. Coming from a of categories current at the time, Wernicke did medical background, with all that goes along often make use of specifi c diagnoses. Sometimes with concepts of disease, Wernicke naturally he refers to established diagnosis (Delirium tre- wanted to make a similar separation; and as early mens, Progressive paralysis), which today would as L14 (p. 86) he writes: ‘We set out initially to hardly be seen as psychiatric diagnoses. In L23, study alterations in the content of consciousness. in relation to ‘anxiety psychosis’ we read (p. 148): We identifi ed acute and chronic mental illnesses ‘In diagnostic terms, the assumption is that the according to the processes by which they arose’. illness will often develop further, forming no This habit came partly from Meynert, since in more than the initial stage of a more complex dis- L37 (p. 284) he writes, on progressive paralysis: ease picture’. Here he refers to one of his own ‘Whenever actual psychoses appear during the concepts unambiguously as a diagnosis; but often course, the illness always shows an acute charac- his special terms, although presented as if they ter, at least temporarily, and Meynert explicitly are diagnoses, seem to be highly specifi c to one classed it with the acute psychoses’. In L17 and or a few cases, and say more about analysis of L18, the subject matter of Grundriss shifts from those cases than of disease entities (e.g. ‘acute chronic to acute conditions, and Wernicke dis- expansive autopsychosis mediated by autochtho- cusses ways to differentiate the two (L18; p. 111), nous ideas’; p. 199). partly on the basis of duration (up to a few weeks Wernicke did recognize that any disorder still being acute) but mainly on the basis of the might include a variety of symptoms, and that processes: Chronic mental disorder refl ects 410 Editorial Commentary changed content of consciousness; acute disorder nal course of individual illnesses. In this respect, refl ects changed activity of conscious processes his descriptions may be better than can be made (p. 111). Later (L40, p. 310), he refers to fi ner today, partly because, with better treatment, long- distinctions: ‘We must subdivide the acute psy- term evolution of severe illnesses is seldom seen, choses according to their time course into per- and partly because organization of mental health acute, acute, and subacute psychoses. This services today make longitudinal follow-up by a distinction is of practical importance; however, single clinician more diffi cult. we would only apply it when we are dealing with a clinical picture of acute coloration which has developed slowly over time, to distinguish it from IX,(e). Wernicke’s Prototype chronic psychosis’. Clearly he does think there Classifi catory System are distinctions to be made, which are practically important; yet he seems to struggle to separate Descriptive schemes, based on a researcher’s acute from chronic syndromes, and in the end intuitions may claim to be theoretically neutral, fi nds clinical realities scarcely permit this. Thus, but there are often implicit theoretical assump- in L17 (p. 105) we read ‘Each newly emerging tions, even if unintended or well-hidden. In L2, symptom of mental disorder may have an acute as mentioned, Wernicke gives his classifi cation character. Most chronic mental illnesses can even of all possible symptoms in a three-by-three be characterized by their acute episodes, with table, with columns identifi ed as ‘Psychosensory’, new symptoms which may occur at any period ‘Psychomotor’, and ‘Intrapsychic’, the rows as along their course. I have intentionally avoided ‘loss of’, ‘excessive’, or ‘aberrant’ excitability. describing these states wherever possible, Given the lack of reasoning underlying the because they belong with acute psychoses; but scheme, and that it encompasses all conceivable this was not wholly successful for separating possibilities, it probably has few hidden assump- such episodes from new-emerging individual tions. It probably is strictly descriptive. symptoms, because even there, just as every- Beyond this, in L1 to L8, a more signifi cant where else in nature, imperceptible transitions system for description is advanced, derived take place’. Likewise in L40 (p. 310) he writes: cogently from basic brain science. Contents of ‘We … differentiate chronic and acute psycho- consciousness fall into one of three domains: ses. However, closer examination of these differ- allo-, somato-, and auto-psychic. This provides a ences of the course over time soon showed that three-way classifi cation of phenomena he sees in acute clinical pictures are occasionally to be his patients. This is not the whole of Wernicke’s found as in chronic cases, somewhere along their scheme for classifying symptoms. Motility time-line’. symptoms and disorders are a special feature in In L40 (and several times earlier) Wernicke his thinking, although he often suggests that they writes of the practical need to chart the severity are linked closely with somatopsychic phenom- of each illness across its course. In L34 (p. 255) ena; and Affective reactions to other psychopa- he concludes that ‘range’ of symptoms is not thology, differing according to the nature of the independent of severity, and therefore the former latter are incorporated into his descriptions is not a secure criterion for classifi cation. In L40 throughout. In early clinical lectures, the three he again considers separate dimensions of ‘range’ fundamental terms are used to describe various and ‘intensity’ of symptoms, but fi nds consider- types of ‘falsifi cation of consciousness’—allo- able diffi culties in their use in practice: ‘We must psychic, somatopsychic, and autopsychic (L9). not hide from the diffi culties in the way of such Between L24 and L29 there are clinical presenta- an undertaking’ (L40, p. 111). A striking feature tions of acute disorders dominated by each symp- of cases presented in Grundriss is nevertheless tom domain—somatopsychic in L24, allopsychic his ability to recognize patterns in the longitudi- in L25 to L27, and autopsychic in L28 and L29. Editorial Commentary 411

Somatopsychosis Allopsychosis Autopsychosis Motility psychosis Anxiety psychosis Acute hallucinosis Acute autopsychosis Hyperkinetic motility (‘second state’) psychosis Hypochondriasis Delirium tremens Hysterical absences Akinetic motility psychosis (Eating disorders) Polyneuritic psychosis Acute expansive Combined hyperkinetic autopsychosis mediated by and akinetic disorders autochthonous ideas Obsessions Affective melancholia Mania Confused mania Compound and mixed psychoses Progressive paralysis Hebephrenia Dementia

The emphasis is nevertheless on symptoms three-way split to organize his descriptions. (rather than diagnoses), some of which, with Despite the clarity of reasoning behind this, one modern names, can be assigned to Wernicke’s can ask three questions: categories: Delusions of persecution are allopsychic. Misperceived body image (in Anorexia 1. Is the implied symmetry scientifi cally valid? nervosa ) is somatopsychic. Delusions of refer- 2. Is the classifi cation clinically useful? ence, and usually overvalued ideas, are auto- 3. Are the three symptom groups statistically psychic. Only later does he use the three-way independent? split to defi ne disorders themselves, subdivisions of the all-encompassing term ‘psychosis’: The fi rst question is theoretical, to be answered somatopsychosis , allopsych osis, autopsychosis , on the basis of brain theory. The other two are and motility psychosis. Specifi c diagnoses then empirical matters, some of which were clearly fall under each of the latter terms. Some of beyond the methodology of his time. Empirical these are Wernicke’s own concepts, usually evaluation of this three-way split may be the most based on a deeper level of abstraction than most important way forward from what Wernicke diagnoses with we are familiar today, a few wrote in Grundriss , but it is a complex task. which we recognize and to which can assign However, he does provide a language, which modern terms. In the Table above are some of condenses many details he heard from his patients the diagnoses (mainly for acute disorders) into generic concepts. He uses that language, in appearing in Grundriss . part to describe individual cases, often in very Given the care with which he derives the sys- interesting ways, for instance: tem, there are bound to be theoretical implications. For instance, Wernicke implies that there is L11 (p. 66): According to this classifi cation the some symmetry in the three (or four) components fi rst patient presented, the gardener Rother, of consciousness. Thus, in one area after would be classifi ed as an example of a total another—falsifi cation of contents of conscious- chronic psychosis; Frau Reisewitz, a chronic ness, explanatory delusions, delusions of related- auto-allopsychotic; the patient Tscheike, a ness, disarray and disorientation, other Affective chronic auto-somatopsychotic; the Biega, reactions, overvalued ideas—he uses the same case, a pure somatopsychotic; Frau Schmidt, a 412 Editorial Commentary

combined chronic allo-somatopsychotic; and for rating his three categories—allo-, somato-, Frau Reising, a chronic allopsychotic. and auto-psychic aspects of his several clinical L33 (p. 239): Previous attacks of the illness, variables. especially the fi rst, which appeared along with Using his language, Wernicke’s many gener- menstruation, were pure manias. Actual dis- alizations have no accompanying detail to docu- orientation in the allopsychic area never ment their veracity, as needed today; but it would occurred; in the autopsychic area it had char- be unwise to ignore statements from an observer acteristics of grandiose delusion, understand- and analytic thinker as shrewd as Wernicke, even able in the context of mania—this having if rigorous proof is lacking. Most of the roughly religious coloration, corresponding with the 5,000 careful clinical records from Breslau have patient’s personality; and in the somatic not survived, except for the around 150 published domain, disorientation consisted essentially of as Krankenvorstellungen aus der psychiatrischen abnormal sensations, perhaps linked with Klinik in Breslau. However, from his short period menstruation, and an explanatory delusion for in Halle records have survived, and Frank the pseudospontaneous movements, particu- Pillmann, who has access to them, has attempted larly of her trunk. to evaluate Wernicke’s system on the basis of 889 (p. 274): … somatopsychic disorientation may be cases so documented [18 ]. He seeks to validate limited to delusions of pregnancy, autopsychic Wernicke’s special diagnoses as mutually exclu- disorientation to accompanying ideas of hav- sive categories, as might be expected today. ing sinned, and allopsychic disorientation However, the core of Wernicke’s system was not restricted only to certain time periods and cer- diagnoses, but symptoms. Pillmann is therefore tain relationships, so that the prevailing situa- judging Wernicke based on today’s assumptions, tion can still be recognized correctly. which Wernicke may not have shared, rather than starting from a tabula rasa, as, in a sense, he him- Such comments are some way distant from self did, with no automatic assumption that there generalizations with which science usually deals; must be categorical diagnoses. In the paragraphs but there are also many general statements, ones below, we discuss the three questions just raised: with which research can deal. However, the sophisticated logic pervading Grundriss is neces- 1 . Theoretical validity . Several objections can be sarily a complex pattern. Moreover, because the raised against the implied symmetry of the 41 lectures were delivered as clinical presenta- three domains of psychopathology. First , tions, the merits of his language for describing memories involved in building our notion of symptoms is not at once apparent: generaliza- personal identity are of a different type from tions are scattered through the lectures in a seem- those giving us a sense of bodily integrity, ingly uncoordinated way. To clarify these and, quantitatively if not qualitatively, from dispersed statements, and to illustrate their poten- those which represent the outside world. The tial—were his system better known and under- difference can now be based on that between stood—a few of the clearest (and most ‘episodic memory’—a trove of memories of oft-repeated) generalizations in each area of unique events occurring throughout our life— symptomatology are given below. The analysis and ‘semantic’ memory—usually acquired by avoids conditions whose specifi c cause we now repetition of events, a distinction not yet for- know, especially alcoholism and syphilis. The mulated in Wernicke’s day. Episodic memory intention is then to focus, as far as possible, on is more important in constructing a person’s what we now recognize as endogenous mental sense of identity than in representing his body, disorders. These paragraphs might point to future and possibly also in representing’ the outside work; but, of course, if this line is to be followed, world. It is now thought to involve interaction the fi rst step would be to devise authenticated of neocortex with the hippocampus [88 ], in instruments, as mandated by modern standards, ways which apply less to the other contents of Editorial Commentary 413

consciousness. Second , the account of fi ndings most easily accounted for by some Delirium tremens (L26) emphasizes dramatic generic feature of the cortex as a whole. If so, allopsychic disorientation, while autopsychic it is at least plausible to incorporate Wernicke’s orientation is remarkably preserved. The somatopsychic disorders into the broader probable explanation, (section VII,(f). ‘Higher scheme, where other symptoms also arise in Levels of Functional Organization’), is that the cortex. The point he makes in later lec- the syndrome described is what is now called tures, about affi nity between somatopsychic ‘REM dissociation’ (a breakthrough of dream- and motility phenomena has support from ing, after prolonged insomnia, within a state modern neuroscience, in which primary areas more akin to wakefulness). This is such an for somatic sensation and motor function are abnormal state that any suggestion of symme- increasingly seen to be functionally interde- try with contents acquired in other ways can pendent. At the same time, it makes scientifi c be dismissed. Third , ‘autopsychosis’ as sense to separate somato-psychic functions described in L28 does not match psychosis in (depending on somato- and proprioceptive other domains (if cases of epilepsy, alcohol- inputs, whose patterned inputs stay fairly sta- ism or other obvious assaults are excluded): ble over long periods of time) from allo-psy- Regardless of the area in which content is chic ones (depending on ever-changing inputs described, there is nothing fi tting usual defi ni- from distance senses), the corresponding cor- tions of either hallucinations or delusions; and tical areas being some way distant from each these should occur in Wernicke’s scheme, other. The conceptual separation of auto- and since, in L30 (p. 204), the point is added that allo-psychosis was crucial in his differential ‘such a disorder of identifi cation [is] assumed diagnosis of Delirium tremens (L26). Lastly, to occur in psychosensory areas’. In any case, his distinctive ‘anxiety psychosis’ and ‘hypo- the ‘alternative personhoods’ described in chondriacal psychosis’ concepts do have fea- L28 are relatively coherent, not dominated by tures in common with today’s concept of any such symptoms. Fourth , if motility psy- psychosis—especially delusions and halluci- chosis is taken as a fourth component, we nations—although the content is quite should be reminded that brain mechanisms different. underlying movement differ vastly from most 2 . Predictive validity in the clinic . Is Wernicke’s of those of the cerebral cortex seen just as an system for describing symptoms useful in pre- ‘organ of association’. Despite presence of a dicting early signs, development, course, and motor cortical region, the important role of the eventual outcome of different conditions, and basal ganglia and cerebellum (amongst other possibly in predicting the relative effectiveness structures) make symmetry with other con- of different treatments? One of the broadest tents of consciousness most unlikely. The dif- generalizations based on his system is about ference between motility functions and the the sequence in which symptoms appear and other domains is implicitly recognized when disappear during acute syndromes: Autopsychic Wernicke refers to ‘independent development phenomena appear fi rst, and, during recovery, of akinetic and parakinetic mobility symp- disappear last. Thus, when discussing a young toms, separate from normal mechanisms of patient with a fl uctuating state of consciousness association’ (L12, p. 74). he writes (L18, p. 116): ‘We can discern, Given this, several positive things can be amongst the internal stimuli mixed together in said about Wernicke’s broadened concept of the centre of his radiant mind, abnormal sensa- psychosis. Many cases discussed in L23 and tions, self-generated ideas, and simple disori- L24 appear to arise from disordered sensory entating phonemes. Disorientation occurs processing. Modern research shows that sen- predominantly in the autopsychic area, fol- sory thresholds and sensitivities across sev- lowed by the allopsychic area.’ Many examples eral modalities often correlate (e.g. [141 – 143 ]) of this principle are reported in the context of 414 Editorial Commentary

anxiety states. In L23 (p. 146), for a patient Suggestions that autopsychic symptoms with anxiety psychosis, we read: ‘These auto- appear fi rst and disappear last, compared to psychic ideas of anxiety existed on their own in symptoms in the other domains makes theo- the initial period of illness, and only shortly retical sense. For Wernicke, autopsychic before his admission were they joined by those symptoms appear to have been more diffi cult of fantastic threats, and at the same time, there and complex than allo- or somato-psychic was an increase in the patient’s restlessness ones, since they are discussed from L26 which became so noticeable that it was inevi- onwards, after fi rst discussing the latter two. table that he be transferred to an institution’. In In L33 (p. 240) he offers this rationale: ‘The L23 (p. 147) he offers a view that ‘Such anxiety situation may arise that the fi rmest associative regularly leads to emergence of various ideas, links exist in the domain of consciousness of which therefore deserve to be called ‘anxiety the body, the next fi rmest in consciousness of ideas’. They show grades of intensity such that the environment, and the loosest—and like- the autopsychic ideas of anxiety correspond to wise the last to be acquired, with the greatest lower intensity, the allopsychic and somatopsy- individual differences—in consciousness of chic ones to more severe anxiety’. Then, as a personhood. Correspondingly, a similar mea- generalization, he writes (p. 147): ‘When the sure of severity of illness, or, according to disease starts, and as it subsides only autopsy- Meynert’s concept, of general weakness of chic ideas of anxiety are usually present. In association, was always manifested fi rst in the some cases anxiety persists, accompanied just autopsychic region, and second and third in by such ideas; far more often the ideas are allopsychic and somatopsychic domains.’ “dressed up” as phonemes. At the height of the Today, much stronger reasoning lends support anxiety state, hallucinations can also appear to this rationale: As already mentioned, the temporarily in other modalities, and in some of sense of personhood each of us constructs the most acute cases, as in the example of anxi- depends on a trove of unique memories of ety in a case of epilepsy described above, can individual events, while our sense of corpore- occur simultaneously in all senses, as com- ality and of the outside world, are usually bined hallucinations.’ On p. 253 we read: ‘it acquired by a degree of repetition of events. seems to be intrinsic to such cases of agitated Retrieving the former, acquired by episodic melancholia that autopsychic ideas of anxiety memory depends largely on reinstating the outweigh by far any others in their content, neural context which prevailed when they even though allopsychic ideas may never be were acquired. At the level of brain function, totally absent.’ Later, (L40, p. 311) he notes the contexts for each memory depend on that ‘most anxiety psychoses are examples of interaction between neocortex and hippocam- such a remitting course, in which anxiety, and pus, more so than do the other types of mem- the autopsychic disorientation based upon it, ory. These are the most sophisticated brain usually exist in a persistent fashion, but are mechanisms we have, the most vulnerable to increased in attacks that lead to allopsychic dis- failure, and likewise the last to be reinstated. array, and corresponding ideas of allopsychic Some of Wernicke’s generalizations are anxiety in the guise of phonemes.’ He also about grading the intensity of a mental disor- extends the generalization to exacerbations in der. The intensity of Affective reaction, chronic illness (p. 199): ‘We have concerned according to Wernicke, is important in deter- ourselves earlier with more sophisticated ideas; mining overall severity of an illness. So, we but if we consider just the time course to be the read (p. 161) ‘… the autopsychic area shows decisive factor, we often have to attribute new itself always to be involved, to varying stages of these to acute autopsychoses, occur- degrees, corresponding with the Affective ring during a chronic course of illness.’ state induced by anxiety or somatopsychic Editorial Commentary 415

disarray.’ In L40 (p. 310) we read: ‘… most somatopsychic and allopsychic domains, and acute psychoses, especially all subacute ones, between somatopsychic and motility disor- initially show a worsening course. An exam- ders. Whether psychosis (as defi ned by ple of this is given by acute hallucinosis … Wernicke) in different domains respond to The clinical picture, apparently rises rapidly today’s antipsychotic medicine in similar to full disease intensity according to its ways is an empirical question, which, at pres- Affective coloration …’ Again (p. 312): ent, cannot be given a defi nite answer. ‘There are essential variations in the degree of However, single case studies have reported orientation here, and these depend in a dis- remarkable benefi ts for body dysmorphic distinctive way on the intensity of Affect. The order by treatment with antipsychotic medi- name we give—autopsychic anxiety ideas (we cines [144 – 146 ], a disorder which, as defi ned, might also call them “misfortune ideas”, may include delusions. Understandably, there undermining ideas of happiness)—shows have been no controlled studies, given the their derivation from an Affective state.’ vast conceptual divide between the disorder in However, the relation to intensity of the question and those for which antipsychotic Affective response may vary across the course medicines are usually prescribed. of an illness: In contrast to the above state- 3 . Statistical independence of the three domains ments, he writes (p. 281): ‘The most severe of psychopathology . To assess properly the hypochondriac presentations show themselves statistical relation between symptoms in with hardly any Affective component, such as Wernicke’s three domains, the fi rst require- having no head, no heart, no lungs, no stom- ment would be to have authenticated instru- ach, or being completely hollow, “only a ments for assessing each; and then, after tube”, as one educated patient put it so starkly collecting suitable data sets, deployment of … However, for weeks in an earlier acute methods such as factor analysis. This might be stage of his illness, the same patient had pre- possible with the data to which Pillman [ 18 ] sented the picture of most severe somatopsy- had access. As a beginning, we can search chic disarray, admittedly not as agitation, but among Wernicke’s general statements looking only as almost total inaccessibility and help- particularly for ones about association or dis- lessness, while only occasionally were there sociation across the different domains. isolated expressions and actions pointing to With regard to statements about associations , the total loss of bodily orientation.’ most abundant are between auto- and allo- There are also many straightforward gener- psychic domains: alizations about course of illness, prevalence L10 (p. 62): She had no abnormalities of sensa- at various ages, and prognostic signs of tion, nor did her general condition reveal any favourable and unfavourable outcomes, which disturbances. Nevertheless, more extensive need not be repeated here. In addition, there is examination showed other severe changes, nothing to predict which specifi c treatments noted as defects, which encroached princi- might be appropriate, and effective in differ- pally into allopsychic and autopsychic areas. ent disorders, since there were no specifi c L23 (p. 147): Often, only autopsychic ideas are treatments in his day. Nonetheless, questions present, at a moderate level; or there may even are raised for today: If it is true that there is be a combination of autopsychic and allopsy- some kinship between symptoms arising in chic ideas of anxiety, with added phonemes different domains, because of their origin in only at times when anxiety intensifi es. different areas of the one structure—the cere- L23 (p. 147): Common contents of autopsychic bral cortex—some treatments now used in one ideas of anxiety and matching phonemes class of disorders may be usefully applied in express concern for family members, for the others. The cases in point are kinship between fi nancial situation, challenges to personal 416 Editorial Commentary

honour, and there may be micromania, self- self-accusatory content—which at the same recrimination, with corresponding abusive time she rejected—insomnia, fear of silence at phonemes. The content of allopsychic ideas of night when the noise increased, and thoughts anxiety is usually a threat to life or of igno- of suicide. minious disciplinary actions, abuse, etc. L28 (p. 188): From our point of view the case is L25 (p. 166): The main symptoms we know also very clear, because it presents a typical about are phonemes, whose content, corre- example of autopsychic disarray and disorienta- sponding with his anxious state, is partly of a tion. The addition of somatopsychic disarray threatening nature, and partly expresses his and disorientation should not distract us from reduced personal status (that is, part allopsy- this view, but will, on the contrary, strengthen it. chic part autopsychic notions of anxiety). Associations between allo- and somato-psychic L25 (p. 170): A specifi c characteristic of acute domains are few, including: hallucinosis seems to be the occurrence of L10 (p. 63): The patient was apparently suffering phonemes on a grand scale, their content a slowly developing paranoia, the basis for being autopsychic and allopsychic delusions which could be found mainly in a series of of reference. morbid sensations and tactile hallucinations. L29 (p. 201): In addition, everything that people The patient notices changes in her body but, in in the neighborhood say or do is assessed as if contrast to the previous patient, attributes those people know the patient’s thoughts; and these to outside infl uences; and thus she so it reaches the point, symptomatically, of reaches allopsychic—in addition to somato- generalized autopsychic delusions of refer- psychic—falsifi cation of consciousness. ence, with corresponding reinterpretation of L36 (p. 272): Moreover, there exists an internal the outside world. Allopsychic orientation connection between somatopsychic symp- will then also be impaired. toms, and (in this case), allopsychic symp- L33 (p. 242): Cases of weakened association, toms, due partly to simple explanatory with autopsychic and allopsychic defi cit delusions, and in part to the elementary symp- symptoms but no motor excitatory symptoms tom of somatopsychic delusions of reference, (therefore: ‘asthenic autoallopsychoses’) which, at the time, we categorized as newly which I have often seen in very acutely ill formed associations. young girls. L39 (p. 306): Moreover there are some—mainly L36 (p. 278): Residual sequelae involved severe severe—clinical pictures of psychoses related confusion with autopsychic and allopsychic to the puerperium, especially when, apart from disorientation corresponding to previous hal- the puerperium, other harmful circumstances lucinations and a moderately irritatable mood. are present, such as excessive lactation, febrile Those for association of auto- and somatopsy- illness, or painful mastitis, that have reduced chic symptoms include: the levels of energy. In such circumstances the L10 (p. 61): We will talk later about the processes most severe hypochondriacal psychoses may by which such falsifi cations of conscious- occur, with allopsychic disorientation. ness—partly somatopsychic, partly autopsy- Associations of motility symptoms with other chic—actually arise. domains include: L24 (p. 154): However, the dolour and autopsy- L39 (p. 303): Almost always in these cases, chic focus of her anxiety remained, as did the phrenic nerve insuffi ciency can be demon- somatopsychic perception of anxiety about strated as the basis for the fear. Twilight states having small bowel movements. lasting several days sometimes occur in young L 24 (p. 158): When the noise was bad, restless- people in connection with major emotions, ness in her heart and anxiety also occurred. with total allopsychic disorientation almost to Also present were severe unhappiness, hope- the point of asymbolia, blended with episodes lessness, autopsychic ideas of anxiety with a of parakinetic symptoms. Editorial Commentary 417

L39 (p. 306): Of the mixed forms, a special intro- L30 (p. 210): Affective melancholia totally lacks duction is needed to manic allopsychosis and ideas of allopsychic anxiety so typical of most manic hyperkinetic allopsychosis. cases of anxiety psychosis. L39 (p. 307): To all these delirious states, apart L33 (p. 239): Recovery in this case was accom- from familiar symptoms of hallucinations (in plished, in that the last attacks acquired a form particular the dreamlike hallucinations), occa- more of pure mania, while the fi rst attack, sional ideas of anxiety, and a restlessness even more than the second just described, more-or-less reminiscent of jactation, an allo- bore an overwhelming stamp of hyperkinetic psychic disorientation appears always to be motility psychosis. Allopsychic orientation in distinctive, at least temporarily. this case was completely intact. Statements on dissociation between domains are L33 (p. 239): Previous attacks of the illness, also interesting. Ones where allo-psychic especially the fi rst, which appeared along with experience is normal, while symptoms abound menstruation, were pure manias. Actual dis- in other domains include: orientation in the allopsychic area never L10 (p. 60): You will observe the contrast occurred; in the autopsychic area it had char- between this case with such pronounced allo- acteristics of grandiose delirium, understand- psychic falsifi cation of consciousness and able in the context of mania. another patient, in whom consciousness of the L33 (p. 240): Preceding attacks had a form more outside world is in no way involved over the akin to hyperkinetic motility psychoses, while entire course of the illness right up to the pres- the following sixth attack and last attack was ent time, while the main alterations are in purely manic followed by permanent restitu- awareness of physicality, and, in due course, tion, once a stage of exhaustion had passed. of personhood as well. We can take it as an This patient always remained perfectly orien- example of residual, mainly somatopsychic tated in the allopsychic domain. falsifi cation of consciousness. L35 (p. 261): At other times the fantastic menac- L23 (p. 149): … in acute hallucinosis, a charac- ing delusional state occurring within well- teristic paranoid stage develops very early, retained allopsychic orientation is to be seen which is not the case for simple anxiety psy- in the same paranoic stage, combined only chosis. In the latter condition, allopsychic ori- with hypochondriacal sensations mainly intes- entation remains intact, unlike the tinal in nature. anxiety-laden state found in Delirium L36 (p. 274): Nonetheless, I want to emphasize tremens . explicitly that a defi nite combination, specifi - L25 (p. 170): The rapid, comprehensive, and cally that with hypochondriacal symptoms, indeed allopsychic falsifi cation of content, makes up an almost normal picture; again this and the emergence of a manner of being perse- indicates that motility psychoses should be cuted physically, and usually soon directed included with the broader concept of somato- against specifi c persons of groups of persons, psychoses. On the other hand, in many cases, is highly characteristic acute hallucinosis; the fact that complete allopsychic orientation while in acute anxiety psychosis, except for is retained, has been established with reason- certain less common cases with chronic pro- able certainty. gression, this is absent. In other situations allopsychic symptoms alone L25 (p. 170): … the predominant features of predominate (often as exceptions to the idea acute hallucinosis, the preserved allopsychic that autopsychic symptoms are the fi rst to orientation, and the absence of any formal appear and the last to disappear): thought disorder, can persist for weeks, until L33 (p. 240): Confused mania, in the sense we an increase in defensive emotions and the give to the name, does not by any means occurrence of new symptoms mark the pro- embrace all cases of the so-called periodic gression of the illness. mania. Quite often, attacks of periodic mania 418 Editorial Commentary

do indeed correspond to the clinical picture Normality of somatopsychic experience while outlined, yet allopsychic disorientation is also symptoms appear elsewhere is seldom present, manifested as ignorance—or mistak- mentioned. ing the place—of the situation and persons, L36 (p. 274): I want to emphasize explicitly that often even of objects …We will therefore pro- a defi nite combination, specifi cally that with ceed correctly, if we regard such cases not as hypochondriacal symptoms, makes up an confused mania, but as periodic manic allo- almost normal picture; again this indicates psychosis —and they are often also totally sen- that motility psychoses should be included sory psychoses. with the broader concept of somatopsychoses L33 (p. 242): In one case of this kind, the principal … In one such case, there was complete characteristics of the state of exhaustion were somatopsychic orientation, but complicated found as previously described, namely a certain by fantastic micromania, and in general by a defect in spontaneity; failure of ideation in picture of Affective melancholia. more complex demands; attentiveness retained Occasionally, Wernicke’s three-way split allows just through excitement; but very poor memory him to make differential diagnoses: retention and simultaneous allopsychic disori- L25 (p. 170): The illness [acute hallucinosis] is entation, accompanied by symptoms of motor easily differentiated from Delirium tremens and sensory irritation of moderate nature. because of the point of difference from the A few statements mention dissociation between former—the fundamental symptom of allo- different abnormalities in the same domain: psychic disorientation in its strict sense. L27 (p. 181): Nevertheless, the existing [mem- L25 (p. 170): The differential diagnosis [of ory] defi cit will explain the fact that no trace Delirium tremens ] from acute anxiety psycho- of disarray was present, in obvious contrast to sis can easily lead to confusion, because of the the severe allopsychic disorientation. main point in common between the two, L36 (p. 275): The combination of allopsychotic which we should acknowledge: the abusive symptoms with mania is important practically, and fantastically threatening character of pho- and deserves special mention. The clinical nemes, and that they arise out of ideas of anxi- picture of choleric mania, found quite often as ety of an autopsychic and allopsychic nature is an independent illness, consists essentially of undoubtedly common to both. But with anxi- a combination of mania with ideas of anxiety ety psychoses, ideas of autopsychic anxiety and corresponding phonemes, but without any namely those of belittlement, quite often pre- necessary allopsychic disorientation. Usually dominate, these being grouped not so often however, allopsychic delusions of relatedness into phonemes, as here. and hypermetamorphosis are present. To the best of our knowledge, no one has ever Normal autopsychic experience with symptoms developed Wernicke’s language for symptoms appearing in other domains is mentioned along the lines of modern research. Admittedly, occasionally: his language has theoretical fl aws, yet they are no L26 (p. 230): Results of the clinical examination worse than those of instruments in use today. It is so far can be summarized, that we are dealing nevertheless an interesting language, and if with a patient who, in contrast to near- untried, seems useful at least as a descriptive completely preserved autopsychic orienta- scheme. The above section, where some association—up to the last 2 days—presents severe tions and dissociations appear frequently, others allopsychic disorientation. rarely, suggests that there is structure yet to be L26 (p. 176): the contrast between well-preserved discovered, with important developments yet to autopsychic orientation and severe allopsy- come, were this to be attempted. A case in point chic disorientation which provides a decisive is that the association of allo- and somato-psy- criterion. No other illness that I know provides chic abnormalities is relatively rarely reported. such a striking contrast. The three (or four) broad domains for symptoms Editorial Commentary 419 may correspond well to large regions of cerebral In the preceding section, we saw how cortex, which are some way distant from each Wernicke struggled to adapt the traditional dis- other; and if so, these broad concepts seem well tinction between chronic and acute disorders to suited for modern studies with functional imagin- realities in his clinic. Likewise, in L11, he has ing, seeking excesses or defi cits in cerebral activ- diffi culty separating illnesses which have ‘run ity in large cortical regions corresponding to the their course’ from those that are still active. The predominant symptom domains. fact that these decisions proved largely beyond him may indicate that his model of mental disorders based on medical precedents required major X. Wernicke’s Struggle to Adapt amendment to match clinical realities. In particu- Medical Concepts to Clinical Reality lar, if his essentially holistic view of human nature, including each person’s never-ending The 20 years from 1885 during which Wernicke quest to integrate past with present experience, is practiced psychiatry were of critical importance correct, it might make sharp separation between for the emerging discipline in continental acute and chronic illnesses impossible in princi- Europe. This is partly because interactions often ple, except by administrative fi a t . This appears to occurred between the three components of psy- be the conclusion to which he is forced in L17. chiatry, which came together to form the modern Wernicke’s struggle is similarly evident in his profession, arguably more fruitful than in later attempts to defi ne prognosis. In L16 (p. 150) he years. In addition, it was during this period that writes of ‘… cases where active illness is fully the idea took root that mental disorders could be extinguished …’ Clearly he uses medical termi- subdivided (as elsewhere in medicine) as named nology, with implications about ‘prognosis’. To categories. Wernicke’s medical training, and the speak of ‘fully extinguished cases’ appears to assumption that mental disorders were diseases imply a physical disease process with its natural like those being defi ned elsewhere in medicine course, rather than a rift in a person’s sense of inevitably led him to apply medical concepts to ‘wholeness’, which might be healed during that what he saw in his clinics. However, there are person’s later journey through life. In any case, signs that he struggled in this attempt. We have the prognostic indicators to which he does refer already seen his scorn for many categories of are of a quite different nature: the natural healing mental disorder gaining currency in his day, a patient might derive from his awareness of although he did not deny that valid categories inherent contradictions in belief, the impact of might be revealed by later research, and he malign social environments which provoke defi ned a few such himself. His psychological return of symptoms, dangers of undue rumination reasoning, guided by general principles and for resurgence of symptoms, and the difference acute awareness of cerebral functioning, is often between unlettered people and educated rational- highly individualized based on immediate or dis- ists in coming to terms with past episodes of ill- tant events in each patient’s life, and on individ- ness. Again we see unresolved tension between ual habits of thought acquired during education medical training and clinical experience. or employment. This personalized approach An aspect of mental disorders on which we might have been more familiar in the newly have more appreciation today, and which casts emerging dynamic psychiatry, rather than within doubt on medical conceptualization of such disor- medical paradigms, and does not easily fi t into ders, is that these disorders are by no means diagnostic concepts, applied in a generic man- purely negative in their impact, but an inseparable ner. His three-way split of symptom domains amalgam of negative and positive features, was of value to him in describing what he saw, although the latter are given little weight by doc- but by no means were they separate disease enti- tors trained to detect psychopathology . This does ties, or even separate pathological processes, not easily fi t medical concepts of disease. with separate causes, courses, and treatments. Wernicke shows some awareness of the principle. 420 Editorial Commentary

He is aware that in some acute conditions, patients basis for classifi cation. Admittedly, he knew little may have sharper attentional focus than normal. of fundamental causes, and usually replaced this A patient ‘on one occasion … expressed his with ‘proximate causes’, substituting correlation astonishment that the head warder had disap- for causation. Even so, he fi rmly rejects aetiol- peared through one door of the hospital and ogy, defying principles established elsewhere in simultaneously entered through another door. On medicine (notably for infectious diseases). So, in another, food suddenly stood before him without L39 (p. 307) he writes of ‘… the maxim that, so any delay, a process that reminded him of the fairy often, I sought to instil, that aetiological consid- tale “wishing table”’ (L18: p. 114): Both events eration offers a benefi t only if we separate it indicate a break in temporal continuity, due to sharply from clinical defi nition of the various total lapses of attention to the outside world. (See psychoses, making no claims to artifi cial con- section XV. ‘Allusions Requiring Clarifi cation’ struction, or certain clinical forms defi ned exclu- for clarifi cation of ‘wishing table’). He comments sively by aetiology’. Similar statements occur (L18, p. 116): ‘The state of distraction is reminis- throughout Grundriss . Clinical pictures of cent of delirium, and appears to be associated diverse kinds arise from any one aetiology; the with a dream-like clouding of consciousness. We two are in no specifi c relation to each other. can conceive of no sharper contrast than the atten- What, one might then ask, could determine which tive, razor-sharp consciousness, which follows clinical picture emerges in each patient? For immediately afterwards’. However, from brain Wernicke, we have some hints: Stage of life, theory, or psychological theory, we realize that accumulation of past experiences of mental dis- these two states, apparently dramatically differ- order, education, employment, sophistication of ent, are closely related: If attention has an exces- baseline mental processes, and other life experi- sively sharp focus, it can focus either on internal ences in the recent or remote past—mainly social information, or on the external world, in either factors not medical ones. A modern writer might case excluding anything else. Since both are rep- add baseline personality. resented in the cerebral cortex, a state of sharp- Perhaps the most fundamental source of ten- ened attention to one may apply to the other. sion evident in Grundriss , perhaps intrinsic to Wernicke also suggests that in acutely disordered psychiatry as a whole, is between mechanism and states, patients may have a better-than-normal meaning , or alternatively between physical disor- sense of sound localization (L5, p. 29). In L19 der and informational discord . Wernicke ‘cut his (p. 118) he elaborates thus: ‘Usually the direction teeth’ as a neurologist on clinico-anatomical cor- from which voices appear to come can be pre- relations; as a psychiatrist, he naturally sought cisely specifi ed; and patients often develop, in this neuronal pathology as a basis for mental disor- regard, quite striking ability to localize, found ders he studied. The sejunction theory was sup- only in cases of illness. The source of the voices is posed to provide this basis. While quite indicated not only by the direction, but even by hypothetical, it showed him striving to fi t mental the very precise location and distance from the disorder into medical concepts; yet, even in his ear.’ What is missing in Grundriss is an awareness day, it failed. In L14 (p. 74), in an account of ret- of how enduring personality traits combine an rospective delusional explanations, he writes that inextricable mix of both impairment (even severe ‘modifi ed contents of consciousness must be rec- disability), and, in other faculties, major strengths, onciled, according to our prevailing notions of which may amount to outstanding talent. That is causality, with old, as yet unchanged domains’; also missing in much of today’s psychiatry, and yet he clarifi es this as occurring ‘according to although it is now a possible development, with strict standards of logic’. However, causality and our greater awareness of the intrinsic diversity of logic are not the same! In L20 (p. 125) he con- personality types. fronts the ambiguous status of mental disorders A major sign of Wernicke’s struggle to apply as diseases akin to those of general medicine. medical concepts is his rejection of aetiology as a Pathologies along these lines, he argues, like Editorial Commentary 421

cortical lesions in neurology, should be random clinical science in psychiatry even possible? The (‘subject to chance’). We fi nd this echoed later in answers of the two were quite different, and Bleuler’s words on schizophrenia: ‘This disease hinged around their respective approach to clas- seems to interrupt, quite haphazardly, sometimes sifi cation. For Kraepelin, classifi cation had to such single threads, sometimes a whole group, come before explanation. Wherever possible, it and sometimes even large segments of them’. In should be based on pathology or aetiology. contrast, Wernicke suggests that hallucinations However, Kraepelin accepted by the mid-1890s are not random, not haphazard; not so much a that for key concepts this was no more possible deranged mechanism, but rather a disturbance in than in Wernicke’s system. He therefore focused processing meaning . on symptom clusters and long-term outcome; but Overall, throughout Grundriss, he gives little the ways in which complexities of symptoms direct evidence of a neuro pathological basis for were to be assimilated could not be strictly ratio- any mental disorder, apart from disorders now nal, but, based on ‘long experience’, ultimately clearly part of neurology. Perhaps there is no reliant on personal authority—especially his such qualitative pathology, at a cellular level, own. Kraepelin was under the infl uence (as was such as would be understood by a competent neu- Wernicke) of the neo-Kantian revival, led by ropathologist. Abnormalities at this level which Hermann Cohen (1848–1918), dating back to the are now evident, are more likely to be subtle 1870s. Kraepelin took basic categories of Kant— quantitative departures from the norm in cellular especially ‘cognition’ and ‘emotion’ as separate make-up, which do not amount to pathology; and and irreducible faculties [106 ]—as the basis for these can then combine to produce unstable distinct disease types; but Wernicke gets closer to vicious circles in large-scale functioning of the the core of Kant’s philosophy, in emphasizing the brain. ‘Pathology’ (if that is the right word), is distinction between content and form (as did then at the level of whole-person functioning, Jaspers), but also took primary experience as the especially in social functioning, which is beyond key to the language of the natural sciences. In a person’s normal capacity for reintegration. The psychiatry, this meant symptoms, albeit used implicit defi nition of Wernicke’s term indirectly via their sensory and motor representa- Geisteskrankheit, thus becomes ‘loss of sense of tion in the brain, and supported by reasoning personal wholeness’—a non-medical concept, from neuroscience. In contrast, Kraepelin’s dis- which does not fi t within system-based ideas of orders of cognition and affect (respectively disease. The fundamental question posed is then: Dementia praecox, with its supposed characteris- Can medical paradigms assimilate disorders tic of ‘thought disorder’, and Manic-Depressive whose essence is the brain’s handling of informa- psychosis), were rooted directly in Kant’s phi- tion, and therefore in its apprehension of mean- losophy and his psychological categories, with ing? There is another huge imponderable: Had he no link to their physical basis, and thus separated lived longer, would he ever have resolved the from the common language of science. tension? … and if so, how would he have done it? Kraepelin—at least in separating Dementia prae- At this point, it is appropriate to mention dif- cox from manic depressive psychosis, and with ferences between the clinical style of Wernicke, long term outcome as a criterion—fused clinico- and that of his contemporary, Emil Kraepelin, scientifi c and administrative requirements giving who outlived him, and whose infl uence continues supposed scientifi c disease categories, while to this day. Most of the points summarized here Wernicke acknowledging that the two required have already been mentioned in other contexts, different, co-existing systems of classifi cation, and are brought together here to show the sharp criticized over-use of terms such as degeneration, contrast between the two researchers. Both and never uses the Dementia praecox concept. wanted to adopt standards and methods of gen- The categorical typology of Kraepelin, and eral medicine, to give psychiatry the status they especially the implied gloomy prognosis of thought it deserved. In L8, Wernicke asks: Is Dementia praecox undermined any attempt to 422 Editorial Commentary see mental disorders as dysfunctions at the level ened now by vocal contributions from service of personal wholeness, and any implications this users. The defi nitive answer still escapes us. might have for a clinician trying to rebuild that sense in his patients. Wernicke’s system of thought was altogether more holistic, and more XI. Wernicke’s Reasoning optimistic, not only in his approach to classifi cation, but also in his ability to make explanations XI,(a). Style of Reasoning at an individual level. We see this in his neuroscience- based concept of personal whole- Already in his fi rst lecture we sense the great care ness, where the three components of memory are with which Wernicke constructs his arguments: brought together to form a single larger entity. His word Begriffszentrum, translated as We also see it in his accepting that emotional and ‘Conceptualization Centre’, is qualifi ed as ‘sup- cognitive aspects of experience are parts of this posed’ (supponierten ), suggesting that he is set- same whole, always interacting, whether in ting up a hypothesis for later modifi cation; and health or in disorder. His holism is also seen in this is how it unfolds in L2. Sometimes he sets up his search, wherever possible for ways by which a ‘straw man’, with the intention, later, of show- different symptoms interact, one symptom often ing it up for what it is. In L3, in relation to visual taken as ‘elementary’, the root of all others, a after-images, he sets up a hypothesis, in order to style not found in Kraepelin. For him, Dementia present counter-arguments, and so gain better praecox was a disorder primarily of cognition, understanding, almost a classic reductio ad manic depressive psychosis one of mood; his absurdum argument. In addition, he often uses a work on Dementia praecox , seldom mentions style common in natural philosophy (and impor- abnormal emotions. tant for Ernst Mach), of putting forward a sce- In terms of overall style, Wernicke is impres- nario, which is not realistic, just to clarify an sive in that he attempts to bring scientifi c reason- argument. Overall, the more we have worked on ing—albeit of an unusual style—to bear on his German text, in our attempt to get the most psychiatry. He believed that neurology and psy- accurate rendition in English, the more are we chiatry were different parts of a single discipline, impressed by his attempts to use terms in his very or at least natural partners, unlike Kraepelin, who complex system of thought in a consistent way, want psychiatry to be an independent discipline. which does not blur his essential concepts. His By his faith in reasoning—and in other ways— reasoning is often subtle, but, especially in later Wernicke tried to distance himself from any per- lectures, complex, and at times hard to follow. sonal authority he might have had; nor did he For example, in L36 (p. 271), he writes of the easily accept the authority of others. Kraepelin, relationship between three concepts of melan- by contrast, both accepted authority (such as psy- cholia—hypochondriacal, depressive and chological categories of Kant), and expected that Affective. We view this as a contrast between he himself should wield such authority. Wernicke, hypochondriacal and depressive melancholia, of course did have power conferred on him by while Affective melancholia, referred to in pass- virtue of his position, but appears to have been ing, provides further explanation—but it is hard aware of his need constantly to earn it, in daily to be certain. interactions with many people. It is perhaps no In the fi rst eight lectures , Wernicke’s reasoning coincidence that, in this period, when militarism is mainly ‘psychobiological’, that is ‘cross-level was growing in Germany, involving many psy- reasoning’ as found elsewhere in the natural sci- chiatrists, Kraepelin was actively involved in ences. Specifi cally, he establishes rational links military research [5 ], while Wernicke, who cer- between, on the one hand, facts from neuroanat- tainly knew about military matters, ‘stood some- omy (the abundant long and short cortico- cortical what apart from the main stream and military connections) and from putative physiological roads of science’, according to Theodor Ziehen’s principles (modifi ability of these connections), obituary. The debate continues to this day, enliv- and on the other hand psychological facts of Editorial Commentary 423 memory, that memories of quite different types imperative that such inconsistencies should be and acquired at different times are assimilated to eradicated, all fail. He is keenly aware of the provide a somewhat integrated sense of person- anomaly in many patients, when ‘The very fact hood. In the clinical lectures, a more special and that this patient is unaware of contradictions distinctive form of reasoning becomes prominent, between his various misconceptions, suggests by which symptoms are related to each other that the combination of all higher associations (usually from ‘elementary’ to secondary symp- into a single unit, the ego, has ceased’ (L12; toms), to events in a person’s life, to habits of p. 72). However, he also suggests that use of thought acquired during education or training and explanatory delusions in a ‘corrective’ sense is employment, or to immediate social circum- important in retrospective review of psychotic stances in which a person might fi nd himself, such beliefs, especially in educated in people with as after discharge. The relationships are not mere habits of logical thought. So, in L14, we read: correlations; nor are they ‘causal’ in the sense that ‘The more that discernment can be regained or they employ known causal principles from else- has been retained during chronic psychoses, the where in science; nor are they strictly logical rela- more mental activity takes place according to tions in the usual deductive sense. The relation strict standards of logic, and the more imperative between elementary symptoms and explanatory it is to restore some semblance of order in struc- delusions is formally the reverse of normal deduc- tures brought into disarray by illness’. Again, tion, a word which Wernicke uses seldom (the when discussing mania: ‘As long as this “circum- exception in L1 being: ‘Symptoms must be spect collectedness” is not lost, secondary asso- deduced’). Thus the premise for an argument (e.g. ciations may be noticed to an intensifi ed degree, the fact of an explanatory delusional belief) fol- and yet the main association is retained. This pos- lows rather than precedes (in the patient’s mind) sibility exists particularly in highly trained minds’ the thing to be explained—an experience which is (L31, p. 216). These are good examples where primarily abnormal. So (L10, p. 60) ‘… every- life experience, work experience, or education thing is identifi ed in a reconfi gured manner to provides skills which counteract ‘mental illness’. match certain prevailing notions’. A preformed However, sometimes, a facility in reasoning hin- conclusion suggests ‘how the evidence is to seen’. ders resolution of confl icts of belief acquired dur- This style is of course common in everyday life, ing psychosis, as in the case suggested in L16, of sometimes adopted deliberately when expedient, a patient with a highly trained legal mind, who for instance when a person needs to defend them- applies his training to provide ever-more elabo- selves against charges of wrong-doing. For those rate accretions to his sense of injustice about with little experience in reasoning, and no alterna- involuntary detention. A rational habit which tive model of inference, it is quite instinctive. benefi ts one person can be devastating in another. Provision of an explanation for a new experience Some would argue that the highly individual- is initially then an exercise in imagination, only ized style of Wernicke’s reasoning reduces its later checked deductively for consistency. As scientifi c status; but it is hard to uphold such such it is similar to a creative scientist seeking an objections in the face of Wernicke’s skilled argu- explanation, a process far more complex than syl- ments, where a patient’s education, professional logistic deduction. This, of course, is the patient ’s activity, and social milieu after discharge are style. Wernicke’s reconstruction of this style is built into his understanding of how delusional genuine scientifi c reasoning, albeit of a form material arises, declines, or is subject to progres- unusual in science. sive increment or decrement. The way Wernicke formulates patients’ Wernicke occasionally uses the word ‘experi- thought process includes some fascinating elabo- ment’, but usually as Mach’s ‘thought experiment’, rations. Mainly he sees the process of delusion or as experiments conducted in animals by formation as near-normal in terms of rationality, researchers in other fi elds. In L20 (p. 129) he but, with sejunction, that rationality, that aware- describes what he actually did, to establish hyper- ness of the existence of inconsistencies, and the metamorphosis: ‘by bringing favourite sensory 424 Editorial Commentary stimuli into the vicinity of the patient: for example, eloquently, three centuries earlier, and for exactly pulling out a watch, a handkerchief, the stock mar- the same reason, in Francis Bacon’s Novum ket report, or noting how objects are casually Organum [ 66] a founding text for the natural sci- played with, to give a sense of sight …’ In L13 ences as a whole. For Wernicke, the ‘conceptual (p. 81) he writes ‘In this example, in one case only gap’, which forced him to adopt this strategy, was ideas full of anxiety, or “anxiety ideas”, as I call his ignorance of basic processes, especially the them, in the other, frightening and threatening pho- physical basis of nervous signals. nemes, that is the same ideas, but put into words. Many examples of analogies have already We can assess such experience …’ He appears to been given, some predating Wernicke, such as refer to tests which may have been carried out on those from Meynert. He refers to Meynert’s his patients, possibly word association tests. Such image of an ‘enclosed pipe system’, and in L4 tests were fi rst used by Francis Galton, and, devel- (p. 23) and L8 (p. 46) extends this to a ‘wave of oped further by Wilhelm Wundt, with reaction psychophysical motion’, citing Fechner, but time as the dependent measure. Theodor Ziehen referring to his earlier work on aphasia, in which was the fi rst to explore the method thoroughly in a succession of associations is described as ‘a 1898 [147 ], and it was from him that C.G. Jung wave motion in an enclosed pipe system’. learned the method to use on his patients at the Sometimes analogies are drawn from his earlier Burghölzli Mental Asylum in early years of the works, as when (LI) he draws the analogy twentieth century [148 ]. It is thus plausible to between nonsensical speech in psychiatric suggest that Wernicke also used the method in patients, and transcortical aphasia, a concept some form. In any case the idea of innocuous already defi ned; and when in (L4) he points out experiments to test hypotheses about motives or the similarity in forming perceptions from sen- cognitive strategies used by individuals was elab- sation, as for concepts from percepts. Sometimes orated further in later years by ethologists and analogies come by broadening the meaning of child psychologists such as Jean Piaget, and accepted terms, as when he clarifi es the notion of Nikolaas Tinbergen. the Conceptualization Centre (L2): He refers to Wernicke cites exact quantitative data only inputs to it, using the word versinnlich , usually once (L37, p. 288 seq. ), Meynert’s rather than his translated as ‘sensual’, although the situation is own, on brain weights in various patient groups. strictly neither sensual, nor sensory. He implies He claims that the data for progressive paralysis that a person’s understanding (of a question just show greater proportionate loss in frontal composed) becomes a quasi-‘sensory’ input to subse- pared to other regions. The values presented hardly quent stages of processing, where formulation of prove this in males, where the percentage losses in the answer occurs. frontal, temporal, and occipital lobes are 16 %, The boldest and most far-reaching analogies 14 %, and 11 %, respectively; and in females do so are usually based on recent advances in other only in so far as the temporal lobe in paralytics areas of science, a recurring feature in Grundriss . loses 5 % of the weight of the comparison group, The fi rst example is in L1, when, to clarify the compared to 20 % and 15 % losses in frontal and indirectness of relay between cortical regions, he occipital lobes. Variance is not reported, this being refers, to telegraphy. Presumably he referred to before the days of statistical analysis. cables and Morse code, not radio-telegraphy— ‘wireless’—since it was only in 1894 that Nicola Tesla fi rst demonstrated the ‘wireless’ principle, XI,(b). Reasoning by Analogy and the fi rst commercial system of radio transmission, patented by Guglielmo Marconi, was not in It has been pointed out already that, when trying use until 1906. Electrical metaphors (‘resistance’ to understand a new fi eld, reasoning by analogy, in L19 and L30; ‘short-circuit’ in L20, p. 131) despite its shortcomings, is often the only way occur periodically. In L4 and L8, and often there- forwards. Exactly the same style is found, most after, he refers to a physicist’s graphical display Editorial Commentary 425 on rectangular coordinates, to depict interaction physics (‘energy per unit mass’ or ‘energy den- of two interdependent psychological variables. In sity’). In developing the sejunction hypothesis in L4 these are ‘strength’ (or ‘intensity’) and ‘extent’ L12, he mixes several analogies, in part mechani- (or ‘circumference’). In L8, they are the ‘level’ cal, hydraulic and electrical, including reference and ‘extension’ of consciousness, the former also to ‘resistance’ (L20, p. 126). He invokes localiza- expressed as intensity of excitation or activation tion of function far beyond any empirical evi- by a stimulus. The word ‘extent’ is often replaced dence; and uses the concept of energy less in our translation by ‘range’. precisely than as the robust physical variable we The most prevalent physical analogy is the now know. In phrases such as ‘build up of ner- concept of energy (Kraft ). Originally this term vous energy’ he seems to draw on the concept of was akin to ‘life force’, a metaphor often used by conservation of energy. He may also have drawn scientists or philosophers (J.F.Herbart, Fechner, on the fact that novel events force themselves on Helmholtz) in nineteenth century German us with unusual vigour if suppressed (as he psychology, and by Sigmund Freud in psychia- argues in L8, p. 46, when describing how a miller try. The scientifi c concept of energy emerged is awakened from sleep when machinery in his slowly from this, and in mid-nineteenth century, mill stops its steady grind). Inevitably, inferences various forms of physical energy were unifi ed in are made about underlying physical processes, the fi eld of thermodynamics. The fi rst use of which lacked any empirical support. Kraft in Grundriss is in L2, where the word iden- Sometimes analogies lead to serious errors, tifi es potentialities latent in any stored memory and, from today’s perspective it is easy to see (and again in L8). In L30 (p. 206) we read of mistakes from undue reliance on analogies. ‘necessary expenditure of energy’. ‘Potential Memories are not ‘stores of energy’; discharge of energy’ is specifi c term, coined in the nineteenth nervous activity along associative links does not century by the Scottish physicist William ‘drain away’ anything; failure of such discharge Rankine. Its use in L8, draws a conscious anal- does not lead to ‘build up’ of energy (the sup- ogy with the physicist’s concept, where Wernicke posed ‘irritant’ for symptoms such as hallucina- refers (p. 46) to there being ‘only a certain store tions). Often he draws analogies between of “life force” available in the brain for psycho- neurology and psychiatry, which turn out to be physical movement’; and in L32 (p. 223) his false. So, in L11 (p. 67) he writes: ‘We can fairly words (our translation) are: ‘all her energy has equate residual alteration in content as a local- been quite used up’. These phrases hint at a con- ized process, with changes in content when psy- servation law for (psychic) energy, as did Freud’s choses progress slowly’, implying that changed hydraulic metaphor. Conservation of energy is a content of consciousness (like focal brain injury) concept with a long history, but had been formu- is irreversible, an error based on his choice of lated concisely within living memory by analogy. In his analogy between progressive Helmholtz. It is no coincidence that Ernst Mach paralysis and other psychoses (L37, p. 280), we had also published in 1872 a book entitled now know that the pathological change in the for- History and Roots of the Principle of Conservation mer is greater than ever documented in endoge- of Energy [149 ] (strictly ‘conservation of work’: nous psychoses. Sometimes, in use of analogy, Erhaltung der Arbeit ). Modern concepts of fi xed close juxtaposition of error and visionary fore- limits to ‘processing resources’ for attention have sight is startling. In L20 (p. 126) the ‘specifi c similar implications. energy’ metaphor is used to point to the intrinsic Sometimes Wernicke takes physical analogies holism of the entire associative machine, a meta- too far: In L11 (p. 66) the term ‘specifi c ener- phor which may seem strange to us today; but gies’, like ‘potential energy’, is adopted from then he mixes this with the metaphor of ‘reso- thermodynamics, but its meaning—‘specifi c’ in nance’. Use of this analogy is astonishing because so far as it is linked with specifi c patterns of it was 30 years before any reliable method of information—is quite different from its use in recording the EEG was available. 426 Editorial Commentary

Errors in inference by analogy are not fl aws in rea- Unidentifi ed assumptions ; inconsistency in using soning: They are expected in this style of inference, assumptions: In L4, Wernicke discusses the num- to be recognized and, in due course, corrected. ber of concepts we might have in our heads, and However, conclusions based on analogies should writes ‘The number of words gives us a clue to the never be given credence greater than at the time of number of concepts’: Of course there is a fl aw: Any their origin. The concept of ‘mental illness’, as analo- word (perhaps more so in English than German) gous to illnesses of general medicine is a case in has a variety of uses: Many words are ambiguous point. Is it an appropriate? Is it given greater credence until the context is specifi ed. The claim that than it deserves? Does it survive just on the basis of Shakespeare used an unmatched variety of differ- habitual use? These questions need to be posed. ent words is commonly made, but has been ques- Throughout Grundriss , we see Wernicke tioned. Studies using modern methods do not fi nd searching for simplicity and symmetry, but Shakespeare’s vocabulary exceptional, compared sometimes, in hindsight it is simplistic. As already to many other eminent writers. In developing the argued, the implied symmetry of the three-way sejunction theory, an assumption is implied which split of contents of consciousness, is inexact. He is inconsistent with one made later in Grundriss. also implies symmetry between melancholia and Thus, in L13, ‘sejunction’ is seen to involve build- mania, opposite sides of the same coin, namely up and ‘back- propagation’ of energy along for- excessive ease or impairment in exercising ‘will’. wardly projecting pathways from primary sensory However, the underlying mechanisms, even as areas to higher areas, as if there are no direct path- analyzed by Wernicke, are not opposites of one ways in the opposite direction; but as early as L6 another, and modern research would show this (and in L19; p. 124), it is clear that concepts (espe- more clearly; so, there is no true symmetry. cially that of ‘corporeality’) are elaborated through associative interconnections with ‘perception cells’, implying (as we now know) that primary XI,(c). Flaws in Wernicke’s Reasoning sensory areas receive inputs from higher cortical areas, distant in forward-projecting connectional Hindsight, it is said, is a wonderful thing. With terms from primary sensory areas. The inconsis- the benefi t of 120 years’ hindsight, it is easy to tency reveals the struggle in Wernicke’s mind to fi nd fl aws in Wernicke’s reasoning. The same can explain hallucinations, and the incompleteness of be said of those intrepid pioneers, the fi rst who his system. Another inconsistency is his assump- had the temerity to venture into terra incognita , tion about inhibitory interactions in the ‘organ of by attempting to bring Reason to bear on Nature. association’ (implicitly the cerebral cortex). In L8 Johannes Kepler, for instance, was one such pio- he states his belief that there are only excitatory neer, and, despite great achievements, could interactions between neurones, but very soon, and resort to ‘mystical numerology’, supposing there in later lectures implies inhibitory interaction (see to be simple whole-number ratios between dissection VII,(a). ‘Wernicke’s Contribution to tances of different planets from the sun. Here he Neuroscience, Psychology and Overall Medical followed the precedent of Pythagoras, who found Knowledge’, Basic neuroscience ). that simple whole-number ratios of lengths of vibrating strings produced harmonious musical Confusion of neuronal with psychological lan- intervals; and he was followed by John Dalton, guage: Wernicke often jumps too easily between whose successful hunch along similar lines was biological (neuronal) statements and psychological critical in the reasoning supporting his atomic ones, as if they were the same. Philosophers might hypothesis; yet in this Kepler was incorrect. The call this a ‘category error’: It is also another way in following comments are therefore offered, with which analogies lead to errors. An example is where full awareness that, with Wernicke, we deal with he writes (L14, p. 85) that ‘… breakdown of ner- another intrepid pioneer. Some fl aws we identify vous structure, a change occurring at a defi nite loca- are small details, others more profound and far tion, leads to signs of defi cit, with no possibility of reaching, and some quite subtle. recovery …It seems that dissolution of associations Editorial Commentary 427 in some circumstances is equivalent to destruction care, and restoring proper nutrition. There is no of certain psychological units’: This paragraph has indication that Wernicke adopted treatments obvious ambiguity, over whether defi cits referred to which were innovative, beyond high quality in are primarily in physical (nervous) structure or in this area, and his personal attention. Some sup- psychological (information) structure. Nevertheless, posedly specifi c treatments were hang-overs in his comparison of the views of Meynert and from days when medicine had no pretentions to a Neumann on hallucinations (p. 123) and the way he scientifi c basis. The few available medicines uses the word ‘pathology’ (never ‘psychopathol- aimed to alleviate immediate symptoms and ogy’) he shows a keen awareness of this very issue. ensure good sleep rather than address fundamental issues. The history of medicines in psychiatry Overinclusiveness : Sometimes Wernicke’s argu- in this period is reviewed by Healy [150 ]. ments are based on supposed areas with specifi ed Of the few medicines used in mental hospitals, functions, supposed pathways, or supposed lesions, several were herbal. Most often mentioned in without anatomical or pathological proof. This Grundriss is opium, used in various contexts, style is common in today’s clinical neuroscience, without prescription, and not mainly for pain and is criticized by purists. In truth, it is hard to relief. It appears to have been widely used in late avoid, but best taken as ‘hypotheses to be explored’ nineteenth century Germany for disorders of not as known facts or conclusions based on secure mood, anxiety, or the two combined [ 150 , 151 ], deduction. Imaginative construction of explanatory and in L23 (p. 149) its use in anxiety psychosis is hypothesis is part of Wernicke’s style, as it is in the mentioned. Such treatment may not have been natural philosophy tradition. The concept of ‘motil- complication-free: Thus, in L25 (p. 305) we read ity’, an abstract noun related to ‘movement’, is also ‘A strict bed regime must then be imposed, to extended in ways some might call overinclusive ensure adequate sleep and nutrition, and to combat (such as the pressure to speak), although his ratio- occasional fi ts of anxiety induced by opium’. nale is made clear in suitable places. Again, in L35 (p. 262), in a case of ‘severe loss of intrapsychic function along with hypochondriacal Failure to Separate Deductive from Inductive symptoms’, we read: ‘At times of remission, or Inference: This has been referred to several times with a favourable response to a medication such as already, along with the idea that what Wernicke opium, you may hear from patients that they feel claims to be missing in some of his patients is a too ill to think, or speak or to do anything.’ In L32 faculty which—in truth—most people never had. (p. 234) we read: ‘Use of narcotics in hyperkinetic The supposed lost ability is closely related to one motility psychoses is generally contraindicated’. of the classical ‘laws of thought’—the Principle of Modern support for this statement is that, in Non-contradiction—going back as far as Aristotle, Tourette’s syndrome, opioid agonists, far from and formalized in Russell and Whitehead’s alleviating symptoms, may exacerbate them [152 ] Principia Mathematica , published 4 years after the and opiate antagonists may be effective treatment 1906 edition of Grundriss. Wernicke—logician [ 153]. For ‘restless legs syndrome’, a condition to that he was—may have regarded this principle as which some patients in L32 may correspond, they more of a universal human norm than it actually is. may be effective treatment [154 ]. Another product originally extracted from plants (now manufactured synthetically) was XII. Treatments and Medical camphor. Its medicinal use was mainly by exter- Technology of the Day nal application to the skin, but it was used in small doses orally to strengthen the heart, during Specifi c treatments for any disorder were very heart failure (L26, p. 173). Hyoscine (scopol- limited in Wernicke’s day; rational chemotherapy amine), an alkaloid extracted from henbane, and of any disorder was some way in the future. For a muscarinic antagonist, was used from mid- mental disorders the best that could be offered nineteenth century, with both sedative and eupho- was often little more than high quality nursing riant properties. It is mentioned in L23 (p. 149) 428 Editorial Commentary for treating anxiety psychosis (in combination Kast (1856–1903), worked at Breslau from 1892. with opium), and recommended doses are given. It is now known to have neuronal inhibitory In L32 (pp. 223, 225) it is recommended for actions, related to GABA. There is no mention of treating hyperkinetic disorders, and as a sedative any overall drug treatment for psychoses as in patients with such disorders. It is not men- understood either by Wernicke or in today’s con- tioned as treatment for melancholia (nor is any cept, but a combination of opium and hyoscine medication recommended for this condition). was probably used widely, since we also read in This is noteworthy, since one of today’s hypoth- L23 (p. 150): ‘Incidentally, treatment of anxiety eses for depression is based on overactivity of psychoses gives outcomes just the same as those muscarininc cholinergic systems, and anticholin- for psychoses generally’. ergics are effective in some cases of depression. Treatment of syphilis is mentioned in L37 Amongst synthetic products, bromide , intro- (p. 287). For centuries this had made use of mer- duced in the 1860s, was used as a sedative and cury, applied externally to lesions. From 1843 sleeping draught (L28, p. 192) [155 ]. Bromide potassium iodide by mouth was introduced, com- overdose has toxic effects, but there is no mention bined with mercury. That Wernicke recom- of this in Grundriss . However, in L34 (p. 246) we mended it for paralytic psychoses, which he read: ‘Stress and many sleeping drugs were given differentiated from cerebral syphilis, indicates as the cause of the illness’. Then as now, hazards the unresolved relationship between the two dis- of regular use of sleeping pills seem to have been orders in his thinking. No other treatment was well known. Amyl hydrate is a product mentioned available until salvarsan was introduced in 1910, in L20 (p. 134), as having an ‘immediate calming which also was relatively ineffective. effect’ in relation to psychosis with epilepsy. This Other biological or physical treatments are may have been amyl alcohol, which, although a mentioned. Magnetic cures, mentioned in L29 natural product of fermentation, was being pro- (p. 199) had a long history, and a century earlier duced industrially at the time, and was used as a in Europe had been popularized by Anton sedative and anaesthetic between 1880 and 1950. Mesmer (1734–1815). They were still recom- Amyl hydrate also has properties as a vasodilator. mended in some medical textbooks in Wernicke’s Paraldehyde was fi rst synthesized in 1829 by day for mental disorders, convulsions, insomnia, Wildenbusch and introduced into medical prac- migraine, fatigue or arthritis [ 157 ]. In L10 (p. 60) tice in 1882, by Vincenzo Cervello, as a central we hear of ‘“vaporization” of chloroform and the depressant. It was found to be anticonvulsant as “electrical treatment”’: Chloroform and various well as sedative, and is administered in various means of electrical stimulation were used in asy- ways. It is mentioned in L25 (p. 167); and in L26 lums in many countries in the late nineteenth cen- (p. 176) recommendations on dose as a hypnotic tury. Electrical stimulation in neurology clinics is are given which correspond well to modern rec- also mentioned in L27 (p. 182), it being used ommendations, according to Medsafe, New widely in both Europe and Britain in the second Zealand [156 ]. In L25 (p. 166) there is mention of half of the nineteenth century [158 ]. Use of Phenacetin , fi rst synthesized in the USA, and leeches to initiate menstruation went back long chemically related to paracetamol (its metabo- before Wernicke’s day, but was still apparently in lite). It was introduced clinically in 1887, as a use (L32, p. 234). non-opioid analgesic, and fever-reducing drug, Medical technology was very basic. ‘Infusion’ but was banned by the FDA in the USA in 1983, is mentioned in L24 (p. 155), but it is not clear because of evidence of serious side effects. what is meant. Intravenous injection was a diffi - Trional , mentioned in L29 (p. 197) was fi rst pre- cult procedure at the time, being favoured just for pared in 1888, and introduced clinically in the some medicines, and into the fi rst decade of the same year, as a sedative and hypnotic. The chem- twentieth century, at which time it was still a sur- ist behind this was Eugen Baumann (1846–1896), gical procedure. In L32, (p. 223) we read of and the specialist in internal medicine, Alfred ‘injection of hyoscine and morphine’ as a sleeping Editorial Commentary 429 draught for a hyperkinetic patient who would not loss of fi bres [in progressive paralysis] has now stop singing. This was a subcutaneous injection been proved to be a systematic loss, correspond- (L23, p. 150; L32, p. 235), which was easier ing to secondary degeneration; and Lissauer also [159 ]. In L26 (p. 174) Papilla nervi optici is men- succeeded in demonstrating the source of this tioned, no doubt visualized by ophthalmoscopy. secondary generation in the destruction of entire The ophthalmoscope was invented in 1851 by cell layers, in certain cases’. A later examination von Helmholtz (although some say primacy goes of neuropathology in cases of progressive paraly- to Charles Babbage, 4 years earlier). Its design sis [ 161 ], discusses the original fi ndings and sub- underwent improvement after Wernicke’s death. sequent ones, concluding that the pathology can There is little on any psychological approach be attributed to a variety of factors, not directly to treatment in Grundriss , and nothing compara- related to the spirochete. ble to any form of psychotherapy. However, in L30, there is detailed guidance, on the sort of Defi ned neurological disorders: ‘Visual agnosia’ nursing care most conductive to recovery from (fi rst mentioned in L3, p. 16) was originally Affective melancholia, along lines which follow defi ned by Lissauer. Wernicke mentions it in easily from the concept of this disorder Wernicke cases of polyneuritic psychosis (Wernicke- describes. Likewise in L32 (p. 233; also L20, Korsakoff syndrome) (L38, p. 295). Modern evi- p. 130) he writes ‘If sources of hypermetamor- dence shows that visual problems can occur in phosis are removed by seclusion of patients, such thiamine defi ciency, albeit rarely (e.g. [162 ]), and motor impulses subside quite predictably’: Today, that this is also associated with widespread corti- in good mental health facilities, the corresponding cal damage [163 ]. strategy is to use rooms specially designed to limit In L30 (p. 208) Wernicke comments on the all kinds of sensory stimulation. Wernicke also high prevalence of seizures in cases of melancho- gives his views on indications and contraindica- lia. This is echoed in today’s research literature tions for using seclusion (L41, p. 324). [164 – 169] the likelihood being that there are causal components in common between the two disorders rather than seizures being either cause XIII. Update on Scientifi c Issues Raised or consequence of melancholia or depression. There may be atypical features to depression In preceding sections there has already been dis- when the two occur together. The relationship is cussion of some scientifi c issues raised by hard to defi ne precisely because ‘seizures’ may Wernicke, in the light of modern research fi nd- be non-epileptic, and when they are epileptic, it ings. Here we summarize modern views on fur- is at present unclear which, of many types of epi- ther issues raised in Grundriss . lepsy collected under the single term, is involved. Wernicke’s comment (L29, p. 200) that com- Neuroanatomy: The number of nerve cells in the pulsive acts are more common at time of men- cortex (L4, p. 22) was ‘about a milliarde , by struation has modern support: Both motor Meynert’s count’ (about one billion). Modern compulsions (‘tics’) and obsessive thoughts are estimates put the fi gure much higher—19 and 23 known to increase in the premenstrual period in billion (mean fi gures for female and male respec- some patients with OCD or Tourette’s syndrome tively, with large individual variation: [160 ]). [ 170 , 171 ]. Neuropathology is mentioned occasionally in Grundriss. The neuropathology of progressive Symptomatology: Although Wernicke knew little paralysis is mentioned in several places, and of the principle of psychological reinforcement, Wernicke makes very bold conjectures in L7, he makes an interesting point in this context (L8, where he suggests that there is pathology in an p. 49) that ‘all more complex processes of associ- outer lamina of the cerebral cortex. In L41 ation—“mental processes” as we called them— (p. 326) we read: ‘As Lissauer has shown, this are accompanied by a moderate degree of Affect’, 430 Editorial Commentary and again ‘mental activity is usually associated mechanism is a general lowering of neuronal with a slight degree of Affect.’ He writes: activation threshold, so increasing the ease with ‘Whatever is conducive to consciousness of per- which threshold is reached, this being a dynamic sonhood—the Ego—evokes a pleasant state of shift, spread across the whole of the cortex, but mind; whatever is harmful to it, evokes an unpleas- without new learning. That for the second style of ant state of mind.’ This might be questioned, delusion formation may be dopaminergic excess, since unpleasant emotion—such as ‘shame’— acting in the basal ganglia to shape beliefs in a may involve intense consciousness of personhood. more fundamental way. Nonetheless, the notion conveyed, especially in In L30 (p. 208) Wernicke takes failure of the fi rst quotation, is that the very act of associa- imagery, or of imagination, as equivalent to a tion is itself subjectively attractive, perhaps wider failure of association, possibly a subjective because ‘things start to make sense’. This idea has manifestation of the very process of sejunction. a long history, from St Augustine’s ‘Eros of the However, imagery and association are not identi- Mind’, through Alfred North Whitehead’s [ 172 ] cal. Modern literature, based on ‘semantic prim- fi rst stage of learning (‘Romantic emotion is ing’ methods fail to fi nd any abnormality in the essentially the excitement consequent on the tran- process of association in major depressive disor- sition from the bare facts to the fi rst realizations of der [ 173 – 175 ]. A non-tachistoscopic method the import of their unexplored relationships’). (‘spreading activation’) suggests that students In terms of symptoms, Wernicke also writes scoring high on a depression scale have freer the following on mania (L31, p. 216): ‘… every- access to a wider range of associated words than thing seems just as easy for a person who is controls [176 ]. However, with regard to reduced manic as it is hard for one who is melancholic’. imagery in depressed patients, Wernicke is sup- An assumption here is that free association is ported by two modern studies [ 177 , 178 ]. rewarding (reinforcing); but the implication is Curiously, in modern literature, it is in schizo- that overactive reward is a consequence , not the phrenia as diagnosed, where increased associa- cause of fl ight of ideas, a point of relevance to tion is found, at least with the semantic priming today’s dopamine hypothesis of schizophrenia method, along with reduced cognitive inhibition (or ‘of psychosis’). I also have used the idea, in documented in various ways [103 ] both of which that to construct an explanation is itself a rein- would lead to excesses of association. In euthy- forcement ([103 ]; p. 86). If, in addition, rein- mic bipolar disorder, there are few studies, but forcement itself can encourage some type of one shows no abnormality in the semantic prim- association, a positive feedback loop is closed, so ing task [179 ] and another shows reduced prim- that mania would then progressively accelerate. ing [180 ], while yet another [181 ] investigating In L31 (p. 216) Wernicke also writes ‘… such cognitive inhibition produced evidence of reduc- manifestations of grandiosity usually remain tion which was rather equivocal. In mania itself within limits not far removed from what is pos- there are no such studies, presumably because of sible, or which are manifest only conditionally, as the practical diffi culties of the experiment. opinions and expectations, or which are expressed ironically, as though the patient were joking, and Defi ned mental disorders: In L34 (p. 256) indulging in “make-believe”’. That is, the full Wernicke comments on the prevalence of motility veracity of belief is not recruited, suggesting its psychosis as a function of age and gender: The origin is not overactive reinforcement. Pierre comparison with Kraepelin’s Dementia praecox Janet, about the same time, thought that much has to be made, and clearly, the young age of onset psychotic thought was akin to ‘play acting’ ([16 ]; is a point of similarity; but from what we now p. 218). On the other hand, some delusions appear know about schizophrenia—the concept derived to be backed by the full force of belief. There is from Dementia praecox—it tends to occur more an important issue here, with implications for commonly in young males than females of similar diagnosis as well as treatment. Possibly the fi rst age, in contrast to Wernicke’s statement. Editorial Commentary 431

Modern research has rarely compared herita- of Emil Kraepelin. In 1906, a patient he had been bility of melancholia or depressive disorders studying died and her brain was subjected to between adolescent and adult illness, but when it analysis using the Nissl’s silver staining method. has [182 , 183 ] results confi rm Wernicke’s state- This was the fi rst documented case of what ment (L30, p. 213) that the childhood variety is became known as Alzheimer’s disease. Alzheimer more strongly heritable. Modern evidence also was appointed professor at the University of supports Wernicke’s view that bipolar disorder Breslau in 1912, but died 3 years later, probably has a stronger genetic basis than unipolar depres- as a result of rheumatic heart disease (L41, sion (L31, p. 219); and that obsessive disorders, p. 328). or at least some of their forms of it, are also Oskar Berger (1844–1885), studied at Breslau, strongly inherited, (L29, p. 201; L38, p. 297) in Berlin, and Vienna, a student of Griesinger, a common with Tourette’s syndrome [ 184 ]. neuropathologist, and an expert on electrotherapy Wernicke also makes a more general comment (L29, p. 200). (L38, p. 294): ‘I want to make just one point here, Jules Gabriel François Baillarger (1809– that I still do not fi nd suffi ciently emphasized: 1890), a French neurologist and psychiatrist, stu- that a strong hereditary predisposition may be dent of Esquirol, the fi rst to describe the layered present without its ever leading to acute or a structure of the cerebral cortex, and as a psychia- chronic psychosis’. This fact is fi rmly supported trist, continued Esquirol’s analysis of hallucina- today: Risk of psychotic disorders in those with tions (L31, p. 220). familial loading for psychosis, although elevated Otto Ludwig Binswanger (1852–1929), a compared to the general population, is still quite Swiss psychiatrist and neurologist. After studies small. Following through from this, eugenic mea- at Heidelberg, Strasburg, and Zurich, he worked sures such as were soon to be deployed were at a psychiatric clinic in Göttingen, and in 1880 unlikely to reduce the prevalence of such weakly worked under Karl Westphal in at Charité heritable disorders. Hospital Berlin (at which time Wernicke was also In L38 (p. 296) Wernicke refers to psychoses working in Berlin). From 1882 to 1919 he held a in users of cocaine and morphine. In modern lit- chair in psychology at the University of Jena. His erature, paranoid psychosis induced by cocaine is publications include studies of epilepsy (on well-known, but almost completely unknown for which he wrote a textbook), neurasthenia and morphine; and there is no evidence of any hysteria, and included research on neuropathol- enhancement of the psychotogenic effect when ogy (L37, p. 291). morphine is added to cocaine. Clearly, what he Paul Broca (1824–1880), a French physician, saw was cocaine-induced paranoid psychosis. surgeon, and anatomist, the fi rst, in 1861, to describe a relationship of a specifi c psychic function and a specifi c cortical region (‘Broca’s area’ XIV. Historical Context in the left frontal lobe). As a neuroanatomist he contributed to defi ning what is now known as the XIV,(a). Identifi ed Researchers or ‘limbic lobe’ (L37, p. 291). Clinicians Jean Martin Charcot (1825–1893), a French pioneering neurologist and neuropathologist, stu- These profi les include most of the researchers dent of Duchenne, and founder of the neurology cited by Wernicke, but for some (usually doctoral clinic at Hôpital de la Salpêtrière, in Paris. Apart theses) details were unobtainable. To this list can from defi ning many neurological syndromes, he be added profi les of some of Wernicke’s own stu- was one of the fi rst academic physicians to take dents (included in section IV: Wernicke’s seriously the phenomenon of hypnotism, leading Personal Style etc). to the incorporation of dynamic psychiatry into Alois Alzheimer (1864–1915), a Bavarian mainstream medicine (L7, p. 40; L22, p. 142; psychiatrist and neuropathologist, and colleague L35, pp. 264, 265). 432 Editorial Commentary

Julius F Cohnheim (1838–1884), a patholo- and with a great infl uence, which spread far gist, fi rst to show that accumulation of pus was beyond psychology. Educated in what is now due to migration of white blood cells. He worked western Poland, he studied medicine in Dresden at Breslau from 1872 to 1878, later at Leipzig, and Leipzig (where he spent most of his life). At and would have been known to Wernicke (L7, an early stage in his career he held a professor- p. 41; L36, p. 273). ship in physics, but resigned this after he devel- August Cramer (1860–1912), published, in oped an eye disorder. His scientifi c contributions 1889, the fi rst description of proprioceptive and are many and varied, but he is perhaps best known kinesthetic hallucinations (L11, p. 69; L13, p. 83; for formulating what is now called the ‘Weber- L28, p. 201; L34, p. 251; L41, p. 326). Fechner law’, based on ‘just noticeable differ- Duchenne de Boulogne—often referred to as ences’ which allows subjective sensation to be ‘Duchenne’—Guillaume-Benjamin Amand studied quantitatively. In philosophical terms he Duchenne (de Boulogne) (1806–1875), a pio- espoused a rigorous version of psychophysical neer and, arguably, the founder of neurology parallelism (L8, p. 46). in post-revolutionary France (L5, p. 28; L6, Auguste Forel (1848–1931), a Swiss neuro- p. 33). anatomist and psychiatrist, acknowledged by Hermann Emminghaus (1845–1904), a Cajal as one of the contributors to the neurone German psychiatrist, studied at Göttingen and theory. As professor of psychiatry, he ran the Jena, and worked later at Würzburg, before tak- Burghölzli asylum (established in 1870) for 20 ing up in 1886 the chair in psychiatry at the years. His writings include works on sexology, University of Dorpat (then ‘East Prussia’; now and on the biology of ants. Attention has also Tartu, in Estonia), in which position he was to be recently been drawn to the fact that eugenic succeeded by Emil Kraepelin. He is best known ideas pervaded much of his work [ 50 ], but he for his writings on psychopathology (L1, p. 4; had abandoned such ideas, and, in 1920, became L28, p. 185; L40, p. 314; L41, p. 326). a member of the Bahá'í Faith (which originated Jean-Étienne Esquirol (1772–1840), a pioneer in mid-nineteenth century in Persia) (L28, of psychiatry in France, a pupil of and successor p. 190 seq. ). to Philippe Pinel, at Hôpital de la Salpêtrière , in Carl Samuel Freund (1862–1932), a German Paris (L19, p. 117). psychiatrist and neurologist, born in Breslau, and Sigismund Exner (1846–1926), an Austrian studied medicine there and in Zürich, and later physiologist, best known for work on compara- with Westphal in Berlin and Charcot in Paris. tive psychology, and on perceptual psychology Later, In Breslau, he became chair of the (especially of colour), and structure of the visual Psychiatrische-neurologische Vereinigung. cortex (L37, p. 289). Married the sister of Fitz Haber, Nobel laureate Jean Pierre Falret (1794–1870), a French psy- in Chemistry (L7, p. 40). chiatrist, a disciple of Pinel and Esquirol, is best Gustav Fritsch (1838–1927), a neuroanato- known for the concept of folie circulaire . A strict mist and physiologist, who studied natural sci- philosophical dualist, he believed that mental ill- ence and medicine at Berlin, Breslau, and ness rose from an abnormal interaction between Heidelberg. With Edouard Hitzig (see below) he body and soul. He was also the fi rst to suggest a is best known for pioneering use of electrical principle adopted by Kraepelin, that the course of stimulation of the exposed cortex of unanaesthe- an illness was useful in delineating psychiatric tized dogs, which helped establish the principle entities: ‘for… the idea of a natural course of ill- of cerebral localization of function. The publica- ness that can be foreseen presupposes the exis- tion on this in 1870 also included ablation of the tence of a natural kind of disease’ [185 ] (L31, same cortical regions, as mentioned in L40 p. 220). (p. 320). Gustav Fechner (1801–1887), a philosopher, Sigbert Josef Maria Ganser (1853–1931), a physicist, pioneer of experimental psychology, German psychiatrist, and a neuroanatomist who Editorial Commentary 433 assisted Bernhard von Gudden in Munich. He is frequent phenomena of sane life than they are. In best known for work on a hysterical disorder order to escape these diffi culties, Hagen refers to (Ganser syndrome, now seen as a dissociative ‘subcortical sensory centres’ as the seat of hallu- disorder, originally described in prisoners— cination [187 , 188]. Tamburini [ 189 ] writes: sometimes called ‘prison psychosis’) (L39, ‘according to Hagen all peripheral stimuli arriv- p. 301). ing at the sensory centres are immediately Friedrick Goltz (1834–1902). In the experi- diverted to two destinations: the ideational cen- ment referred to in L34, reported in 1869, Goltz tres (where they will generate images in con- took two frogs, decapitated one and blinded the sciousness) and back to the periphery (by the other to prevent any voluntary motions that principle of external projection). Stimuli gener- might arise from visual sense. He placed both ated in the brain sites themselves would suffer animals in a vessel of water and gradually raised the same fate, thereby giving rise to apparent per- the temperature. Both frogs kept quiet until the ceptions’ (L19, p. 123). temperature rose to 25 °C; at this point the frog Ewald Hecker (1843–1909), a German psy- whose brain was uninjured showed signs of dis- chiatrist, a student and collaborator of Kahlbaum. comfort; and as heat increased, tried to escape, Together they challenged the idea of a ‘unitary and died at 42 ° C. During this entire time the psychosis’, and constructed their own system for other frog sat perfectly still, and gave no evi- classifying mental disorders (L38, p. 303; L41, dences of distress or pain, and did not die until p. 320). temperature reached 50 °C. The experiment was Hermann Ludwig Ferdinand von Helmholtz purported to prove that the brain itself was (1821–1894): Born at Potsdam, near Berlin, he needed for conscious sensation, a conclusion initially trained in physiology (and might have which, needless to say, aroused much subsequent become a medical student). Later he held various debate (L34, p. 250). academic posts—at Königsberg, Bonn, William Richard Gowers (1845–1915), a Heidelberg, and then professor of physiology at British neurologist, the most outstanding of his the University of Berlin. His scientifi c contribu- time. He is the only British physician mentioned tions included both physical sciences (mechan- in Grundriss , for his method of measuring blood ics, conservation of energy, acoustics, haemoglobin (L27, p. 181). electromagnetism) and physiology and neurosci- Wilhelm Griesinger (1817–1868), born in ence (sensory physiology, nerve conduction, Stuttgart, studied medicine at Zürich. Later he ophthalmic optics) (L1, p. 6). was professor of medicine in Tübingen, helped in Heinrich Ewald Hering (1866–1948), best planning the Burghölzli Mental Asylum in Zürich. known for defi ning respiratory refl exes control- He was a reformer for asylums of the day, believed ling inspiration and expiration (L35, note). in integration of former patients back into society, Johann Otto Leonhard Heubner (1843–1926), supported the ‘Somatiker’ viewpoint and opposed a pioneer of paediatrics (and director of the chil- the ‘Psychiker’ school of thought (L1, p. 4; L8, dren’s clinic at the Charité Hospital in Berlin). p. 83; L17, pp. 103, 105 seq.; L18, p. 113; L28, He was also an expert on infectious disease, and p. 185; L30, p. 204; L38, p. 294; L41, p. 326). one of the fi rst to use the newly prepared diphthe- Friederich Wilhelm Hagen (1814–1888), a ria antitoxin in his practise. Co-author of German pioneer of psychopathology, who, Handbook of Acute Infections (1874). Referred amongst other achievements, developed the con- to, in context of ‘luetic infections’ in L37 (p. 262). cept of ‘delusional mood’. On hallucinations, in Hirth, CGLO. Biographical details not located. 1897s, Edmund Parish [186 ] wrote of Hagen’s A paper of his is cited (L20, p. 126) on older con- ideas, as follows: ‘If an energetic ideational stim- cept of ‘epigenesis’ (see section ‘Terminology’). ulus could arouse a corresponding activity in the Edouard Hitzig (1839–1907), a neurologist sensory centres, hallucinations, and especially and psychiatrist, studied medicine at Würzburg voluntary hallucinations, would be much more and Berlin. He is well known for experiments at 434 Editorial Commentary

Berlin with Gustav Fritsch (above) and later Emil Kraepelin (1856–1926) studied medi- became director of the Burghölzli asylum in cine at Leipzig (and neuropathology under Paul Zürich, and later became professor at Halle until Flechsig, and experimental psychology under he retired in 1903 (L40, p. 320). Wilhelm Wundt), and also at Würzburg. In 1883 Adolf Jarisch (1850–1902), an Austrian der- he published the fi rst edition of his textbook on matologist, and a specialist in syphilis, cited in psychiatry. In 1886, he was appointed to the chair L3 (p. 16) as an early researcher into modifi abil- of psychiatry at the University of Dorpat (Tartu, ity of spinal refl exes as a result of repetitive present-day Estonia), and was later head of psy- stimulation. chiatry in Heidelberg, and then Munich. His con- Friedrich Jolly (1844–1904), a neurologist cept of Dementia praecox was fi rst formulated in and psychiatrist from Heidelberg. His work the 1896 edition of his textbook, on the basis of includes studies of hypochondria, and pioneering his clinical studies; and this and related concepts electrophysiology on myasthenia gravis. He is formed the basis for a system of classifi cation cited in Grundriss as approving the naming of which is still the mainstay of the profession in ‘Korsakoff’s psychosis’ (L38, p. 296). many countries. After the First World War, he Karl Ludwig Kahlbaum (1828–1899), founded a German Institute for Psychiatric obtained training at Berlin University, and Research. Later he advocated social Darwinist worked fi rst at an asylum near Königsburg, then policies and eugenics (L14, p. 87; L30, p. 234 as a lecturer in that city, before buying a private L34, p. 256; L39, p. 304). asylum, of which he became director, at Görlitz, Richard Krafft-Ebing (1840–1902) was an a German city close to borders with present-day Austro-German psychiatrist, best known for his Poland and Czech Republic. He never had an work on sexual pathology, and his work on this academic position, but was a noted pioneer in entitled Psychopathia Sexualis (L32, p. 234; L41, psychiatry, challenging the idea of ‘unitary psy- p. 275). chosis’, introducing a focus on the long-term Jean Baptiste Octave Landry de Thézillat (1826– course of illness into psychiatry, with suggestions 1865), a French physician and researcher, who, in that different forms of mental disorder occurred 1859, discovered the paralytic disorder now known at different transitional periods of life. With as Guillain–Barré syndrome (L27, p. 182). Ewald Hecker he defi ned motor (‘catatonic’) Henri Le Grand du Saulle (1830–1886). His symptoms [190 ] (L1, 4; L13, p. 83; L19, pp. 118, book, from 1875, entitled La folie du doute (avec 119, 122, 124; L22, p. 141; L24, pp. 162, 163; délire du toucher) (Madness of doubt, with fear L28, p. 194; L31, p. 220; L34, pp. 253, 254; L37, of contact by external objects) is cited by p. 280; L39, p. 303; L40, p. 320). Wernicke (L29, p. 200). Jacobus Ludovicus Conradus Schroeder van Heinrich Lissauer (1861–1891), a neurologist der Kolk (1707–1862): a Dutch psychiatric and neuropathologist at the psychiatric institute in reformer, and a defender of vitalism against Breslau. Despite his early death, his name is asso- encroaching materialism in Germanic and French ciated with several important advances, being the thought (L19; pp. 123, 24). fi rst to describe visual agnosia, as well as studies Sergei Sergeevich Korsakoff (1854–1900), a on pathology of Progressive paralysis, and a tract pioneering Russian neuropsychiatrist, student of in the spinal cord being named after him. Cleary Meynert, later based at the Preobrazhenski men- Wernicke thought very highly of him (L20, tal hospital in Moscow, and founder of journal p. 128; L37, pp. 284–286, 289–291; L41, p. 326). which still bears his name. His work encom- Jules Bernard Luys (1828–1887), a French passed psychiatry, neuropathology, forensic med- neuroanatomist, and a neuropsychiatrist, who led icine, and alcoholism. He is best known for the the way in defi ning connections of the basal gan- syndrome of memory loss seen in chronic alco- glia, the fi rst to describe the subthalamic nucleus holism (L38, p. 296). (sometimes still called ‘corpus Luysii’), and the Editorial Commentary 435

fi rst to produce a photographic brain atlas. From ence is made to ‘Meynert’s celebrated optic thal- the late 1880s, he was fascinated by hypnotism amus case’. It is not clear what this case was. and hysteria, using extravagant experiments, and However, Meynert and his doctoral student at the sometimes public demonstrations. His enthusiasm time, Auguste Forel, are credited with defi ning in made him the most widely caricatured of those 1872 the anatomy of the optic thalamus (L1, p. 4; exploring such topics [191 ] (L19; p. 123). L2, p. 11; L4, pp. 22, 23; L5, pp. 26, 27, 29, 30; Valentin Magnan (1835–1916) studied medi- L6, p. 34; L17, p. 106; L19, pp. 123–124; L21, cine in Lyon and Paris, and became an infl uential p. 135; L26, p.172; L30, pp. 210, 211, 213; L33, psychiatrist. He focused on the concept of pp. 236, 237, 240; L34, pp. 243–252, 253; L36, ‘degeneration’ and also on the adverse effects of pp. 275, 277; L37, pp. 284, 285, 288, 290, 292; alcohol and street drugs. His system of classifi ca- L40, pp. 314, 315, 318, 319, L41, p. 326). tion, which was infl uential in France, but was Constantin Von Monakow (1853–1930), a superseded by Kraepelin’s system, held that men- Russian neuropathologist from the region north tal disorders were of just two types, which were of Moscow, spent much of his life in Switzerland, quite separate, one based on hereditary degener- as a student in, and then at the Burghölzli Mental acy, the other defi ned by presence of delusions. Asylum under Edouard Hitzig, subsequently ‘Magnan’s sign’ refers to parasthesias, which can becoming leader of the Brain Anatomy Institute arise in cocaine addict (L17, note; L38, p. 297). in Zürich. He made many contributions to neuro- Adolf Meyer (1866–1950), with a medical anatomy, and in conceptual terms recognized that degree from the University of Zürich, studied the different localized mental faculties needed to subsequently with Auguste Forel and Constantin be integrated, as were thalamus and cerebral cor- von Monakow. In 1892, he found that he could tex. In 1925, with Georg Koskinas, he published not secure a university position, emigrated to the the most detailed cytoarchitectonic map of the USA to become the fi rst chief psychiatrist at human cerebral cortex (L37, p. 290). Johns Hopkins Hospital. Subsequently he was to Johannes Peter Müller (1801–1858), a German challenge the idea that mental disorders were physiologist from Koblenz. In neuroscience he is natural types of disease, replacing the concept noted for formulating the ‘law of specifi c ener- with that of ‘reaction types’. The paper cited on gies’, from which Wundt could later derive the p. 291 (L37) was published 2 years before he ‘law of isolated conduction’ (L1, p. 4; L19, emigrated. p. 124). Ludwig Meyer (1827–1900), obtained a medi- Hermann Munk (1839–1912), a Professor of cal degree from the University of Berlin, and Physiology at the University of Berlin, from 1876 from 1866 to his death was professor of psychia- (L5, p. 26; L6, p. 36). try at the University of Göttingen. He studied Clemens Neisser (1861–1942), a German psy- infl ammatory changes in the brain in Progressive chiatrist, working in north Germany (today, paralysis, and, in 1867, with Wilhelm Griesinger, Poland). His ‘morbid self-reference’ ([112 ]. founded Archiv für Psychiatrie und Neisser, 1891) is mentioned as origin to delu- Nervenkrankheiten (L31, p. 221). sions of reference (L13, p. 82; L37 p. 208; L38, Theodor Hermann Meynert (1833–1892), pp. 285, 298). polymath and pioneer in neuroanatomy and neu- Heinrich Wilhelm Neumann (1814–1884), of ropsychiatry, amongst whose students are Breslau, one of the last German ‘Psychiker’ psy- included Carl Wernicke, Sigmund Freud, Auguste chiatrists, and therefore potentially an opponent Forel, Sergei Korsakoff, and Julius Wagner of Griesinger. He was director of the Breslau Jauregg. He gave the fi rst detailed description of Psychiatric Institute, with Wernicke as an assis- the laminar architecture of the cerebral cortex, tant, until his death, when Wernicke took over. In and various brain structures are named after him a footnote (L20, p. 130) Wernicke acknowledges (notable the nucleus basalis of Meynert ). He was him to be discoverer of the symptom of hyper- also a well-published poet. In L36 (p. 336), refer- metamorphosis. Despite his having an opposed 436 Editorial Commentary philosophy for mental disorder, Wernicke does Josef Starlinger (1862–1943), an Austrian not hesitate to cite, and commend his work. physician and psychiatrist, studied medicine in (L1, p. 4; L19, p. 124; L20, p. 130; L22, p. 141). Vienna, worked under Meynert and then under Franz Nissl (1860–1919), a neurohistologist Julius Wagner-Jauregg. Little details could be and pathologist, studied medicine at the found about him, but he was clearly abreast of University of Munich, with Bernard Gudden as developments in neurohistology, in using the one of his professors. He is best remembered for osmium-based method of Vittorio Marchi for the ‘Nissl’ stain for cytoplasmic granules within staining degenerating myelinated fi bres, with neuronal cell bodies. Later he became a collabo- potassium bi-chromate added to prevent normal rator with Alois Alzheimer, and joined Kraepelin myelinated fi bres being stained. (L41, p. 326). fi rst at Heidelberg, and later, as full-time profes- Franz Tuczek (1852–1925) studied medicine sor, in Munich (L37, p. 290; L41, p. 326). in Berlin with Westphal and in Munich with von Edouard Friedrich Wilhelm Pfl üger (1829– Gudden, and then ran a psychiatric facility in 1910), born at Hanau (near Frankfurt am Main), Marburg. His research work was mainly in neu- studied medicine at Marburg and Berlin, later ropathology, in relation to various conditions to become professor of physiology at the (ergot poisoning, progressive paralysis pellagra, University of Bonn. He contributed research in alcoholism) (L37, pp. 289–291). diverse areas of physiology, and, in 1868, Rodolf Virchow (1821–1902), a pioneer in the founded the journal Archiv für die gesammte discipline of pathology at a time when the Physiologie des Menschen und der Thiere doctrine of the humours still had infl uence. He (now: Pfl ügers Archiv: European Journal of studied under Johannes Peter Müller in Berlin, Physiology) (L5, p. 27). and later worked at the Charité Hospital there. Arnold Pick (1851–1924), a Czech neurolo- Later he became the foundation professor of gist and psychiatrist, trained under Karl Westphal Pathological Anatomy at Würzburg, and later in Berlin, and later headed the Prague institute returned to a chair in Berlin University. Apart for neuropathology. He was one of those to use from his prodigious scientifi c work he was politi- the term Dementia praecox before Kraepelin cally very active, including support for the revo- adopted the term (L19, p. 126). lution of 1848, a strong advocate for public health Wilhelm Sander (1838–1922), a German psy- measures, and a strong opponent of Darwin’s chiatrist and neurologist (L17; p. 107). theory of evolution (and of his own student Ernst Schütz H, Little details could be found about Haeckel). He declined the ennobling title ‘von this pathologist, but, his 1891 paper cited in L37 Virchow’ (L37, p. 289). came from the laboratory of Paul Flechsig in Carl von Voit (1831–1908), a German physi- Leipzig. He held the position of ‘Privatdozent’ ologist and dietician regarded by many as the and ‘erster Assistent der Klinik’. ‘father of dietetics’ (L34, p. 258). Ludwig Snell (1817–1892), a psychiatrist and James Ward (1843–1925), a British philoso- asylum director, who refuted the concept of ‘uni- pher and psychologist. From Kingston upon Hull, tary psychosis’, and is cited in Grundriss for the he originally trained as a congregational minister, concept of monomania (L17, pp. 105, 106), and but won a scholarship to Germany, where he (L17, note), for the view that grandiosity is not a worked under Hermann Lotze (section primary symptom. ‘Wernicke’s Underlying Philosophical Views’, Herbert Spencer (1820–1903), a wide-ranging Wernicke’s Adoption of the European Style of philosopher, and a social commentator, who was Natural Philosophy.) On return to Britain he writing about social evolution some years before entered Cambridge University, with a scholar- the publication of Darwin’s Origin of Species, ship to Trinity College, and published a paper and it was he, not Darwin, who coined the phrase entitled ‘An interpretation of Fechner’s Law’. ‘survival of the fi ttest’. His work ‘Principles of His two papers on physiology in 1879 and 1880 Psychology’ was published in 1855 (L7, p. 39). were in German language journals, and one is Editorial Commentary 437 cited in Grundriss (L3, p. 16). It is the only work L27 (p. 181): Blood haemoglobin measurement by a British scientist he cites. is mentioned ‘… haemoglobin content (Gowers) of Karl Weigert (1845–1904), a pathologist and only 55 %’. The crystalline form of the red pigment neurohistologist, who developed important meth- in erythrocytes had been seen as early as 1848, and ods for selective staining for myelin, and for glial Hoppe-Seyler identifi ed the constituent, now called cells. He had worked at Breslau, and held a chair haemoglobin in 1868. He devised a method of in pathological anatomy at Frankfurt am Main at measuring haemoglobin content, subsequently the time of the fi rst edition of Grundriss ) (L16, improved in various ways. The method of L41, etc.) (L37, p. 289; L41, p. 328). W.R. Gowers (1845–1915), who was primarily a Carl Friedrich Otto Westphal (1833–1890), a neurologist, is referred to by Wernicke [192 ]. neurologist and psychiatrist from Berlin, under L28 (p. 186): The description of railway jour- whom Wernicke worked in the late 1870s. He neys of the time (‘… the journey home in a rail- coined the term ‘agoraphobia’, and also showed way compartment was particularly terrible; she the relationship between Tabes dorsalis, and felt that she had to leap out of the compartment’) Progressive paralysis. In L37 (p. 283) he is cited seems to be a case of what had recently been as supporting Wernicke’s view—that paralysis called ‘claustrophobia’, fi rst documented in the almost always allows one to detect early signs of 1870s in France, when dense urban dwelling was dementia (L29, p. 200; L36, p. 283). common. H. Zacher. Few details could be found about L35 (p. 267): We read of ‘… “reactive mut- this pathologist, cited in L37 (pp. 291, 292). ism”; and the fact that it emerges when confront- Clearly he studied neuropathology of progres- ing a physician, is immediately understood, if I sive paralysis and also published on syringomy- remind you of the distinction favoured by a tem- elia (Fuestner and Zacher, 1883. Arch f peramental colleague, between a “super-” and a Psychiatrie band. XIV). “sub-consciousness”’: This is unlikely to have Theodor Ziehen (1862–1950), studied medi- been Sigmund Freud, but may have been Albert cine at Würzburg and Berlin, after which he Schäffl e, a Schwäbian sociologist, political theo- worked under Kahlbaum at Görlitz, and then as rist and journalist with roots in German idealist assistant to Binswanger at Jena (where one of his thought. His four-volume work Bau und Leben patients was Friedrich Nietzsche). After a brief des sozialen Körpers, appeared in its second edi- period at Halle he became an expert on mental tion in 1896 [193 ]. disorders of childhood, and from 1917 was a pro- L36 (p. 277): The idea that sexual abstinence fessor of philosophy, again at Halle. He retired in was a cause of psychopathology was made popu- 1930 (L3, p. 18; L4, p. 23; L33, p. 236; L36, lar by Freud, but had older roots. Freud for p. 276). instance cited Schoppenhauer in this context, and the idea can even be traced back to Galen, who had suggested that hysteria in women was the XIV,(b). Other Medical or Scientifi c result of sexual abstinence. Topics

L27 (p. 182): ‘Gastroenterostomosis’: This oper- XV. Allusions Requiring Clarifi cation ation for cancer in the lower part of the stomach, or pylorus, was very advanced for its day, and These allusions are usually made by Wernicke’s involved reconnecting the rest of the stomach to patients, but are occasionally ones by Wernicke the jejunum. It was fi rst accomplished by Theodor himself: Bilroth (1829–1894) in 1881, at which time he held a professorship in Vienna. Bilroth was a pio- L9 (p. 57): ‘Gottfried von Bouillon’: A medieval neer of surgery and a gifted amateur musician Frankish knight, leader of the fi rst crusade and friend of Johannes Brahms. from the year 1096, and in the successful siege 438 Editorial Commentary

of Jerusalem in 1099. By the nineteenth cen- represents no more than an aetiological reca- tury, he was a somewhat mythical fi gure, but pitulation of psychoses, which otherwise dif- several accounts of the crusades in the second fer widely from each other’: The phraseology half of that century would have made him a here again hints at Haeckel’s maxim. plausible theme for delusions. L10 (p. 61) ‘Since that time she had doubled L10 (p. 59) ‘Dalldorf’: presumably refers to one everything—double nerves, double heart beat, of the asylums in Berlin. even a double brain.’: Concepts of a ‘double L10 (p. 60) ‘Duchess of Arco’: probably refers to brain’ circulated widely in popular versions of ‘Duchess of Arcos, member of a long- neuroscience in the late nineteenth century established line in the Spanish nobility. [194 ], and in this case may have drawn on ‘Kaiser Friedrich’: who, in 1888, succeeded recent fi ndings—including Wernicke’s own— Kaiser William (King of Prussia, and German about cerebral asymmetry and language. Emperor), but who died from throat cancer L10 (p. 61) ‘According to her, a person has 27 after only 99 days. senses’: The reference is curious. The phrase L10 (p. 60) ‘… the patient, having now survived ‘27 senses’ is associated, especially in Norway, the examination period, to play the role of a with the name Kurt Schwitters, a German art- priest or prophetess’: The imagery is reminis- ist, one of the Dadaist movement, and refugee cent of the plot in Mozart’s Zauberfl öte. during WWII. Born in 1887, he can hardly L10 (p. 61) ‘… at the time that she felt that a pre- have been the inspiration for this patient’s historic man, or a bloodthirsty man, or a lance- imagery, but there may have been an earlier let … had entered her body’: This and the source for their use of the phrase. following description draws heavily on writ- L11 (p. 68) ‘Duke of Sagan’: Old title, in French ings of Ernst Haeckel (1834–1919) a biologist aristocracy, linked to the name Talleyrand, and popular science writer, who introduced a French diplomat from the Napoleonic area. version of Darwinism to German readers. L11 (p. 70) Patients’ explanation of auditory hal- ‘Primitive man’ (Urmensch ) and lancelet (a lucinations in terms of telephone transmis- species important in early arguments about sion: The telephone, and (just as important) evolution, also called amphioxus ), fi gured the telephone exchange, predated Wernicke’s prominently in his writings. From the late 1894 edition of Grundriss by 15–20 years. 1860s Haekel promoted the idea that ‘ontog- ‘Telephone’ also referred to in L25 (p. 166). eny recapitulates phylogeny’, illustrated with L12 (p. 74): ‘… movement makes an increasing drawings of dubious scientifi c authenticity. By contribution to the entire personality, as levels the time of Wernicke’s Grundriss these ideas of schooling increase’: This comment may were well-enough known to be distorted in refl ect the special emphasis in German schools imagery in psychotic illness, and here, appear on physical education, strongly present in to make use of the illustrations in Haeckel’s most of the nineteenth century. Increased books. Later: ‘She mentions the book Häckel bodily awareness to which it led may have Urmensch oder Lanzettfi sch, but believes that been one of the infl uences which led fi rst Häckel means something like binding, or Meynert, and then Wernicke to emphasize belonging together’ (derivation obscure). continuity of body awareness as the fi rst Sometimes Wernicke himself hints at source of personhood (the ‘Ego’). Haeckel’s concepts, but it is unclear whether L13 (p. 82) Raskolnikov: Principle character in he refers to phylogeny or ontogeny, as in L8 Fyodor Dostoievsky’s ‘Crime and (p. 49), where he writes: ‘we see a protective Punishment’, fi rst published in 1866 (also or defensive device that the brain may have p. 193). acquired during its development’. In L37 L14 (p. 87) ‘… their perceptions show every (p. 280) he writes ‘… we again need to hold nuance of referential delusions, which an out- onto our view that the progressive paralysis standing psychiatrist has described succinctly Editorial Commentary 439

with the words “tua res agitur”’: ‘It is a matter eastern religions. Wagner’s operas, not least that concerns you’, a quotation deriving from his Ring cycle make continual reference to this Horace Book I, epistle 18, line 84: ‘… you too belief [195 ]. are in danger when you neighbour’s house is L18 (p. 114) ‘Head warder’: Presumably this was on fi re’. a warder at the hospital, not a character from L14 (p. 88) ‘Götz’: A contraction of ‘Gottfried’. post-revolutionary France. The person referred to (Götz von Berlichingen, L18 (p. 114) Reference to a ‘wishing table’: This ‘of the Iron Hand’) was a stormy nobleman is based on a fairy tale of Brothers Grimm: from what is now southern Germany, involved ‘The Wishing-Table, the Gold-Ass, and the in many battles and feuds in the sixteenth cen- Cudgel in the Sack’. For English text see tury. This left him with an iron prosthesis, Taylor [196 ]. The key section reads—‘… a after losing an arm. A play based on his life little table … made of common wood … had by Goethe had appeared in 1799. The offend- one good property; if anyone set it out, and ing defi ant phrase and gesture, which said, “Little table, spread thyself,” the good Wernicke is too polite to specify, is found in little table was at once covered with a clean Wikipedia: ‘He can lick my arse’, with the little cloth, and a plate was there, and a knife universal accompanying gesture of a bared and fork beside it, and dishes with boiled backside. meats and roasted meats, as many as there was L15 (pp. note) Animosity between Wernicke and room for, and a great glass of red wine shone Hitzig: ‘These prejudices are related to what I so that it made the heart glad. The young jour- claim to be the often misunderstood partiality neyman thought, “With this thou hast enough of the disease in such cases. In what sense I for thy whole life:”’. conceive this partiality will become more L18 (p. 115) ‘He was both a Christian and a Jew, readily apparent from the presentation given and had a previous existence; and he refuted here, so that I shall probably refrain from a my doubt by pointing to the third article of detailed refutation of the attack directed Faith, that relates to the resurrection from the against me by Hitzig (1895)’. dead’: This statement presumably relates to L17 (p. 106) ‘animal delirium’: a literal transla- one of the Christian creeds, used in church tion, ‘delirium of being an animal’ (a.k.a. services, and often written as three para- lycanthropy). graphs, in the third of which comes the state- L18 (p. 113) ‘Wotan’, ‘Ahlbrecht the Bear’: ment about resurrection from the dead. There is a mixture of images here. ‘Wotan’ is L19 (p. 121) ‘… the spirits which he also heard from ancient Norse/Germanic mythology, wanted to conduct various procedures on him incorporated by Richard Wagner into Die on purpose, for the spectators, even the dream Walküre , the second part of his four-part cycle images that he described’: The patient’s imag- Der Ring des Nibelung, fi rst performed in ery is reminiscent of a clinical demonstration. 1870. ‘Ahlbrecht the Bear’, otherwise known L19 (p. 124) ‘… the vestiges of aural mobility, as Albert I (c 1100–1170) was the fi rst which humans still possess’: Vestigial Margrave of Brandenburg, from which ‘The organs—those similar to functioning organs in Bear’ became a symbol for the city of Berlin. other species, but themselves lacking any However, the allusion here may again be to obvious function—have been recognized Wagner’s Ring cycle , since the fi rst part of the since antiquity. They became objects of scien- cycle (Das Rheingold) includes a character tifi c study in the later part of the eighteenth with the name Alberich. As Wernicke notes, century, and after Darwin’s Origin of Species the patient appeared to believe in ‘transmigra- were widely seen to indicate a species’ ances- tion of souls’, a common belief in the try. Wernicke is well aware of this, an idea Germanic world in the nineteenth century, which was also prominent in writings of Ernst partly resulting from recent scholarship on Haeckel. 440 Editorial Commentary

L21 (p. 135) ‘Diaconate institution’: An institu- L25 (p. 169) ‘Sewn into a cow-hide’: Two tion for training deacons, a position in possible interpretations are offered Rudolph Christian churches which can be traced back IV, a Hapsburg ruler died in Milan in 1365; his to the Gospels, whose role is care of and min- body was carried back to Vienna, sewn into a istry to the poor. cowhide, to preserve the body. ‘According to L22 (p. 140) ‘Pleasure garden’: A concept going the directions of the medieval Passion plays back to antiquity, but which fl ourished in most from Donaueschingen and Freiburg, the young European cities from the eighteenth century. priest who played the role of Judas fi rst had to Pleasures gardens (or their modern equivalent, be sewn into a cowhide. Underneath, onto his ‘Theme parks’ or ‘Entertainment parks’) chest, were to be placed the intestines of a could provide various forms of entertainment, sheep together with a live blackbird, or even a but, in cities with overcrowded homes, were live black squirrel, symbolizing the damned also always places for romantic encounters. (i.e. black) soul. During the act of hanging, L22 (p. 146): ‘He would receive 50 lashes, which was performed rather realistically, the counted-out ’. We have interpolated the word cowhide had to burst from the priest’s chest ‘lashes’ as we understand his context. downwards in order to let out the blackbird or L25 (p. 166) ‘Several times the criminal bell had squirrel and to show the intestines’ [197 ]. rung, as if he were now going to his death’: In L25 (p. 169) ‘Wenceslas is coming’: King some jurisdictions in Europe, in the not too- Wenceslas, a Bohemian monarch, who died in distant past, bells were rung at the time of an the tenth century (but who is remembered in a execution. popular English Christmas Carol), was a L25 (p. 167) ‘Last prayer’: Presumably refers to potent symbolic fi gure in central Europe, Catholic ritual, this being (present-day) commemorated in Wenceslas Square, in cen- Poland, now a Catholic country. In Wernicke’s tral Prague. day Catholic faith, while not adhered to by the L26 (p. 172): ‘… He knows the key dates of the majority, was adhered to by a large minority last war; knows about Bismarck, Moltke, and (~35 % of the populace). the three Kaisers, his participation in the L25 (p. 169) ‘Lawyer of the right, lawyer of the election’: The German empire had full adult left’ (Rechtsanwalt, Linksanwalt , etc.): This male suffrage since the election in 1871. The satirical song is based around word-play, and reference here is probably to the election in double meanings, in German, as in English of 1887. the words ‘Rechts’ and ‘Links’ (‘right’ and L26 (p. 172): ‘Krupp’s cannon’: The Krupp fam- ‘left’). Rechtsanwalt means an attorney, whose ily, long-established as industrialists in the concerns is with legal rights; Linksanwalt, is a Ruhr district of Germany, started manufactur- term used in jest, a deceiver, a shyster, one ing cannons from 1840, under Alfred Krupp. who twists the law. By the late 1880s this amounted to about 50 % L25 (p. 169) ‘Into the well, and under the water of Krupp’s total output. with him; he should be pumped full and cut L26 (p. 173) ‘… the walls closing together or open; then into the puddle with him; put him to threatening to collapse’: Does this image refer death’: In medieval Europe, as in Scotland, to events in Edgar Allen Poe’s story, ‘The Pit drowning was a more common means of capital and the Pendulum’, published in 1843, based punishment than hanging, surviving there until loosely on torture during the Spanish the seventeenth, even the eighteenth century. Inquisition? (Poe himself had a lurid life-style, Dismemberment after execution (including dis- in which personal experience of Delirium tre- section in an anatomy school), was also possible mens may have inspired some of his writing). as an extreme measure, for instance in cases of L26 (p. 173) ‘When alcohol abuse deserves to be attempted regicide in eighteenth century France, punished, it is bestowed in abundance, which supposedly to prevent ‘resurrection of the body.’ leads to delirium’: Does this refer to the mari- Editorial Commentary 441

time legend (echoes of which are found in RL L29 (p. 196) ‘30,000 Marks’: A huge sum of Stevenson’s Treasure Island ), of Blackbeard, money. With Germany since 1876 using the a notorious English pirate, who abandoned 15 Gold standard, 1 kg pure gold exchanged for, crew members on Dead Chest Island for a at most, a few thousand Marks. month, leaving each with no more than a bot- L29 (p. 196): ‘Niederwald monument’: Located tle of rum, and a sword? at Rüdesheim, in the Rhine Gorge, commemo- L27 (p. 183): ‘Choleric’, indicating a fi ery tem- rated the founding of the German Empire, perament, excitable, extrovert, and egocentric after the Franco-Prussian war, in September (or, in terms of body fl uid, infl uenced by ‘yel- 1871. low bile’). It is interesting to see a term derived L29 (p. 196): ‘Julian tower’: Probably referring from the doctrine of the four humours appear- to a Romanesque church tower, of ancient ori- ing in Grundriss. gin, at Sankt Julian, not far south of L28 (p. 189): ‘… delusion of being President of Rüdesheim. France and of his being appointed to Warsaw L29 (p. 197): ‘… go into the Oder’: Colloquial by the Tsar fi rst’: Warsaw at this time was term for a suicide attempt by drowning, prob- under Russian suzerainty. ably a common method in northern Europe at L28 (p. 191): ‘if you want to validate the popular the time. Peter Tchaikovsky made such an expression ‘drunkard’, note simply that, attempt in 1877 in St. Petersburg. through external circumstances, the opportu- L29 (p. 198): ‘two witnesses’: Mentioned in nity to drink alcohol and seek out like-minded the New Testament Book of Revelation company, is repeated each quarter year for [Chapter 11 ]. The role of the two witnesses is certain social classes’: This may refer to the to decry the reign of the Antichrist-Beast. fact that, following a decree in July 1888, L29 (p. 198) ‘… handed over to anatomy’: In Kaiser Wilhelm had decreed a succession of many medical schools of the time, bodies for public holidays throughout the year across the dissection were those remaining unclaimed, German empire [198 ]. who died in asylums. L29 (p. 195): Staatsexamen : A university qualifi - L29 (p. 200): ‘Panel doctor’: Presumably a phy- cation, required for teaching. At this time, the sician charged with offi cial duties authorized bias in this state examination favoured the by government. nobility, but varied between länder and L29 (p. 201): ‘Journeyman’: Tradesman’s quali- according to the year; and, until some years fi cation from an apprenticeship, not yet quali- later, it excluded females. fi ed as a ‘master’ able to employ others. L29 (p. 196): ‘special providence’: Shakespeare Journeymen were often travelling tradesmen. uses the phrase (‘there is special providence in This system of qualifi cations still exists in the fall of a sparrow’; Hamlet, Act V, scene 2). parts of Europe. It refl ects Protestant rather than Catholic the- L30 (p. 204): ‘How did you fi nd me , Professor?’ ology, in that divine intervention was achieved We felt this lady may have been a bit seduc- not so much by dramatic miracles as objective tive, hence our added intalicization of ‘me’. public events, but by subtle workings of natu- L30 (p. 203): ‘even were war to be declared’. ral laws. In any case, this reference refl ects This lecture was presumably prepared in the very well the details of Wernicke’s approach late 1890s, at which time across Europe there as a clinician, exploring details of this patient’s were already forebodings of a major war to delusions, and how well he was attuned to the come. culture and popular imagery of his times. L32 (p. 225): ‘enforced exaggeration in the L29 (p. 196): ‘He could only regard his time here expressive movements of a minuet’: The min- as probation imposed upon him’: The imagery uet was really a dance (or rather an important is perhaps of purgatory, although this concept social occasion) of the seventeenth and eigh- is rejected in most Protestant traditions. teenth century, which was transformed into 442 Editorial Commentary

the Waltz by the nineteenth century. However, ‘a year and a day’. On the continent of Europe, the title ‘Waltz-minuet’ was well known in laws codifi ed as legal statutes had greater sig- central Europe in the nineteenth century. nifi cance than precedents in the English com- L32 (p. 226): ‘Occupational deliria’: Elaborate mon law tradition, especially after the French pantomimes, as if continuing a usual occupa- revolution. Nonetheless, in Europe, legal stat- tion in the hospital bed, possibly depicted as a utes were infl uenced by customary law, and caricature in Charlie Chaplin’s portrayal of the use of this phrase by Wernicke derives assembly line employment in his ‘ Modern from this fact. This is why his use of this Times ’ . phrase is interesting. Today, in English as in L32 (p. 232): ‘Dr. Sch’: This refers to ‘the patient’ German—it means ‘for an indefi nite period with a PhD, not a medical doctor. In any case into the future’. this patient seems to attribute his disruptive L37 (p. 288): ‘medullary strips of the gyri and the motor symptoms easily to divine common underlying white matter’ Die intervention. Markleisten der Windungen und das gemein- L32 (p. 233): ‘sight of … a slate … brings schaftliche Marklager zeigen sich ebenfalls patients … to write on the slate.’ presumably beträchtlich verschmärlert. We infer that this the ‘slate’ used in schools, in preference to refers to white matter between the walls of a paper, for handwriting. gyrus, and that lying deep to the gyrus. L33 (p. 240): ‘Chansonette’: Roughly a ‘cabaret L38 (p. 294): ‘The acquired predisposition to singer’. ‘Cabaret’ emerged in France from mental illness is based usually on adverse around 1881, and did not appear in Germany infl uences that are also expressed as organic until the turn of the century, to reach its defi ni- changes in the brain. These include tive German form during the years of the Hydrocephalus internus [W], even if this has Weimar republic. reached the stage of recovery, as we often see; L34 (p. 244) ‘… she crosses her legs in a totally but we also see it even where no conspicuous inappropriate manner’: Presumably a breach alteration of the head has been left behind’: of lady-like etiquette. Head- shape is referred to here: A bulbous L34 (p. 247): ‘Prince Bismarck came and gave skull, then being seen as a consequence of him a malicious look’: This patient, encoun- Hydrocephalus, presumably the only way this tered during Wernicke’s Berlin period, was condition might be identifi ed in vivo at the seen at a time when Bismarck was politically time. powerful. (He was removed from power in L40 (p. 314): ‘… if you challenge an elderly phy- 1890 by Kaiser Wilhelm I). sician, lawyer, or mathematician with a test of L34 (p. 249): ‘Sleeping uhlan’: A military meta- word form in ancient Greek’: This presumably phor. The Polish word ‘Uhlan’ (‘Ulan’ in refers to the classical education in ancient German) refers to Polish light cavalry, armed Greek, which educated people are likely to with lances. The metaphor is thus similar to have received at an early age in Wernicke’s that of a fi erce animal ‘lying doggo’. time. L37 (p. 284): ‘For a year and a day’: This curious L40 (p. 316): ‘Karlchen Mießnick’: Pseudonym phrase (über Jahr und Tag ), has its origin in for Friedrich Wilhelm Ernst Dohm (born, customary legal settings, both in England and Breslau, 1819; died Berlin, 1883), a translator, in Europe, for instance wherein a person who actor and editor (of, inter alia , a satirical mag- dies more than ‘a year and a day’ after some azine Kladderadatsch ). assault, can no longer be deemed to be a mur- L40 (p. 316) ‘Berliner Wespen’: ‘Berlin Wasps’, a der victim; or where a couple must be married satirical magazine, founded in 1868 by Julius ‘for a year and a day’ before a spouse can Stettenheim (of Hamburg) known as claim a share of inheritable property. In medi- ‘Wippchen’, which, amongst other campaigns, eval Europe, a runaway serf became free after fought against growing anti-Semitism. Editorial Commentary 443

XVI. Terminology sory perception, while here, a higher-level process is meant. When used in this sense, the ‘Abusus spirituosorum ’ (L25, p. 168): Alcohol English word ‘apperception’ will be used, whose abuse went under a variety of names, such as defi nitions (OED) is: ‘perception with recogni- Marcel’s Folie des ivrognes ; Kraepelin’s akuter tion or identifi cation by association with previous halluzinatorischer Alkoholwahnsinn, etc. ideas’. ‘Abulia’ (L35, p. 267): The 1906 German ‘Apoplexy’: ‘Stroke’ is the common English medical dictionary defi nes ‘Abulie’ as ‘want of term, Up to the end of the nineteenth century, will-power’. ‘apoplexy’ referred to any sudden death with sud- ‘Acousma’: This term, used in L19 (p. 207), is den loss of consciousness, today given the term scarcely known today, referring to simple acous- ‘stroke’. Literally it refers to bleeding of internal tic experiences, illusory non-verbal auditory organs. ‘Apoplectiform ’ implies as if leading to sensations. sudden death, usually describing what is now ‘Activation’ (e.g. ‘Nervous activation of mus- called ‘stroke’. (See also L28, p. 186; L37, cle’ [L6, p. 32]): Muskelinnervation). We do not p. 284). translate ‘innervation’ directly because, in ‘Arsenic green’ (L38, p. 296): This is proba- English, it refers to structure not function. bly the same as ‘Paris green’, a highly toxic com- ‘Aegophony’ (egophony) (L37, p. 280): pound of arsenic (copper acetate triarsenite), Changed vocal quality, with lower frequencies used in Paris as a rat poison (in sewers). From fi ltered out, resulting in high-pitched bleating or about 1900 it was used in America and elsewhere nasal timbre. in agriculture, as an insecticide. ‘Affect’: see section VIII,(h). ‘Wernicke’s ‘Ascending’ (aszendierend ’): Although Distinctive Clinical Concepts in Psychiatry’ Wernicke frequently uses the metaphorical (Affective impact of mental illness ). German word, we replace it by ‘worsening’, ‘Alcoholic psychosis’: ‘most acute form of except when the German word is used in another alcoholic psychosis’ (L26, p. 174) a.k.a: sense. ‘drunkenness’. ‘Asymbolia’ (Asymbolie ; also to be translated ‘Amentia’ (L33, p. 235), a term originally as asemia or asemasia) (L27, p. 183), a severe used by William Cullen (1777) to mean ‘mental form of aphasia, in which there is inability to retardation’. For Meynert in his 1890 clinical lec- understand (and for the latter terms, perhaps also tures, the meaning had shifted—a sudden-onset to use) symbols in communication. (See also state of confusion, as a disorder of thinking— L20, p. 128; L38, p. 295). contrasted with ‘dementia’, which for him was ‘Atonicity’ (L34, p. 253): Pathological lack of ‘deterioration of personality’ [199 ]. Symptoms muscle tone. of Meynert’s (p. 240) ‘amentia’ ranged from ‘Atrophy’ (Atrophie ) First appears on L38, excitement to stupor, occasionally ending in p. 295 Atrophie der Optici; then L38, p. 288 deterioration. Atrophie des Großhirnmantels; pp. 288, 289; ‘Anxiety’ ( Angst) (L23, p. 145): We almost L40, p. 317 Optikusatrophie. It invariably refers always render the German word as ‘anxiety’, to biological change. only occasionally as ‘fear’, since ‘anxiety’ is ‘Autochthonous’: We usually retain more familiar in psychiatry, and fear implies Wernicke’s word, although ‘self-generated’ may ‘fear of something’, which is often not the case be less ambiguous. (Section VIII,(i). ‘Wernicke’s for anxiety states. Distinctive Clinical Concepts in Psychiatry’, ‘Apperception’ (fi rst used in L2, p. 9: Delusions and Related Phenomena for Wernicke ). Vorstellung ). The German word has many shades ‘Brain-softening’ (Encephalomalacia ) (L11, of meaning. ‘Perception’ is one rendition in p. 67) was an accepted medical term in the late English, but, as becomes clear by L8 (p. 43), the nineteenth century, deriving from autopsy exami- English word ‘perception’ usually refers to sen- nations of the brain, and later entered popular 444 Editorial Commentary vocabulary. It referred to localized change in the that it captured a widely recognized concept for brain, due to haemorrhage or infl ammation. German-speakers [204 ]. Three varieties, distinguished by colour, repre- ‘Blasé’ (Blasiertheit ) (L30, p. 207): This does sented different stages of morbid processes, not have quite the meaning of the French ‘blasé’ known respectively as red, yellow, and white (‘indifferent to normal sources of interest because softening. In Wernicke’s day such changes were they are familiar’; or ‘indifferent as a result of commonly seen post-mortem in aged people and excessive earlier indulgence’). Wernicke implies in those dying from syphilis, as well as in cases ‘indifferent due to repeated failure to fi nd enjoy- of stroke. ment in usual source of interest.’ ‘Cause’: We take this to be a debated concept, ‘Catalepsy’, ‘cataleptic attack’ (L28, p. 191): and avoid using it except in special circum- This is the fi rst mention of the term ‘cataleptic’ stances. It meaning is different from ‘aetiology’ or ‘catalepsy’ . It is an old term, whose meaning which we translate directly from the German. has varied, and has included a variety of differ- ‘Channeling’ (Bahnung ), fi rst used in L22 ent conditions or states. According to Berrios (p. 139). The root word (Bahn ) is common [ 190 ], in its complete form, it is a state of overall (Bahnhof, Eisenbahn, etc.). Dictionary transla- motor paralysis, sometimes with normal muscle tion of Bahnung includes ‘canalization’ or ‘chan- tone, or increased tone, sensory disconnection neling’, terms originating in engineering at a time without anaesthesia or analgesia, passive postur- when major rivers in Europe were being made ing, and total amnesia for the period of its pres- navigable. We use ‘channeling’ as a more famil- ence. In early nineteenth century it was classed iar word than ‘canalization’. The meaning of amongst the ‘neuroses’ in the original sense of Bahnung is captured in Wernicke’s phrases such William Cullen (along with paralysis, tetanus, as ‘frequent repetition’ and ‘deliberate practice’, and epilepsy). It was important to Kahlbaum, is suggesting ‘a pathway created by frequent use’, referred to by Wernicke in L34 (p. 253), and is ‘stamping in’ or ‘blazing’ of a trail. In psychol- mentioned by Ernst Kretschmer [ 61 ], for whom ogy it means an ever-narrowing focus of attention it was very similar to the instinctive ‘death feint’ and of motives for behaviour—as a result of men- known in most mammalian species. Curiously it tal disturbance, education, or other life events. is not reported today in humans, although it is a This term ‘canalization’ appears to have origi- term widely used in animal studies of psycho- nated with Pierre Janet as early as 1889. It is pharmacology (e.g. ‘neuroleptic-induced cata- unlikely that it originated with Wernicke, to be lepsy’ in laboratory animals), which is probably adopted later by Janet, because Janet had little different from the condition described by ability to read German [200 ]. The term Bahnung Wernicke, even when one restricts the compari- was also known in France and translated as fray- son to motor signs. age , (‘facilitation associative par répétition’). ‘Chorea minor’ (L32, p. 231): Sydenham’s Freud used it in Entwurf einer Psychologie [ 201 ], chorea, occurring after streptococcal injection also named Erinnerungsspur (‘memory trace’). affecting the brain. ‘Canalization’ was used later by Gardner Murphy ‘Column disease’ (‘L37 (p. 274): [ 202], acknowledging Janet as the source. Its use Strangerkrankung. Strang is a somewhat out- in psychology has diversifi ed since Murphy’s dated German word for (spinal) column; monograph. Bahnung has been used metaphori- Erkrankung is a more general, less specifi c word cally in science in various other contexts, includ- than Krankheit, referring to the start of a disease ing genetics (after Waddington). In physiology it process. was fi rst used by Sigismund Exner [203 ] and was ‘Complex’: see section VIII,(s). ‘Wernicke’s explained through an electrotechnical analogy. Distinctive Clinical Concepts in Psychiatry’ The coincidence of dates of Exner’s Wernicke’s (Wernicke’s Links to the Emerging Dynamic and Freud’s publications using the term suggests Tradition in Psychiatry. ) Editorial Commentary 445

‘Conform’ ‘The requirement for intellectual German text often uses deliriant, but we avoid material to “conform”’ (L40, p. 313): The sense this term in our translation. here is of discourse to ‘conform’ to what is ‘Delusion’ ( Wahn ): The German word can accepted (for instance to church doctrine). refer either to a delusion or to a state where delu- ‘Confusion’ ( Verwirrtheit): We take this to sions can occur. We have attempted to indicate indicate a state when conﬂ ict between mental which meaning is intended. contents becomes overwhelming. Likewise ‘Delusion of belittlement’ (Kleinheitswahn ) ‘bewilderment’. (L29, p. 200), a term with a slightly different ‘Consolidating’: ‘um so fester ’ (L4, p. 22). sense from ‘micromania’ (see below). ‘Consolidation’—of memory—is accepted ter- ‘Delusion of persecution’: Verfolgungswahn. minology for memory researchers today, intro- ‘Delusion of relatedness’, ‘delusion of refer- duced by Muller and Pilzecker [205 ] but ence’ see section VIII,(l). ‘Wernicke’s Distinctive Wernicke does not use Konsolidierung. Clinical Concepts in Psychiatry’ (Delusions and ‘Crests of the gyri’ (L37, p. 288): Related Phenomena for Wernicke ). Windungskuppen site where localized pathology ‘Depression’/‘Depressed’: see ‘Melancholia’. develops after brain injury. ‘Descending’ (Descendierend ). See above ‘Crime against morality’ (L25, p. 168): under ‘Ascending’. Presumably a sexual crime. ‘Disarray’: see section VIII,(h). ‘Wernicke’s ‘Cure’ see section III. ‘The Medical Scene at Distinctive Clinical Concepts in Psychiatry’ Breslau in Wernicke’s Day; Typical Psychiatric (Affective impact of mental illnesses ). Practice’, on criteria for discharge; and section ‘Disorientation’: see section VIII,(h). VIII,(q). ‘Wernicke’s Distinctive Clinical ‘Wernicke’s Distinctive Clinical Concepts in Concepts in Psychiatry’ (Prognostic Indicators; Psychiatry’ (Affective impact of mental illnesses). Concepts of ‘Cure’, or ‘Return to Health’ ). ‘Drive’: Wernicke’s usual word is Antrieb , ‘Curve’: This idea is used to characterize the usually implying a degree of voluntariness, but plot of illness extent or intensity over time. This sometimes, a response driven by a sensory stimu- word captures Wernicke’s meaning more exactly lus, sometimes a behavioural urge, occasionally than ‘plot’ or ‘graph’. ‘voluntary effort’. The word Zwang is used only ‘Daimonion’ (L29, p. 196): Roughly ‘a dae- once mon’; and, according to Merriam-Webster dic- ‘Dyspneic’ (L39, p. 307): Short of breath. tionary: ‘an inward mentor conceived as ‘Eburnisation’ (L37, p. 289): Degenerative partaking of the nature of a demon or inspired by process of bone occurring at sites of articular car- one’. The legendary Socrates also experienced an tilage erosion commonly found in patients with inner voice giving advice (now perhaps called osteoarthritis. ‘command hallucinations’). ‘Elementary symptom’: see section VIII, (g). ‘Deduce’ (Abzug ): Used only once in ‘Wernicke’s Distinctive Clinical Concepts in Grundriss (L1, p. 4). Psychiatry’ (Wernicke’s Concept of ‘Elementary’ ‘Deﬁ cit’: We prefer this to ‘Defect’ to render symptoms ) the German Defekt. ‘Emotions’ (L8, p. 48): see section VIII,(h). ‘Degeneration’ (Entartete, or Degeneration ). ‘Wernicke’s Distinctive Clinical Concepts in See section V. ‘Contemporary Knowledge in Psychiatry’ (Affective Impact of Mental Illness ). Neuroscience; Contemporary Practice in General ‘Emotional incontinence’ (L40, p. 320): It is Medicine and Psychiatry in Wernicke’s Day’, not clear where this term originated in the paragraph on ‘degeneration’. English-speaking world. For many years it ‘Delirium’ (Delirien ) is almost always sepa- appears to have been little used, but recently, a rate from ‘Delusion’ ( Wahn ), but p. 211, where number of papers on stroke patients in East Asia Wernicke cites Meynert is an exception. The have used the term. 446 Editorial Commentary

‘Endowment’: Besitzstand. ‘Fear’: see ‘Anxiety’ above. ‘Energy’: Usually Wernicke’s word is Kraft, ‘Feeling tone’: see ‘Organ sensation’. but the word Energie occurs sometimes, espe- ‘Feudal estate’ (L27, p. 180): The German cially when used for a specifi cally physical meta- word is Herrschaft, indicating the fi efdom of a phor (p. 43: pontentiellen Energien; p. 66: feudal lord of earlier days. specifi sche Energie ; p. 73: ‘drained away ,’ ‘bal- ‘Fibrae propriae ’ (Meynert) (L37, p. 290): ancing up’, ‘build up’: Energie strom; p. 80: The coherent band of white matter lying immedi- ‘damming up of nerve energy;’ p. 81: nerven ately deep to the cortical grey matter. Energie; p. 86: ‘perpetual motion’; p. 89: ‘energy ‘Fixed idea’(fi xen Ideen ) (L41, p. 329), obvi- accumulated etc’; p. 126: ‘specifi c energy’; BUT ously a direct translation from the French idée p. 183: ‘verbal utterance, and their energy ’ fi xe. (enkraften ). p. 218: ‘unrestrained energy’). (See ‘Flexibilitas cerea’ (L34, p. 250): This is a section XI,(b). ‘Wernicke’s Reasoning’, latinized version of the term ‘waxy fl exibility’ Reasoning by analogy ). which Wernicke also used; but he appears to use ‘Envenomation’ (L26, p. 176): This word the two terms as though they have slightly differ- implies some toxin of exogenous origin; but the ent meanings. exact meaning is unclear. ‘Forgery’: ‘Forgery of consciousness’ (L40, ‘Ependymitis granulosus’ (L37, p. 25): p. 313): Whereas ‘falsifi cation’ of contents of Infl ammation of the ventricular lining, with accu- consciousness’ (Fälschung des mulation of granular tissue. Bewußtseinsinhaltes ) need be no more than a ‘Epigenetic’: Use of this term (L20, p. 125) is one-off error, ‘forgery of consciousness’ confusing to a modern reader. Today the noun (Bewußtseinsfälschung ) is a more systematic, form ‘epigenetics’, introduced by Waddington in comprehensive and fi nalized version of such 1942, refers to the fact that the genome does not error. unfold in a manner determined solely by its own ‘f.S. artery’ (L11, p. 67): Presumably the nature, but is subject to numerous infl uences dur- artery supplying the superior longitudinal fascic- ing development, including, indirectly, ones from ulus (major hemispheric white matter tract). the outer environment [206 ]. However, in adjec- ‘Ganglion cell’ (Ganglienzellen ), fi rst used in tival form (‘epigenetic’), the term is much older, L3 (p. 16): This was Wernicke’s word for a cell rooted in a theory of ‘epigenesis’, that the germ is body, or perikaryon of a neurone, However, the brought into existence (by successive accretions), term is used in various ways, often in L3 refer- and not merely developed, in the process of ring to a specifi c neuronal type in the retina, and reproduction [207 ]. elsewhere just to indicate ‘a central neurone’. In ‘Experiment’: see section XI,(a). ‘Style of the latter context, he usually referred to long- Reasoning’. axon (projection) neurones, although Cajal had ‘Extent’: This word is used to characterize the already distinguished these from the ‘local circuit extent of an illness. We use this word, except neurones’ (in the cerebral cortex). when the German refers to a collection of specifi c ‘Gastric catarrh’ (L26, p. 173); now ‘Gastritis’. symptoms, when we use the word ‘range’. ‘Genetic confusion’ (L33, p. 236): see section ‘Faradisation’ ( Faradisation) (e.g. ‘Faradic VII,(b). ‘Wernicke’s Contribution to excitability of a nerve’, L3, p. 16): This was a com- Neuroscience, Psychology and Overall Medical mon term at the time, although ‘electricity’, ‘elec- Knowledge’ (Wernicke and ‘Associationism’ ). trisation’, were also in common use. The sense of ‘Globus pharynges’ (L22, p. 143): This term terms such as ‘electricity’ or ‘electric’ has shifted can be traced back to Hippocrates, and refers to over the centuries, and was not precise in persistent, but benign sensations originating in Wernicke’s day. Strictly, ‘faradisation’ meant the pharynx or larynx, otherwise known as ‘glo- ‘alternating current’, which, by Wernicke’s time, bus sensation’, just ‘globus’, or in older terminol- had superseded direct current in clinical situations. ogy ‘globus hystericus’—in common parlance ‘a Editorial Commentary 447 lump in one’s throat’. As with many psychoso- sifi cation and for classifi cation of diseases, matic disorders there has been debate about appears here to be used here to designate a per- whether it has a physical origin in the throat or sonality type, rather than a disorder. related structures, or a psychological one [ 208]. ‘Hydrops ventriculorum ’ (L38, p. 296): Here Wernicke appears to use the term to refer Literally, ventricular oedema. to normal anatomical structures from where ‘Hypermetamorphosis’ ‘(L20, p. 125): This such sensations sometimes arise, rather than to term originated with Heinrich Neumann, the symptoms themselves. (See also L30, Wernicke’s predecessor at Breslau [209 ], but also p. 208). has a meaning in entomology. Today the term is ‘Grandiosity’ ( Grössenwahn ), fi rst used in L8 not used, but perhaps should be reintroduced. It (p. 200). We avoid ‘megalomania’ (which has too has similarities to syndromes seen after defi nite many connotations in English vernacular), and cortical lesions [210 ], including instinctive ‘grasp ‘delusions of grandeur’ (which are described reactions’, tactile ‘avoidance reactions’ or later); and we wish to avoid confusion with true ‘instinctive visual fi xation’. The term was to be ‘mania’ for which Wernicke has a precise used later by Klüver and Bucy [211 ] in descrip- conceptualization. tions of a syndrome produced in macaque mon- ‘Granular cell’ (L41, p. 326): This is some- keys after bilateral temporal lobectomy. However, what dated terminology, referring to some layers their use referred to an ‘excessive tendency to of the cerebral cortex as ‘granule cell layers’ or take notice of and to attend and react to every ‘granular layers’. Their main neuronal type is not visual stimulus’. Wernicke gives no indication sharply different from those in other layers, being that the syndrome he describes in psychiatric pyramidal cells (Ganglienzellen in Wernicke’s patients is related to any cortical lesion, and terminology); but they are smaller and more excess of attentional fi xation can occur in any densely packed than in the layers (notably layer sensory modality, but differing from one patient V) containing larger pyramidal cells, hence the to another. It appears to correspond to various term ‘granular’. Lissauer defi ned cell loss in lam- perceptual sensitivities (such as sensitivity to inae II and III, which were referred to as ‘granu- noise, or to visual movement), and can be seen as lar layers’. It is not clear what ‘laborious’ method aspects of selective attention specifi c to one (or was used by Lissauer to trace the degenerating more) sensory modalities. connecting of these cells. The Marchi method is ‘Idiocy’ (L37, p. 292); Blödsinn. based on detection of degenerating myelin, and ‘ Impotentia coeundi’ (L24 (p. 160): erectile Lissauer may have used an earlier version of this dysfunction. method. ‘Inhibition’: see section VII,(a). ‘Wernicke’s ‘Hallucination’: The usual German word is Contribution to Neuroscience, Psychology and Halluzination. An alternative word is Overall Medical Knowledge’ (Basic neuroscience ). Sinnestäuschungen (sensory deception, some- ‘Insane’, ‘Insanity’: In current English usage times including delusions as well as hallucina- these are legal rather than medical terms, although tions). Visual hallucinations are referred to as the two were not separated in Wernicke’s day. We Halluzination , but tactile ones as therefore avoid them unless they were already Sinnestäuschungen . ‘“Hallucinations of common historic, were a patient’s own words, or were sensation”, which we will deal with in more referring to words of another clinician. detail later.’ (L19, p. 121) We are not sure of the ‘Insolation’ (L41, p. 328): Exposure to solar exact meaning of this phrase. radiation, equivalent to ‘sunstroke’, which may ‘Helplessness’: see ‘Disarray’. be relevant to the case of the fugitive from ‘ Homo tardus’ (L31, p. 216): This may have Australia to Switzerland (see also L28). been one of Wernicke’s own terms. It is of inter- ‘Jactation’ (L20, p. 131): As used medically, est, because the latinate binomial nomenclature, this term (also ‘jactitation’) indicates abnormal, devised by Carl Linnaeus for both botanical clas- restless tossing or throwing about of the body. 448 Editorial Commentary

‘Lateral column symptoms’ (L39, p. 301): problems he encountered in his patients as a form Presumably differential loss of pain and tempera- of illness, for which medical terms were appropri- ture sense, while discriminative sensation ate. ‘Geisteskrankheiten’ or ‘Geistesstoerungen’: remains intact. Usually the fi rst of these is used by Wernicke. ‘Lunatics’ (Irrenwesen— fi rst used in L1, p. 4; Cases where the second is used include the fol- likewise: ‘Mad-doctor’: Irrenärzte; ‘Lunatic asy- lowing (with our rendition)—p. 54: ‘mental dis- lum’: Irrenhaus, L32, p. 229, literally ‘mad- turbance’; p. 65 ‘all chronic mental disorders’; house’). These terms are the contemporary p. 66 ‘be advisable to reserve the term ‘chronic English equivalents, according to Lang [212 ]. The mental disorder’ just for residual cases’; p. 71: term ‘lunatic’ was removed from British law in ‘residual chronic mental disturbance’; p. 72 the 1930 Mental Treatment Act, but not from US ‘equally for chronic and acute mental disorders’; Federal law, until 6th December 2012. We often p. 101 ‘right to declare a person mentally ill’; use alienist interchangeably for Irrenärzte, p. 102 ‘paranoid states are mental disorders’, ‘all although Wernicke does not use the equivalent chronic mental disorders’ p. 105 ‘each newly German term. German words for madness do not emerging symptom of mental disorder’ (and yet, refer to the moon. The German word Laune, has a on the same page we have ‘most chronic mental lunar origin, but is more benign than ‘Lunatic’ illnesses’ [Geisteskrankheit ]; p. 158 ‘or senile (indicating ‘mood’, ‘whim’ or ‘caprice’). mental disorder’; p. 161 ‘accessible to the lay ‘Manic aphasia’ (L20, p. 127): A term coined man’; p. 162 ‘chronic mental disorder’; p. 180: earlier by Wernicke, from which he now appears ‘We obtained a report of the exact time of onset to be distancing himself. of her acute mental disorder which was very ‘Manifestation’: The word Ereignis consis- inaccurate’, (but on the same page, tently refers to ‘outward signs’ of mental disor- Geisteskrankheit is used, referring to onset of der, while Erscheinung, sometimes refers to inner menstrual bleeding ); p. 220 ‘circular mental dis- experience, and is better rendered as order’; p. 275 ‘either chronic mental disorder or ‘phenomenon’. dementia’; p. 309: ‘chronic mental disorder ‘Marasmus’ (L24, p. 159): Signs of severe remains’; p. 313 ‘residual mental disorder’. In malnutrition. summary, Geistesstoerungen is usually used ‘Megalomania’ (L14, p. 95), a term that origi- when referring to mental disorders generically, or nated as the French megalomanie , used by Hecker in a less specialized way. [213 ] including the phrase ‘exalted megalomanic ‘Maceration’ (L37, p. 288): strictly, ‘softening lying’, and fi rst appearing in English in 1890. by soaking’, but used in a variety of situations. In Wernicke used the term occasionally, but to refer pathology, refers to tissue degeneration after to other physicians’ usage, not his own. In death (for instance in a still-borne infant). German, it could be straight from French, or it ‘Medulla oblongata’: Oblongata. could become ‘der Grössenwahn ’. However, the ‘Medullary degeneration’: Markdegeneration. latter term refers to delusions of grandiosity, or to ‘Medullary pyramid’: Markkagel. a state where such delusions can occur. ‘Melancholia’/‘melancholy’: This is almost ‘ Menstruatio nimia ’ (L32, p. 225): excessive always the equivalent word in German. We use menstrual bleeding. (Also L38, p. 294). Wernicke’s ‘melancholia’ in most cases except ‘Mental illness’: Despite his assertion at the when it is in adjectival form, or when it refers to start of L1 (following Griesinger) that mental ill- the history of the concept, when we use ‘melan- nesses are brain diseases, Wernicke uses separate choly’. Only occasionally do we use depressed words, respectively Geisteskrankheiten versus (p. 219), when the German word is deprimiert . Gehirnkrankheiten , and, from time to time points ‘Meteorism’ (L34, p. 247): Gaseous disten- out differences between psychiatry and neurol- sion of stomach or intestines. ogy. His word for mental illness— Geistesk- ‘Metritis’ (L24, p. 157): otherwise known as rankheiten—clearly shows that he identifi ed the ‘Pelvic infl ammatory disease’, an infl ammation Editorial Commentary 449 on the uterine wall, as opposed to ‘endometritis’, as sometimes in psychology. This contrasts ‘low- an infl ammation of the functional lining of the level details’ of individual elements, and ‘high- uterus. level properties’ emerging collectively from ‘Micromania’ (L23, p. 147): A modern dic- many such elements. Wernicke, in effect, tionary defi nition is ‘excessive or unbridled acknowledges that ‘cross-level’ explanations are enthusiasm for self-deprecation’, or ‘delusions of the cornerstone of the most important scientifi c littleness or belittlement’, (‘low self-esteem’ per- explanations. haps in modern terms; an autopsychic delusion in ‘Molimina alvi’: (L30, p. 208). Archaic term Wernicke’s terms). ‘Micromania’ in this sense is for premenstrual diarrhoea. the opposite of megalomania, and Wernicke term ‘Molimina uterina’ (L30, p. 208): Archaic is usually Kleinheitswahn . We almost always use term for premenstrual uterine symptoms. ‘belittlement’ rather than ‘micromania’, except ‘Motility psychosis’: Signifi cantly, this is a when citing Meynert. Pierre Janet [214 ] gave disorder for which Wernicke appears to have had ‘micromania’ a quite different meaning, when he a special affi nity, since he starts Grundriss by writes as follows: ‘Micromania deserves atten- mentioning this disorder (L1, p. 6) and also fi n- tion: It is evident that many of these patients ishes the series (L41, p. 329). grant more importance to that which is small than ‘Motor impulse’ (L6), and ‘Impulse’ (used that which is big, Chu…, a woman of 36 years, extensively in L31 and L32) to indicate a driver anxiously searches for the “small crumbs of of motor activity. ‘Impulsive’ is also used a num- grease, crumbs of dirt” but does not take care of ber of times in L32. It is not clear whether he was “big dirtinesses.” Bow… is afraid of “small using ‘impulse’ as a deliberate analogy drawn noises,” not of the “big ones”. A canon blow does from physical science (as he did with other terms, not do anything to me, but I want to kill the peo- such as ‘energy’). ple that chew, who pick their teeth, who cough… ‘Mytacism’ (L27, p. 180). Excessive use of Mr. Stadelmann of Würzburg relates a nice the letter ‘m’, or an equivalent sound. observation of a man of 30 years, bothered since ‘Negativity’ (L34, p. 243): Negativismus. puberty by the preoccupation of what various ‘Nerve’ (Nerven ) (e.g. L3, p. 16) leaves it insignifi cant objects will become in the future, a unclear whether it refers to a nucleus, a pathway, fl y that fl ies, a lifeless match, the ash of the cigar, or to peripheral versus central nervous system. the spots of candle fallen to earth, etc. Mr. Farez ‘Nervous’ (L29, p. 196): Apart from its use in also relates obsessions and disgust for very small neurology and neuroscience, this word has a ver- objects, match tips, candle stains. It is needless to nacular meaning in English. The German word emphasize the importance that patients attach to nervös is probably more stigmatizing than is the “little bugs.” Into this preoccupation with ‘nervous’ in English, approximate synonyms what is small enters, of course, the mania of being ‘edgy’, ‘irritable’ and ‘agitated’. attention and precision.’ [ 214]. This alternative ‘Neurosis’: see section VIII,(s). ‘Wernicke’s meaning does not refer to the patient’s self, but to Distinctive Clinical Concepts in Psychiatry’ how he/she experiences the outside world (allo- ( Wernicke’s links to the emerging dynamic tradi- psychic in Wernicke’s terms); and since there are tion in Psychiatry ). differences between right and left hemispheres in ‘Nucleus’ (L19, p. 123) has had a variety of perception of large versus small images (at least meanings in science. In biology, its fi rst use for in the visual sense), Janet may be referring to an the intracellular organ in each cell dates from abnormality of cerebral asymmetry. 1831 (Online etymological dictionary). The use ‘Milliarde’ (L4, p. 22): one thousand million, of the term in neuroanatomy for a collection of according to terminology of the period, ‘one bil- nerve cells, or discrete block of grey matter can lion’, in today’s terminology. be traced back as far as 1828, and was used in the ‘Molecular’ (L8, p. 43): This is implicitly con- 1875 edition of Encyclopedia Britannica (OED). trasted with the term ‘molar’, as in chemistry, and After that time it had become standard terminol- 450 Editorial Commentary ogy. Wernicke occasionally uses the German included sense organs such as the skin, eyes or equivalent—Kern —as in Linsenkern (Lentiform inner ear), and these were sensations which, he nucleus: L11, p. 67), but in another instance thought, had a defi nite emotional ‘colouration’. (L19, p. 123), as the sogenannten Kerne (‘the so- We resist the temptation to translate the term as called nucleus’—possibly what is now called the ‘organic sensation’: Wernicke does sometimes dorsal column nuclei). use the adjective organisch, which has a different ‘Nurses’/‘Warders’: Wernicke never uses meaning. We can see the difference in the follow- ‘Schwesterin’ only ‘Warter’ and ‘Warterin’ ing terms we translate: ‘the “organ of conscious- except on p. 180 ( Krankenschwester: ‘the atten- ness”’, or the ‘organ of association’, in contrast dant nurse’ as a delusion). We therefore use with ‘organic brain disease’ or ‘organic (versus warder’ rather than ‘nurse’. functional) psychosis’. There is also a relation to ‘Organ sensation’. In L5 (p. 25) our transla- a conceptual distinction published 2 years after tion reads ‘Feeling tone of sensations’: Grundriss, by Rivers and Head [217 ], who sepa- (Gefühlston der Emfi ndungen ). Wernicke con- rated ‘protopathic sensation’ (poorly localized, trasts the ‘tone’ of sensation, with its ‘sensory conveying sensations of heat, cold and pain), content’. (See also: L30, p. 207: ‘tone of feeling’ from ‘epicritic sensation’ (permitting better spa- vs. ‘quality of sensations’). The former might be tial localization of touch, pressure, etc.). These clarifi ed as ‘emotional tone’. However, two were also separated by their different rates of Gefühlston, is used in a sense different from both recovery (‘protopathic’ sooner than ‘epicritic’) Emotionen , and Affekt (section VIII,(h). after experimental severing of peripheral nerves ‘Wernicke’s Distinctive Clinical Concepts in in the hand (the experimental subject in this case Psychiatry’ [Affective Impact of Mental being Henry Head himself). Wernicke’s use of Illnesses ]). He refers here to aspects of a stimulus the term ‘organ sensation’ is broader in scope associated with some inner ‘drive’ or motive for than ‘protopathic sensation’, and does not appear action. The term then becomes synonymous with to imply vagueness of spatial localization, and, ‘organ sensation’ (again in L6 and later), usually unlike the latter term, includes sensory input from in the original as Organempfi ndung , or muscles and joints (‘proprioception’ in English Organgefühl . The unifying theme appears to be terms), and that controlling eye movements. that ‘organ sensations’ are ones whose primary ‘ Papilla optica’ (L26. p. 174): optic nerve role is related to near-automatic refl ex or behav- papilla, the slight swelling, where nerve axons ioural responses, rather than to detailed conscious originating in the retina head towards the optic awareness. This is not the same as ‘emotional nerve, and the brain. tone’ where the emphasis is on sensory quality ‘Parametrium’ (L24, p. 157): The fi brous layer which may be linked to behaviour, but not to between the bladder anteriorly, and the supravag- behaviour which may be disassociated from any inal cervix, posteriorly. necessary sensory quality. Organ sensations, with ‘Paranoia’: generically, for Wernicke this their implication for automatic refl exive behav- meant a state where there is falsifi cation of con- iour, may be linked with perception at entry to the tents of consciousness (not ‘persecution delu- cortex, but not with memory images elaborated sion’—which is a vernacular meaning today). from these perceptions in higher cortical regions. Wernicke preferred ‘paranoid state’. The term translated here as ‘organ sensation’ has ‘Pathological’/‘Pathology’ (pathologische / a complex history in nineteenth century German krankhafte; Pathologie ): Wernicke limits this scientifi c thought. They can be traced back to almost entirely to abnormal fi ndings at a biologi- Johannes Müller’s Elements of Physiology [215 ], cal level, rather than at an experiential, psycho- and, for him, had a relation to an unresolved issue logical or social level. For abnormality at the about vitalism [216 ]. They were also linked to later levels he is almost completely consistent in sensations arising in defi nite organs (which using Krankhafte . Editorial Commentary 451

‘ Pavor nocturnus ’ (L39, p. 301): night terrors. meaning separate from the English word ‘psy- ‘Peak of illness’: The German word chopath’). This is an important point in Krankheitshöhe can mean either ‘level’ or ‘peak’ contrasting Wernicke’s ideas with those of of illness. Jaspers. The only possible exceptions are on ‘Perception’ (Wahrnehmung ). See above for p. 67, where ‘pathological principles’ ( patholo- separation from ‘Apperception’. gischen Prinzipes) are seen to underlie explana- ‘Perplexity’: see ‘Disarray’ tory delusions; and on p. 111, where we read: ‘To ‘Personality’/‘Personhood’: see Synopsis, L7, show how symptoms of mental illness are derived for use of terms. See section VI,(d). ‘Wernicke’s from this schema, and to put their occurrence and Underlying Philosophical Views’ (Wernicke on importance in various mental illnesses in their Personhood, Unity of a Person, and proper perspective, would be a separate and inde- ‘Self-consciousness’ ) pendent teaching exercise; yet any such attempt ‘Perytyphlitis’ (L39, p. 307): Infl ammation of might take us too far from our real task, which is the connective tissue about the caecum and to become familiar with specifi c cases of illness. appendix: in other words ‘appendicitis’. I shall therefore restrict myself just to the most ‘Phenazismen’ (L19, p. 117) archaic, exact important problems of identifi cation from a theo- meaning unclear retical point of view: I shall discuss these sepa- ‘Phrenic nerve insuffi ciency’: (L12, p. 75; rately, in some detail, as ones which are quite L30, p. 211). This phrase—probably Wernicke’s essential for understanding the general pathology own—does not refer to actual pathology in the of mental illnesses. These are mainly symptoms phrenic nerve, but to a style of breathing, domi- falling in the domain of hallucinations or which nated by costal rather than diaphragmatic muscu- have internal links with such symptoms.’ (empha- lature, likely to be a symptom of hysteria rather sis added) than a disorder of the peripheral nervous system. ‘Psychophysical’: A signifi cant word, ‘Physiological’ (e.g. L13, p. 82): ‘… physi- invented by Fechner. (See pp. 46, 68, 73, 80). ological delusions of reference…’ This word is ‘Psychophysiology’ In L13 (p. 80) we read: contrasted with ‘pathological’, indicating, ‘When introducing psychophysiology, I com- ‘within the normal physiological range’, or mented …’ This is the only time he uses this ‘relatively normal, in the prevailing context’ word in his main text, but he appears to refer back (also L15, p. 33). However, the word is some- to the general heading for L1–8, where the word times used in a more general sense (e.g. L39; appears only at the start of his ‘Contents’ list. p. 307). ‘Psychosis ’: see section VIII,(d). ‘Wernicke’s ‘Politzer method’ (L24, p. 158): A manoeuvre Distinctive Clinical Concepts in Psychiatry’ devised by Adam Politzer in Vienna in 1863, ( Wernicke’s Concept of Mental Illness/Disease. ) using increased air pressure in the nasopharynx ‘Puerperium’ (L32, p. 224), more commonly during the act of swallowing in order to reopen called the ‘post-partum period’ of ~6 weeks. blocked Eustachian tubes, and to equalize pres- ‘Registration’ (fi rst used in L2, p. 13): In sures in the sinuses. accord with the sAZm sequence, Wernicke refers ‘Polyneuritic psychosis’ (L27, p. 179): a.k.a. to the result of the stage s to A as ‘Korsakoff syndrome’. Ausgangsvorstellung (literally ‘output presenta- ‘Psychiatry/Psychiatrie/Psychiater’ (L34, tion’, but sometimes rendered as ‘initial percep- p. 253). These terms came into used after term tion’). Here and subsequently (e.g. L8, L2, L29) Johanne Christien Reil in 1808 coined the term we use the term ‘registration’. Psychiatrie; and they were introduced in France, ‘Resistance’ (L34, p. 244): German: from 1846. They are rarely used in Grundriss Widerstand (Title of book; pp. 253, 326). ‘Seizure’ In Wernicke’s day this was not lim- ‘Psychopathology’: Wernicke never uses the ited to epileptic seizures, an ambiguity recog- word psychopathologie (although, on a single nized in Lang’s medical dictionary of [213 ]. instance, on p. 96, he uses ‘psychopathische’—a ‘Silly’: Dumm. 452 Editorial Commentary

‘Spiritual acquis ’ (‘endowment’) (L39, p. 301; lost. Thus, for Wernicke the meaning of the term L40, p. 314): geistigen Besitzstand. appears to be almost the opposite of that given it ‘Stimulation’/‘Stimuli’: The usual German by later writers. However, the later writers dis- word is ‘Reiz’. tinguish ‘true’ from ‘morbid’ transitivism, which ‘Strength’ (of a concept: Festigkeit ) fi rst used may reconcile these divergent views. in L4 (p. 22) implying ‘security’ or ‘robustness’. ‘Transitory psychosis’ (p. 240): the so-called ‘Substantial’: ehebliche or wesentlich. ‘twilight states’. ‘Substantive’: enhaltlich. ‘Trichinae’ (L24, p. 159): Small parasitic ‘Symptom’ ( Symptome): In English the word nematode worm. ‘symptom’ is sometimes restricted to what a ‘Trophic’ (p. 273) anatomical change due patient complains about, while ‘sign’ is some- mainly to nutritional defi ciency. thing a doctor observes for him- or her-self. This ‘Tuberculosis’/‘Phthisis’: usually German usage is not very consistent, but is a signifi cant is‘ Lungenschwindsucht ’. distinction. Wernicke does not make this distinc- ‘The urge to be active’ (L31, p. 217): The tion for the word Symptome (fi rst used, L1, p. 4, German word Tätigkeitsdrang has no exact see for example, L37, p. 280, where the word English equivalent. ‘Impulsiveness’ has a dif- includes objective evidence from neurological ferent meaning. The word ‘impulse’, or more examination, and subjective evidence—a often ‘impulsive’ has a long history of use to patient’s complaints.); so ‘grandiosity,’ for refer to a more specifi c psychological urge. Wernicke, is a Symptome, although observed by ‘Impulse’ was adapted in Newtonian mechanics him, rather than being a patient’s complaint. to have a more specifi c quantitative meaning Since the distinction is not made consistently in (integral of force over time). (See also ‘Motor English, we translate it as ‘symptom ’. impulse’). ‘Tangible’ (L41, p. 328), presumably a change ‘Vicarious melancholia’ (L30, p. 215), an at the level of gross, rather than microscopic attack of recurrent mania is replaced by one of anatomy. Affective melancholia (see also L33, p. 239). ‘Tenesmus’ (L24, p. 155): A feeling of con- ‘Visual’: In L6 Wernicke often uses optische , stantly needing to pass stools, or void urine, which, in English coveys more of a physics- than despite empty rectum or bladder. a brain-based notion. We render optische as either ‘Thought disorder’: Denkstoerung. ‘visual’ or ‘visual perception/perceptual’. ‘Transitivism’ (L21, p. 137): Wernicke intro- ‘Visual agnosia’ (Seelenblindheit ), literally duced the term, to describe patients who show no ‘blindness in the mind’, usually translated as sign of psychological malaise, but whose entire ‘visual agnosia’ (fi rst used in L3, p. 16), but way of thinking and feeling led him to abandon sometimes as ‘psychic blindness’. ‘Visual agno- any assumption of similarity in trains of thought, sia’ means literally ‘failure of visual knowledge’. behaviour and conduct, which he otherwise In the context of a person born blind ‘visual would apply. The word became part of psycho- agnosia’ is not exact . analytic vocabulary, discussed especially by Wernicke’s Latin and Greek expression child psychologists such as Charlotte Bühler (excluding medical terms): (1893–1974) and Jacques Lacan (1901–1981). For such writers, the concept is closely linked to L3, p. 19 Cum grano salis (‘with a grain of salt’) development of a sense of personal identity, and L7, p. 39: κατ ’ εζοχηv (‘to a prominent degree’) for Bühler, was revealed by the fact that very L13, p. 79: Causa effi ciens (‘effi cient cause’ young children often do not distinguish sharply [after Aristotle]) between their own experiences and those of oth- L13, p. 82: sit venia verbo (‘forgive the word’) ers. Transitivism as defi ned by Bühler is rela- L14, p. 87: tua res agitur (‘It is a matter that con- tively normal, the abnormality coming when it is cerns you ’) Editorial Commentary 453

L18, p. 112: a priori (‘from the outset’) 16. Ellenberger HF. Discovery of the unconscious: the L18, p. 114: Pater familias (‘father of the family’) history and evolution of dynamic psychiatry. New York: Basic Books; 1970. L34, p. 258: prognosis quo/ad vitam (‘Prognosis 17. Ziehen T. Psychiatrie für Ärzte und Studierende. and life expectancy’) Berlin: F Wreden; 1894. 18. Pillman F. Carl Wernicke (1848-1905). J Neurol. 2003;250:1390–1. 19. Seitelberger F. Theodor Meynert (1833-1892) pioneer and visionary of brain research. J Hist Neurosci. XVII. References 1997;6:264–74. 20. Whitrow M. Theodor Meynert (1833-1892): his life 1. Krahl A, Schifferdecker M, Beveridge A. Carl and poetry. Hist Psychiatry. 1996;7:615–28. Wernicke and the concept of ‘elementary symptom’. 21. Dalzell TG. Freud and the Viennese psychiatrists. Hist Psychiatry. 1998;9(36):503–8. In: Dalzell T, editor Freud’s Schreber between psy- 2. Bartsch AJ, Neumärker KJ, Franzek E, Beckmann chiatry and psychoanalysis. On subjective disposi- H. Karl Kleist, 1879-1960. Am J Psychiatry. tion to psychosis. London: Karnac Books; 2011. 2000;157(5):703. p. 149–98. 3. Cohen RS, Seeger RJ, editors. Ernst Mach, physicist 22. Meynert T. Psychiatry; a clinical treatise on diseases and philosopher. Dordrecht: D Reidel; 1970. of the fore-brain based upon a study of its structure, 4. Ziehen T, Wernicke C. Monatsschr Psychiatr Neurol. functions, and nutrition. Part I. New York and 1906;18:I–IV. London: GP Putnam’s Sons; 1885/1968. p. 247. 5. Lengwiler M. Psychiatry beyond the asylum: the ori- 23. von Kölliker RA. Neurologische Bemerkungen. Z gins of German military psychiatry before World wissen Zool. 1849;1:153–63. War I. Hist Psychiatry. 2003;14:41–62. 24. Weigert C. Beiträge zur Kenntnis der menschlichen 6. Sherlock EB. Lunacy practice in Germany. Lancet. Neuroglia. Frankfurt am Main: M Diesterweg; 1905;166(4291):1565–8. 1895. 7. Dock LL. The rise of the German free sisters. In: 25. Buda O, Arsene D, Ceausu M, Dermengiu DE, Dock LL, Nutting MA editors. A history of nursing, Curca GC. Georges Marinesco and the early research from the earliest times to the present day with spe- in neuropathology. Neurology. 2009;72(1):88–91. cial reference to the work of the past thirty years. 26. Wundt WM. Grundzüge der physiologischen New York: GP Putnam’s Sons; 1912. Psychologie. Leipzig: Engelmann; 1874. 8. European Charter of Patients’ Rights. 2002. http:// 27. Pareti G. The ‘all-or-none’ law in skeletal muscle ec.europa.eu/health/ph overview/co operation/ and nerve ﬁ bres. Arch Ital Biol. 2007;145(1):39–54. mobility/docs/health services co108 en.pdf 28. May CA. Description and function of the ciliary 9. NHS Patients’ Rights. 2013. http://www.nhs.uk/ nerves - some historical remarks on choroidal inner- choiceintheNHS/Rightsandpledges/NHS vation. Exp Eye Res. 1997;65(1):1–5. Constitution/Documents/2013/handbook-to-the- 29. Parent A. The history of the basal ganglia: the contri- nhs-constitution.pdf bution of Karl Friedrich Burdach. Neurosci Med. 10. Centers for Medicare & Medicaid Services (CMS), 2012;3:374–9. HHS; Final Rule. Medicare and Medicaid Programs: 30. Haas L. Theodor Meynert (1833-92). J Neurol Changes to the Hospital and Critical Access Hospital Neurosurg Psychiatry. 1999;66(3):330. Conditions of Participation to Ensure Visitation Rights 31. Clarke PGH. pers. com. 19.08.2013. for All Patients. Federal Register. 2010;75:70831–44. 32. Kahlbaum KL. The clinico-diagnostic perspective in 11. Storch E. Psychologische Untersuchungen über die psychopathology (transl. Berrios GE), Die klinische- Funktionen der Hirnrinde, zugleich eine Vorstudie diagnostische Gesichtspunkte der Psychopathologie. zur Lehre von der Afasie [dissertation]. Breslau: Sammlung klinischer Vorträge 1878;126:1127–46. Universität Breslau; 1901. Hist Psychiatry. 2007;18(2): 231–3. 12. Berrios GE, Beer D. The notion of unitary psycho- 33. Bräunig P, Krüger S. Karl Ludwig Kahlbaum (1828- sis: a conceptual history. Hist Psychiatry. 1994;5(17): 1899) - a protagonist in modern psychiatry. Psychiatr 13–36. Prax. 2000;27(3):112–8. 13. Mann L. Klinische und anatomische Beiträge zur 34. Yaprak M. The axon reﬂ ex. Neuroanatomy. Lehre von der spinalen hemiplegia. Dtsch Z 2008;7:17–9. Nervenheilkd. 1896;10:1–66. 35. Spencer H. The principles of psychology. London: 14. Miller R. Approaches to learning spatial relation- Longman, Brown, Green and Longman; 1855. ships in gross anatomy: perspective from wider prin- 36. Rainy H. On the action of diphtheria toxin on the ciples of learning. Clin Anat. 2000;13:439–43. spinal stichochrome cells. J Pathol Bacteriol. 15. Levelt WJM. A history of psycholinguistics: the pre- 1900;6(4):435–58. Chomskyan era. Oxford: Oxford University Press; 37. Mickle WJ. General paralysis of the insane. London: 2012. p. 383. HK Lewis; 1886. 454 Editorial Commentary

38. Nitrini R. The history of tabes dorsalis and the 60. Dejerine JJ, Gauckler E. Les manifestations fonctio- impact of observational studies in neurology. Arch nelles des psychonévroses et leur traitement par la Neurol. 2000;57(4):605–6. psychothérapie. Paris: Masson; 1905. 39. Argyll Robertson DMCL. Four cases of spinal mio- 61. Kretschmer E. Hysteria, reﬂ ex and instinct. sis: with remarks on the action of light on the pupil. New York: Philosophical Library; 1923/1960. Edinburg Med J. 1869;15:487–93. 62. Mach E. On thought experiments. In: Erkenntnis und 40. Folsom CF. The early diagnosis of progressive paral- Irrtum. Leipzig: JA Barth; 1905. ysis of the insane. Boston Med Surg J. 1881;104: 63. Miller R. Validating concepts of mental disorder: 558–60. precedents from the history of science. Biol Cybern. 41. Pfeiffer JAF. A case of Landry’s paralysis with espe- 2014;108(5):689–99. cial reference to the anatomical changes. Brain. 64. Blüh O. Ernst Mach: his life as a teacher and thinker. 1913;35:293–305. In: Cohen RS, Seeger RJ, editors. Ernst Mach – physi- 42. Gowers WR. On the borderland of epilepsy: vertigo. cist and philosopher. Dordrecht: D Reidel; 1970. Br Med J. 1906;2(2377):128–31. 65. Mach E. The analysis of sensations and the relation 43. Lopez Piñero JM. The work of John Hughlings of the physical to the psychical. 1886/1905: (transl. Jackson: Part 2. Hist Psychiatry. 2010;21:224–36. Williams CM, Waterlow S (editor)); New York: 44. Eadie MJ. Cortical epileptogenesis - Hughlings Dover; 1959. Jackson and his predecessors. Epilepsia. 66. Bacon F. Novum Organum, 1620 (repr. Fowler T 2007;48(11):2010–5. (editor)). Oxford: Clarendon Press; 1888 45. Jackson JH. A study of convulsions. Trans St 67. Lotze H. Medizinische Psychologie oder Physiologie Andrews Med Grad Assoc. 1870;3:162–204. der Seele. Leipzig: Weidmann; 1852. 46. Jackson JH. On temporary mental disorders after 68. Hume D. An abstract of a treatise on human nature. epileptic paroxysms. West Riding Lunatic Asylum Keynes JM, Sraffa P, editors. Hamden, CT: Archon Medical Reports. 1875;5:105–129. Books; An abstract of treatise in human nature. 47. McKenna PJ, Lorente-Rovira E, Berrios 1740/1965. GE. Confabulation as a psychiatric symptom. In: 69. Spinoza B. Ethics. 1677: (transl. Curley EM), The Kirstein W, editor. Confabulation: views from neuro- collected writings of spinoza, vol. 1. Princeton: science, psychiatry, psychology and philosophy. Princeton University Press; 1985. Oxford: Oxford University Press; 2009. 70. Heidelberger M. Functional relations and causality in 48. Pearce JMS. Positive and negative cerebral symp- Fechner and Mach. Philos Psychol. 2010;23(2):163–72. toms: the roles of Russell Reynolds and Hughlings 71. Bohr N. The quantum postulate and the recent devel- Jackson. J Neurol Neurosurg Psychiatry. opment of atomic theory. Nature. 1928;121:580–90. 2004;75(8):1148. 72. Mill JS. A system of logic. London: Longman, 49. Kahlbaum KL. Die Gruppirung der psychischen Green; 1879. Krankheiten und die Einteilung der Seelenstörungen. 73. Hebb DO. The organization of behavior: a neuropsy- Danzig: AW Kafeman; 1863. chological theory. New York: Wiley; 1949. 50. Kuechenhoff B. The psychiatrist Auguste Forel and 74. Locke J. An essay concerning human understanding. his attitude to eugenics. Hist Psychiatry. London: Penguin Books; 1689/2004. 2008;19:215–23. 75. Kant I. Critique of pure reason (transl. Meiklejohn 51. Egdahl A. Linnaeus’ ‘Genera Morborum’ and some JMD). London: JM Dent & Sons Ltd; 1781/1934. of his other medical works. Med Library Hist 76. Mojtabai R. Delusion as error: the history of a meta- J. 1907;5(3):185–93. phor. Hist Psychiatry. 2000;11:3–14. 52. Beer MD. Psychosis: from mental disorder to dis- 77. Berrios GE. Delusions as ‘wrong beliefs’: a concep- ease concept. Hist Psychiatry. 1995;6:177–200. tual history. Br J Psychiatry. 1991;159 suppl 53. Noll R. Dementia praecox, 1886: a new turning 14:6–13. point? Hist Psychiatry. 2012;23:255–6. 78. Hacking I. Les Aliénés voyageurs: how fugue became 54. Kraam A, Phillips P. Hebephrenia: a conceptual his- a medical entity. Hist Psychiatry. 1996;7:425–49. tory. Hist Psychiatry. 2012;23(4):387–403. 79. Naef M. Ein Fall von temporärer totaler teilweiser 55. Berrios GE. Presbyophrenia: the rise and fall of a retrograder Amnesie [dissertation]. Universität concept. Psychol Med. 1986;16:267–75. Zürich; 1898. 56. Schifferdecker A, Peters UH. The origin of the con- 80. Megarbane B, Resiere D, Shabafrouz K, Dutholt G, cept of paranoia. Psychiatr Clin North Am. Delahaye A, Delerme S, Baud F. Descriptive study 1995;18:231–49. of patients admitted to an intensive care unit during 57. Dowbiggin I. Delusional diagnosis? The history of the heat wave of August 2003 in France. Presse Med. paranoia as a disease concept in the modern era. Hist 2003;32:1690–8. Psychiatry. 2000;11:37–69. 81. Mead GH. Mind, self and society from the perspec- 58. Munro A. Delusional disorder: paranoia and related ill- tive of a social behaviorist. Chicago: University of ness. Cambridge: Cambridge University Press; 1999. Chicago Press; 1934. 59. Beard GM. Neurasthenia, or nervous exhaustion. 82. Ball KL. Non-psychotic traits of schizophrenia as Boston Med Surg J. 1869;80:217–21. abnormalities of cerebral asymmetry: development Editorial Commentary 455

of a potential early screening instrument [disserta- 103. Miller R. A neurodynamic theory of schizophrenia tion]. Dunedin NZ: University of Otago; 2011. and related disorders. Morrisville (NC): Lulu 83. James W. The will to believe; and other essays in Enterprises; 2008. popular philosophy. New York: Longmans, Green & 104. Berrios GE. Descriptive psychopathology: concep- Co.; 1897. tual and historical aspects. Psychol Med. 1984;14(2): 84. Creed RS, Denny-Brown DE, Eccles JC, Liddell 303–14. EGT, Sherrington CS. Refl ex activity of the spinal 105. Chen HC, Flores d’Arcais GB, Cheung cord. Oxford: Clarendon Press; 1932. SL. Orthographic and phonological activation in rec- 85. Grant G. The 1932 and 1944 Nobel Prizes in physi- ognizing Chinese characters. Psychol Res. ology or medicine: rewards for ground-breaking 1995;58:144–53. studies in neurophysiology. J Hist Neurosci. 106. Kihlstrom JF. To honor Kraepelin. From symptoms 2006;15(4):341–57. to pathology in the diagnosis of mental illness. In: 86. John ER. Mechanisms of memory. New York: Beutler LE, Malik ML, editors. Rethinking the Academic Press; 1968. DSM: a psychological perspective, Decade of 87. Miller R. Meaning and purpose in the intact brain. behaviour. Washington, DC: Am Psychol Assoc; Oxford: Oxford University Press; 1981. 2002. p. 279–303. 88. Miller R. Cortico-hippocampal interplay and the 107. Berrios GE. Jaspers and the fi rst edition of representation of contexts in the brain. Heidelberg: Allgemeine Psychopathologie. Br J Psychiatry. Springer; 1991. 2013;202:433. 89. Braitenberg V. Cell assemblies in the cerebral cor- 108. Mullen PE. A modest proposal for another phenom- tex. In: Heim R, Palm G, editors. Lecture notes on enological approach to psychopathology. Schizophr biomathematics, vol. 21. Heidelberg: Springer; Bull. 2007;33(1):113–21. 1978. p. 171–88. 109. Hoenig J. Schneider’s fi rst rank symptoms and the 90. Adrian ED. Double representation of the feet in the tabulators. Compr Psychiatry. 1984;25(1):77–87. sensory cortex of the cat. J Physiol. 1940;98:16–8. 110. Widiger TA, Crego C. Diagnosis and classifi cation. 91. Gordon G. Active touch. The mechanism of recogni- In: Weiner I, Stricker G, Widiger TA, editors. Wiley tion of objects by manipulation: a multi-disciplinary handbook of clinical psychology. New York: Wiley; approach, 1977. Oxford: Pergamon Press; 1978. 2013. p. 3–18. 92. Miller R. A theory of the basal ganglia and their dis- 111. Miller R. Schizophrenia as a progressive disorder: orders. Boca Raton (FL): CRC Press; 2008. relations to EEG, CT, neuropathological and other 93. Olds J, Milner PM. Positive reinforcement produced evidence. Prog Neurobiol. 1989;33:17–44. by electrical stimulation of septal and other areas of 112. James W. What is an emotion? In: James W, editor. rat brain. J Comp Physiol Psychol. 1954;47: Collected essays and reviews. 1884/1969. New York: 419–27. Russell and Russell; 1969. p. 244–80. 94. Manni R. Rapid eye movement sleep, non-rapid eye 113. Lange C. The emotions. In: Dunlap K, editor. movement sleep, dreams, and hallucinations. Curr Psychology classics. Baltimore: Williams & Wilkins; Psychiatry Rep. 2005;7(3):196–2000. 1922. p. 33–90. 95. Plazzi G, Montagna P, Meletti S, Lugaresi 114. Störring GE. Wesen und Bedeutung des Symptoms E. Polysomnographic study of sleeplessness and der Ratlosigkeit bei psychischen Erkrankungen. oneirisms in the alcohol withdrawal syndrome. Leipzig: Thieme; 1939. Review J Nerv Ment Dis. Sleep Med. 2002;3:279–82. 1940;92:798. 96. Wernicke C. Lehrbuch der Gehirnkrankheiten, für 115. Bleuler E. Dementia praecox: or the group of schizo- Ärzte und Studierende. Kassel: Th. Fischer; 1881. phrenias (transl. Zinkin J) 1911/1950. New York: 97. Jorge RE, Robinson RG, Starkstein SE, Arndt SV, International University Press; 1950. Forrester AW, Geisler FH. Secondary mania follow- 116. Moskowitz A, Helm G. Eugen Bleuler’s Dementia ing traumatic brain injury. Am J Psychiatry. Praecox or the Group of Schizophrenias (1911): a 1993;150:916–21. centenary appreciation and reconsideration. 98. Mohr P, Volavka J. Ladislav Haskovec and akathisia: Schizophr Bull. 2011;37(3):471–9. 100th anniversary. Br J Psychiatry. 2002;181:537. 117. Bested AC, Logan AC, Selhub EM. Intestinal micro- 99. Khushf G. Why bioethics needs the philosophy of biota, probiotics and mental health: from medicine: some implications of refl ection on con- Metchnikoff to modern advances: Part I – autoin- cepts of health and disease. Theor Med. toxication revisited. Gut Pathog. 2013;5:5. 1997;18(1–2):145–63. 118. Noll R. Kraepelin’s ‘lost biological psychiatry’? 100. Maj M. Mental disorders as “brain diseases” and Autointoxication, organo-therapy, and surgery for Jaspers’ legacy. World Psychiatry. 2013;12(1):1–3. dementia praecox. Hist Psychiatry. 2007;18: 101. Thome J. Centenary of Karl Jaspers’s general psy- 301–20. chopathology: implications for molecular psychia- 119. Peters A, Payne BR. Numerical relationships try. J Mol Psychiatry. 2014;2(1):3. between geniculo-cortical afferents and pyramidal 102. Jaspers K. General psychopathology. Baltimore: The cell modules in cat primary sensory cortex. Cereb Johns Hopkins University Press; 1997. Cortex. 1993;3:69–78. 456 Editorial Commentary

120. Miller R. Striatal dopamine in reward and attention: 139. Drabkin IE. Caelius Aurelianus: on acute diseases a system for understanding the symptomatology of and on chronic diseases. Chicago: University of acute schizophrenia and mania. Int Rev Neurobiol. Chicago Press; 1950. 1993;35:161–268. 140. Dysert A. Capturing medical tradition: Caelius 121. Snell L. Die Ueberschätzungsideen der Paranoia. Aurelianus’ on acute diseases. Hirundo. Allg Z Psychiat. 1890;46:447–60. 2006–2007;5:161–73. 122. Neisser C. Dissertation on paranoia from the clinical 141. Haier RJ. Pain sensitivity, evoked potentials and the point of view. 1892. In: Alvarez JM, Hill F, editors. dexamethasone suppression test in depressed Classics paranoia. Spain: DOR Editions Ltd; 1997. patients. Psychiatry Res. 1983;10(3):201–6. p. 85–112. 142. Öhrström E, Rylander R, Björkman M. Noise annoy- 123. Balzan R, Delfabbro P, Galletly C, Woodward ance with regard to neurophysiological sensitivity, T. Confi rmation bias across the psychosis continuum: subjective noise sensitivity and personality vari- the contribution of hypersalient evidence- hypothesis ables. Psychol Med. 1988;18:605–13. matches. Br J Clin Psychol. 2013;52(1):53–69. 143. Whitehead WE, Holtkotter B, Enck P, Hoelzl R, 124. Leonhard K. Cycloid psychoses - endogenous psy- Holmes KD, Anthony J, Shabsin HS, Schuster choses which are neither schizophrenic nor manic MM. Tolerance for rectosigmoid distention in irrita- depressive. Br J Psychiatry. 1961;107:633–48. ble bowel syndrome. Gastroenterology. 1990;98: 125. Phillips CG. Cortical localization and ‘sensorimotor 1187–92. processes’ at the ‘middle level’ in primates. Proc R 144. Nakaaki S, Murata Y, Furukawa TA. Effi cacy of Soc Med. 1973;66:987–1002. olanzapine augmentation of paroxetine therapy in 126. Freud S. The psychopathology of everyday life patients with severe body dysmorphic disorder. 1901/1914 (transl. Brill AA). London: T Fisher Psychiatry Clin Neurosci. 2008;62(3):370. Unwin; 1914. 145. Uzun Ö, Özdemir B. Aripiprazole as an augmenta- 127. Friedmann M. Über den Wahn, eine klinisch- tion agent in treatment-resistant body dysmorphic physiologische Unterstellung, nebst einer Darstellung disorder. Clin Drug Investig. 2010;30(10):707–10. der normalen Intelligenzvorgänge. Wiesbaden: JF 146. Loréa N, Van Wijnendaele R. Body dysmorphic dis- Bergmann; 1894. order and psychosis. Case reports and discussion. 128. Court JH. Manic-depressive psychosis: an alterna- Encéphale. 2012;38(1):37–41. tive conceptual model. Br J Psychiatry. 1968;114: 147. Ziehen T. Die Ideenassoziation des Kindes. Samml 1523–30. Abh Geb pädagog. Psychol Physiol. 1898;1:1–66. 129. Keatinge B. Beckett and language pathology. J Mod 148. Kohs SC. The association method in its relation to Lit. 2007;31(4):86–101. the complex and complex indicators. Am J Psychol. 130. Doesburg SM, Kitajo K, Ward LM. Increased 1914;25:544–94. gamma-band synchrony precedes switching of con- 149. Mach E. Die Geschichte und die Wurzel des Satzes scious perceptual objects in binocular rivalry. von der Erhaltung der Arbeit. Prague: JG Calve; 1872. Neuroreport. 2005;16:1139–42. 150. Healy D. Some continuities and discontinuities in 131. Geschwind N. Disconnexion syndromes in animals the pharmacotherapy of nervous conditions before and man. Part I. Brain. 1965;88(2):237–94. and after chlorpromazine and imipramine. Hist 132. Foucault M. Folie de déraison: Histoire de la folie à Psychiatry. 2000;11:393–412. l’âge classique. Paris: Union Générale d’Éditions; 151. Weber MM, Emrich HM. Current and historical con- 1961. cepts of opiate treatment in psychiatric disorders. Int 133. Molnar M. pers. com. 1.04.2014. Clin Psychopharmacol. 1988;3(3):255–66. 134. Meynert T. Psychiatry: a clinical treatise on diseases 152. Sandyk R. Naloxone withdrawal exacerbates of the fore-brain based upon a study of its structure, Tourette’s syndrome. J Clin Psychopharmacol. functions, and nutrition (transl. Sachs B). New York: 1986;6(1):58–9. GB Putnam’s Sons; 1885. 153. Sandyk R. The effects of naloxone in Tourette’s syn- 135. Freud S. New introduction to psychoanalysis. drome. Ann Neurol. 1985;18(3):367–8. 1920/1973. Harmondsworth: Penguin Books; 1973. 154. Hening WA, Walters AS, Kavey N, Gidro-Frank S, 136. Beer MD. The dichotomies: psychosis/neurosis and Cote L, Fahn S. Dyskinesias while awake and peri- functional/organic: a historical perspective. Hist odic movements in sleep in restless legs syndrome: Psychiatry. 1996;7:231–55. treatment with opioids. Neurology. 1986;36:1363–6. 137. Freud S. The justifi cation for detaching from neuras- 155. Eadie MJ. Sir Charles Locock and potassium bro- thenia a particular syndrome: the anxiety neurosis. mide. J R Coll Physicians Edinb. 2012;42(3):274–9. 1894/1953, Collected papers, Vol 1, London: The 156. Medsafe New Zealand. Data Sheet. Paraldehyde Hogarth Press; p. 76–106. injection solution 100 %. 2009. http://www.medsafe. 138. Slade T, Andrews G. Exclusion criteria in the diag- govt.nz/profs/datasheet/p/Paraldehydeinj.pdf nostic classifi cations of DSM-IV and ICD-10: revis- 157. Philpott WH, Kalita DK, Goldberg B. A brief history iting the co-occurrence of psychiatric symptoms. of magnet therapy. 1996. http://www.innerself.com/ Psychol Med. 2002;32(7):1203–11. Health/history magnets.htm Editorial Commentary 457

158. Steinberg H. Electrotherapeutic disputes: the semantic priming before and after clinical improve- ‘Frankfurt Council’ of 1891. Brain. 2011;134: ment. Eur Psychiatry. 2002;17(2):69–74. 1229–43. 175. Dannlowski U, Kersting A, Arolt V, Lalee-Mentzel J, 159. Exchange Supplies. The history of injecting and the Donges US, Suslow T. Unimpaired automatic pro- development of the syringe. 2014. http://www. cessing of verbal information in the course of clinical exchangesupplies.org/article history of injecting and depression. Depress Anxiety. 2006;23(6):325–30. development of the syringe.php 176. Foster PS, Yung RC, Branch KK, Stringer K, 160. Pakkenberg B, Gundersen HJG. Neocortical neuron Ferguson BJ, Sullivan W, Drago V. Increased spread- number in humans: effect of sex and age. J Comp ing activation in depression. Brain Cogn. 2011;77(2): Neurol. 1997;384(2):312–20. 265–70. 161. Malamud N. Lissauer’s dementia paralytica: a study of 177. Hart RP, Kwentus JA, Hamer RM, Taylor its pathogenesis. Arch NeurPsych. 1937;38(1):27–42. JR. Selective reminding procedure in depression and 162. Hung SC, Hung SH, Tarng DC, Yang WC, Chen dementia. Psychol Aging. 1987;2(2):111–5. TW, Huang TP. T hiamine defi ciency and unex- 178. Morina N, Deeprose C, Pusowski C, Schmid M, plained encephalopathy in hemodialysis and perito- Holmes EA. Prospective mental imagery in patients neal dialysis patients . Am J Kidney Dis. 2001;38(5): with major depressive disorder or anxiety disorders. 941–7. J Anxiety Disord. 2011;25(8):1032–7. 163. Jacobson RR, Lishman WA. Cortical and dience- 179. Kwapil TR, Hegley DC, Chapman LJ, Chapman phalic lesions in Korsakoff’s syndrome: a clinical JP. Facilitation of word recognition by semantic and CT scan study. Psychol Med. 1990;20(1): priming in schizophrenia. J Abnorm Psychol. 63–75. 1990;99(3):215–21. 164. Forsgren L, Nyström L. An incident case-referent 180. Andreou C, Bozikas VP, Ramnalis A, Giannakou M, study of epileptic seizures in adults. Epilepsy Res. Fokas K. Semantic priming in remitted patients with 1990;6(1):66–81. bipolar disorder. J Behav Ther Exp Psychiatry. 165. Hesdorffer DC, Hauser WA, Annegers JF, Cascino 2013;44(1):48–52. G. Major depression is a risk factor for seizures in 181. Besnier N, Richard F, Zendjidjian X, Kaladjian A, older adults. Ann Neurol. 2000;47(2):246–9. Mazzola-Pomietto P, Adida M, Azorin JM. Stroop 166. Hesdorffer DC, Ludvigsson P, Hauser WA, Olafsson and emotional Stroop interference in unaffected rel- E. Depression is a risk factor for epilepsy in chil- atives of patients with schizophrenic and bipolar dis- dren. Epilepsia. 1998;39 suppl 6:222A. orders: distinct markers of vulnerability. World J 167. Kanner AM. Depression in epilepsy: prevalence, Biol Psychiatry. 2009;10(4 Pt 3):809–18. clinical semiology, pathogenic mechanisms, and 182. Weissman MM, Wickramaratne P, Merikangas KR, treatment. Biol Psychiatry. 2003;54(3):388–98. Leckman JF, Prusoff BA, Caruso KA, Kidd KK, 168. Kanner AM, Schachter SC, Barry JJ, Hersdorffer Gammon GD. Onset of major depression in early DC, Mula M, Trimble M, Hermann B, Ettinger AE, adulthood: increased familial loading and specifi c- Dunn D, Caplan R, Ryvlin P, Gilliam F, LaFrance Jr ity. Arch Gen Psychiatry. 1984;41(2):1136–43. WC. Depression and epilepsy, pain and psychogenic 183. Todd RD, Botteron KN. Etiology and genetic of non-epileptic seizures: clinical and therapeutic per- early-onset mood disorders. Child Adolesc Psychiatr spectives. Epilepsy Behav. 2012;24(2):169–81. Clin N Am. 2002;11(3):499–518. 169. Cramer JA, Blum D, Reed M, Fanning K, Epilepsy 184. Pauls DL. The genetics of obsessive compulsive dis- Impact Project Group. The infl uence of comorbid order and Gilles de la Tourette’s syndrome. Psychiatr depression on seizure severity. Epilepsia. Clin North Am. 1992;15(4):759–66. 2003;44(12):1578–84. 185. Beaumont PJV. Phenomenology and the history of 170. Schwabe MJ, Konkol RJ. Menstrual cycle-related psychiatry. Aust NZ J Psychiatry. 1992;26:532–45. fl uctuations of tics in Tourette syndrome. Pediatr 186. Parish E. Hallucinations and illusions: a study of the Neurol. 1992;8(1):43–6. fallacies of perception. London: Walter Scott 171. Moreira L, Bins H, Toressan R, Ferro C, Hartmann Publishers; 1897. T, Petribú K, Juruena MF, Rosaro MCD, Ferrão 187. Hagen FW. Die Sinnestäuschungen in Bezug auf YA. An exploratory dimensional approach to pre- Psychologie, Heilkunde und Rechtspfl ege. Leipzig: menstrual manifestation of obsessive compulsive Otto Wigand; 1837. disorder symptoms: a multicentre study. J Psychosom 188. Hagen FW. Zur Theorie der Hallucinationen. Allg Z Res. 2013;74(4):313–9. f Psych. 1868;25:1–113. 172. Whitehead AN. The aims of education, and other 189. Tamburini A. A theory of hallucinations. Hist essays. 2nd ed. New York: MacMillan Company; Psychiatry. 1990;1:151–6. 1929. 190. Berrios GE. The history of mental symptoms: descrip- 173. Georgieff N, Dominey PF, Michel F, Marie-Cardine tive psychopathology since the nineteenth century. M, Dalery J. Semantic priming in major depressive Cambridge: Cambridge University Press; 1996. state. Psychiatry Res. 1998;78(1-2):29–44. 191. Parent A, Parent M, Leroux-Hugon V. Jules Bernard 174. Besche-Richard C, Passerieux C, Hardy-Baylé Luys: a singular fi gure of 19th century neurology. C. Lexical decision tasks in depressive patients: Can J Neurol Sci. 2002;29(3):282–8. 458 Editorial Commentary

192. Rolleston H. The history of haematology. Proc R 205. Muller GE, Pilzecker A. Experimentelle Beiträge zur Soc Med. 1934;27(9):1161–78. Lehre vom Gedächtnis. Zeitschr Psych. 1900;1:1–300. 193. Schäfﬂ e A. Bau und Leben des sozialen Körpers. 206. Holliday R. Epigenetics: a historical overview. Tübingen: Laupp; 1896. Epigenetics. 2006;1(2):76–80. 194. Stiles A. Robert Louis Stevenson’s Jekyll and Hyde, 207. Haig D. The (dual) origin of epigenetics. Cold and the double brain, 1500-1900. Stud Engl Lit. Spring Harb Symp Quant Biol. 2004;69:67–70. 2006;46(4):879–900. 208. Moser G, Vacariu-Granser GV, Schneider C, Abatzi 195. App U. Richard Wagner and Buddhism. Rorschach/ TA, Pokieser P, Stacher-Janotta G, Gaupmann G, Kyoto: UniversityMedia; 2011. Weber U, Wenzel T, Roden M, Stacher G. High inci- 196. Taylor M. ‘The Wishing-table, the Gold-ass, and the dence of esophageal motor disorders in consecutive Cudgel in the Sack’ by The Brothers Grimm. 1884. patients with globus sensation. Gastroenterology. http://classiclit.about.com/library/bl-etexts/grimm/ 1991;101:1512–21. bl-grimm-wishingtable.htm 209. Danek A. ‘Hypermetamorphosis’. Heinrich Neumann’s 197. Frojmovic E. Imagining the self, imagining the (1814-1884) legacy. Nervenarzt. 2007;78(3):342–6. other: visual representation and Jewish-Christian 210. Denny-Brown D. Cerebral control of movement. dynamics in the Middle Ages and early modern Liverpool: Liverpool University Press; 1966. period. Leiden: Brill; 2002. 211. Klüver H, Bucy PC. An analysis of certain effects of 198. Sösemann B. Hollow-sounding jubilees: forms and bilateral temporal lobectomy in the rhesus monkey effects of public self-display in Wilhelmine with special reference to ‘psychic blindess’. J Germany. In: Mombauer A, Deist W, editors. The Psychol. 1938;5:33–54. Kaiser. New Research on Wilhelm II’s Role in 212. Lang H. A German-English dictionary of terms used Imperial Germany. Cambridge: Cambridge in medicine and the allied sciences. Philadelphia: P University Press; 2003. p. 37–62. Blakistons’s Son & Co; 1907. 199. Shorter E. A historical dictionary of psychiatry. 213. Hecker E. Zur klinischen Diagnostik und Prognostik New York: Oxford University Press; 2005. der psychischen Krankheiten. Allg Z Psychiatrie. 200. Moscovitz A. pers comm. 23.05.2014 1877;33:602–20. 201. Freud S. Entwurf einer psychologie. 1895. In: 214. Janet PMF. Major symptoms of hysteria. New York: Bonaparte M, Freud A, Kris E, editors. Aus den Macmillan; 1906. p. 329–32. Anfängen der ischer, Frankfurt AM, 1950/1975. 215. Müller JP. Handbuch der Physiologie des Menschen p.297–384 Psychoanalyse 1887–1902. für Vorlesungen. Coblenz: J Hölscher; 1833. 202. Murphy G. Personality, a biosocial approach to ori- 216. Finger S, Wade NJ. The neuroscience of Helmholtz gin and structure. New York: Harper and Row; 1947. and the theories of Johannes Müller: Part 1: nerve 203. Exner S. Entwurf zu einer physiologischen Erklärung cell structure, vitalism and the nerve impulse. J Hist der psychischen Erscheinungen. Leipzig: F Neurosci. 2002;11:136–55. Deuticke; 1894. 217. Rivers WHR, Head H. A human experiment in nerve 204. Heim G. pers comm. 26. 05. 2014. division. Brain. 1908;31:323–45. Index

A Allopsychoses , 183, 337, 407, 410, 411, 415 Absent-mindedness , 130 , 348 asymbolic , 183 Abulia , 266 , 443 chronic , 65 Acousma , 117 , 443 hyperkinetic 274 Acoustic patterns , 6 manic , 239, 274 Adaptability (to environment) , 39 paralytic , 281 Administration of mental hospitals , 334, 346 Allosomatopsychoses three categories of patient for , 342 acute , 272 Adolescence, as developmental stage , 359, 388, 399 chronic , 65 Aegophony , 443 Alzheimer, Alois , 358, 431 Aetiology , 335, 337, 364, 400 Alzheimer’s disease , 358, 431, 435 general vs. special , 337 Amentia (Meynert) , 240, 336, 352, 443 inferred from symptoms , 337 Amnesia , 358, 377, 405 internal vs. external , 407 psychogenic (hysterical) , 405 as ‘proximate cause’ , 337, 364, 408, 420 retroactive , 48, 180, 183, 190 ‘psychological’ vs. ‘organic’ , 379 Amyl hydrate , 428 of psychoses , 104, 307 Anaesthesia (symptom) , 331 rejection of by Wernicke, for classiﬁ cation , 420 psychosensory , 65 transitional periods of life and , 337, 434 Analogies, use of by Wernicke , 331 Affect , 48 electrical , 424, 444 exhaustion of , 100 ‘enclosed pipe’ , 351, 424 integration with cognition , 421 energy , 424, 425 Affective reactions , 385, 410 errors due to , 425, 426 Affective states , 332, 334, 385, 406 graphical , 334, 424 abnormal mental states and , 385 hydraulic , 391, 424, 425 reinforcement principle and , 376 from medical to mental disorders , 403, 425 After-images , 16, 355 magnetic , 352 Agoraphobia , 436 from neurology to psychiatry , 374, 379, 424, 425 Akathisia , 336, 379 reasoning by , 424–425 Akinesia , 335, 374, 378, 384, 396, 397, 399, 400, 413 resonance , 402, 425 intrapsychic , 13, 208, 257, 262, 336 from syphilis/progressive paralysis to mental illness , partial , 76 375, 425 psychosensory , 336 Analysis (clinical) tube feeding in , 340 based on individual habits of patients’ thoughts , Alcohol 418–419 acute effects of , 442 based on life events , 418–419 chronic effects of , 335, 340, 356, 358, 359, 412, 434 levels of , 382 episodic binge drinking and , 169, 190, 335, 369 Anticonvulsants , 428 withdrawal syndrome , 340 (see also Delirium tremens ) Anti-psychiatry movements , 340 Alcoholic degeneration , 176 , 340 Anxiety , 335, 350, 379, 415, 443 epilepsy and , 176 allopsychic , 413, 415, 417, 418 restoration, after period in hospital , 340 autopsychic , 413, 414, 415, 418 psychoses and , 294 hysterical , 360

Anxiety (cont.) arguments for , 342 localized feelings of , 135, 373 family visits to , 343 somatopsychic , 373, 405, 413 (see also Symptoms functions of , 323–324, 342, 345–346 (specifi c), consion) life within , 333, 342 states , 413 ‘only for the insane’ , 340 Anxiety ideas , 81, 142, 413, 414, 415 tertiary syphilis patients in , 339 with anxiety psychoses , 146 neurological patients in , 339 Anxiety neurosis , 149, 211, 405 staff (‘warders’) , 342, 439, 449 Anxiety psychosis , 333, 335, 360, 381, 396, 401, 409, violence within , 342 410, 413, 416, 418 voluntary patients in , 341 acute , 145 Atrophy , 443 aetiology , 147, 281 Asymbolia , 128, 183, 379, 416, 443 combined with Affective melancholia , 148 Atonicity , 443 combined with motility psychoses , 276 Attentiveness , 47, 79, 332, 348 course , 147 distraction of, as source of delusions , 114 diagnosis , 148 excessive fi xation by , 447 hypochondriacal , 150, 153, 161, 281, 304 lapses of , 419 prognosis , 149 measurement of , 47 symptoms , 146 paradoxical sudden shifts of , 419 treatment , 149 processing resources and , 424–425 Aphasia , 6, 379, 404, 424, 443 selectivity of , 332, 406, 417, 419, 443–444 manic , 127, 448 Autoallopsychosis, chronic , 65 schema for , 6 Autochthonous (‘self-generated’) ideas , 68, 73, 74, 113, transcortical , 379, 424 130, 361, 390, 392–393, 397, 404, 409, 410, 443 ‘Apoplectiform’ attack , 443 as primary abnormalities , 333, 334, 335, 388 in senescence , 320 Automatism , 406 Apoplexy. See Stroke Autonomic nervous system , 384, 404 Argyll-Robertson pupil (Pupillary rigidity) , 280, 356 Autopsychoses Aristotle , 370 acute , 185, 195, 335, 336, 361, 383, 407, 410, 412, ‘Arsenic green’ , 443 414, 416 Arsenic poisoning, psychosis following , 296 circumscribed , 93 ‘Associated-signs’ (Griesinger) , 106 expansive due to autochthonous ideas , 195 , 336, Association pathways , 5, 18 409, 410 aberrant , 115, 395 in paralysis , 219, 277, 280 binding, fi rmness of , 66, 125, 370, 371, 387, 414 hebephrenic , 303 cells , 23 Autosomatopsychoses cerebral cortex, as organ of , 365, 372, 393, 412, 426 acute , 272 dissolution/breakage of , 333, 371, 387, 398–399 chronic , 65 ( see also Sejunction) Avoidance (of recall) , 406 structure of , 21, 22, 23 Axons transcortical , 23 ‘all-or-none- law’ , 353, 391–392 Association (psychological) conduction time in , 353 across time , 363, 371 cortico-cortical , 354 (see also Association pathways) Affect accompanying process of , 429 ‘law of isolated conduction’ , 4, 353 ambiguity of , 388 signal information independent of energetics in , concept formation and , 331, 366, 373, 374 353, 392 delusion formation and , 195 Ego complex and , 404 hallucinations and , 390 B indirect , 398–399 B acon, Francis , 362, 367, 424 intrinsically error prone , 367–368 Bacteriology , 355, 380 motivational drives and , 399 Baillarger, Jules , 354, 431 overvalued ideas and , 395–396 Basal ganglia , 354, 358, 373, 376, 390, 412–413 pathological facilitation in mania , 336 functions of , 354 processes of , 333, 393 inhibition of by cortex , 376 semantic priming and , 430 intestinal sensation and , 354 word association tests and , 423 lentiform nucleus , 376, 449 ‘Associationist school’ , 370, 371–373 symptoms arising in , 153 Asylums (mental hospitals) Wernicke’s account of melancholia and , 376 alternatives to , 337, 341 Behaviourism , 332 Index 461

Beliefs (normal) , 388 Cerebral cortex , 415, 418. See also Sensory cortical areas bizarreness of , 369, 387, 388 activity level in , 335, 352, 398, 418 as components of personhood , 332 ‘association’ areas in , 378, 391 contradictions within , 388, 401 atrophy of , 287, 319 developed socially in institutions , 343 cytoarchitectonic map of , 435 explanatory , 392 excitation vs. inhibition in , 358, 370–371, 376, 426 fl exibility of , 396 integration across regions , 334, 402 overvalued ideas and , 388 interaction with hippocampus , 372, 388, 412, 414 persistence of , 393, 398 laminar structure of , 352, 354, 429, 435, 446–447 psychotic (see Delusions) lesions of , 374, 420 Benzodiazepines , 377 motor region of , 372, 374, 376, 397, 413 Berger, Oskar , 431 multimodal convergence in , 402 Bertillon, Jacques , 339 number of neurones in , 429 Beziehungswahn . See Delusions, of relatedness; projection areas for taste/smell , 354 Delusions, of reference pyramidal cells in , 354, 446, 447 Bilroth, Theodor , 437 as ‘organ of association’ , 354, 372, 376, 393, Bipolar disorder. See Manic-depressive illness 412–413, 426 Binswanger, Otto , 350, 359, 431, 436 sensory thresholds and , 413 Bismarck, Otto von , 342, 440, 442 sharpened attention and , 419–420 Bladder hypochondria , 156 suppressing subcortical activity , 358 Bleuler, Eugen , 383, 398, 420 Cerebral hemispheres, size of, encephalization , 355 debt to Wernicke , 387 Cerebral localization. See ‘Localization’ ‘Blind thrashing behaviour’ , 360 ‘Channeling’. See Attentiveness, selectivity of Body position (posture) , 371 Character /‘Personality’ , 49, 332, 420, 450 Body weight, behaviour of, in acute psychoses , alteration of, in mania , 217 100, 311 alteration of in progressive paralysis , 318 Bohr, Niels , 364 ‘brain habits’ and , 382–383, 396 Bonhöffer, Karl , 346 choleric personality , 216, 299 Brain-softening , 444 theory of , 383–383 Brain weight table in psychoses , 297–288 , 424 Charcot, Jean-Martin , 350, 357, 360, 369, 379, 403, Breslau , 338, 339, 342, 346–347, 351 431, 432 bacteriology and dermatology at , 339 Charité hospital, Berlin , 431, 432, 436 medical scene in 1890s , 339 Chloroform anaesthesia , 340 Wernicke’s institute in , 339, 412 treatment , 428 Broca, Paul , 431 Chorea , 230, 336, 405, 444 Broca’s convolution , 5, 40, 374, 391 Circular mental illness , 220 Bromide , 427 Classifi cation of mental disorders , 343, 407–419, 433 Buffon, Georges , 377, 406 based on administrative requirements , 333, 383–384, Burghölzli Mental Asylum , 423, 432, 433, 435 407, 421 Burdach, Karl Friedrich , 354 based on aetiology/pathology , 382, 421 based on clinical science , 333, 407, 421 based on illness course/outcome , 409, 421, 432 C based on likelihood of recovery , 407 C achexia , 340 based on severity , 407, 409 Cajal, Santiago Ramón y , 353, 354, 446 based on symptom clusters , 421 Histologie du Système Nerveux de L’Homme et des broad vs. narrow criteria , 408–409 Vertébrés , 354 categorical , 334, 407–408, 409, 412, 418–419 Camphor , 427 comorbidity and , 408–409 Catalepsy , 253, 336, 444 exclusion criteria and , 409 Catatonia , 352, 355, 360, 396, 408, history of , 406–407 433–434 ‘natural order’/‘natural types’ and , 406 ‘Cause’/Causality , 363–365, 443 over-inclusive defi nitions and , 408–409 John Stuart Mill and , 364 personal authority and , 421, 422 falsely equated with ‘logic’ , 420 purposes of , 406, 407–408 need for , 23, 85 rejection of aetiology as principle for sense of, as inbuilt bias , 364 (Wernicke) , 420 substituted by correlation , 361, 420 standardization of , 383–384 substituted by mathematical ‘function’ , 364 theory of (see Taxonomy) Cerebellum , 413 Wernicke’s critique of , 334, 406, 418–419 Cerebral asymmetry , 370, 438, 449 Claustrophobia , 437 462 Index

Clinical case presentations in Grundriss , 332, 335, neuronal cell bodies and , 365–366 345, 410 of one’s own body (corporeality) , 25, 28, 267, 332, complicating presentation of ideas in Grundriss , 412 334, 368, 404 deliberate ambiguity in Wernicke’s wording in , 350 of outside world , 22, 332, 334, 97 neurological as introduction to psychiatric, 334, 378–379 of personhood , 37, 54, 332, 334, 367 opportunistic choice of patients , 345 processes of , 332, 377 use for therapeutic ends , 344, 401 retrospective correction of contents of , 86, 87 use of insightful recovered patients , 347–348 self-consciousness , 368, 369 Clinical examination, methods of , 348 states of , 404 attentiveness , 348 three-way split of contents of , 332, 334 auditory acuity , 348 threshold of , 44, 352 axon fl are refl ex , 348 translation issues and , 365 cognitive capacity , 348 ‘unity’ (narrowness) of , 23, 46, 363 long-term memory , 348 Consciousness, activity of , 43, 54 pupillary refl exes , 348 vs. contents of , 376, 409 short-term memory , 348 Consumer activism , 380 Cocaine , 336-337, 434 Contemplative obsession , 199 psychosis , 296, 431 Contracture position after motility psychoses , 265 Coercion, means of , 325, 342–343 Conversion hysteria , 360, 405–406 Cohnheim, Julius , 431 Conversion symptoms and , 335, 360, 403–404, 405–406 Coma , 48 Coprolalia , 379 Committal, to asylum Corporeality, consciousness of , 332, 351–352, 354, 363, appeal against , 341 404, 414 procedures, initiated by public , 341 Course (of mental illnesses) , 310, 333, 407–408, legal criteria for , 341 409–410, 432, 434 Common sensation, disturbances of , 163, 447 depiction/graphical plot of , 311, 334, 337, 410 Community mental health care , 341 improving vs. worsening , 334, 378, 414, 443, 445 Compulsive speech , 13, 379 intensity vs. extent (range) of symptoms , 337, 410 in mania , 217 ‘natural course’ for disease entities , 419 in motility psychosis , 263 processes leading to chronic disorder , 347 in paralytics , 282 Cramer, August , 431 paraphasic , 127 Cramps, childhood , 340 psychomotor , 227 Cranial nerves , 354 Concepts, abstract , 45 Cranial vault, changes, in paralysis , 288 concrete , 22 Criminality , 39 loss of , 316 Critic , 123 ‘ Conceptualization centre’ , 6, 331, 374, 424 Cullen, William , 336, 404, 405, 443, 444 Conductivity, change in , 13 Confabulation , 87, 180, 183, 357, 359, 379 as memory of dream , 87 D Confusion , 385, 400, 415, 418, 443, 445 D alton, John , 426 acute (see Amentia) Darwinism , 436, 438, 439 agitated , 235, 336, 349 recapitulation theory and , 400, 438 asthenic , 240, 380 social , 358, 434, 436, 142 genetic , 234, 372, 387, 446 Deceptive appearances, legitimate content of , 142. See fl ight of ideas , 216 also Hallucinations and Illusions manic , 398 Decision making, by brain , 372 primary asthenic , 241, 274 impairment in , 207 primary (dissociative) , 235, 240 increased facility of , 217 substantive , 103, 313 melancholia and , 376 Consciousness , 16 Decortication , 288 alternating , 188 ‘Deduce’ (abzug )/deduction , 362, 368, 406, 422, 423, 445 in animals , 366 confused with inductive inference , 387–388, 427 cerebral cortex and , 365 ‘context’ needed for deduction , 388 contents of , 16, 21, 43, 66, 332, 334, 404, 410 deduction not a natural skill , 368 defi ned by process of association , 365–366 Defaecation hypochondria , 145 frontier with unconscious processes , 404 Defi cit symptoms. See Symptoms, negative grades of , 46, 48, 404 Degeneration , 358–359, 401, 426, 445 ‘herd’ , 344 alcoholic , 176, 340 narrowing of , 406 cross-generational, in families , 358–359, 434–435 Index 463

evolutionary theory and , 358–359 relation to hallucinations , 395 hysteric , 302 retrospective explanatory , 334, 394 neurotic , 219 somatopsychic , 394, 395, 396, 410, 416 Délire chronique à evolution systématique , 104 stable vs. developing , 393 Delirium , 349, 394–395, 416, 419, 445 systematization of , 67, 87, 400 acute , 273 ways to attenuate , 395–396 clouding of consciousness in , 419 ways to exacerbate , 395–396 grandiosity in , 417 Delusions of belittlement (micromania) hysteric , 301 in affective melancholia , 142, 207 occupational , 173, 441 in anxiety psychoses , 147 paralytic , 281 fantastic , 209 ‘primordial’ (Griesinger) , 105, 113, 385 in obsession psychosis , 200 sensory , 390 Delusions of persecution , 360, 378, 379, 394, 410, 445 Delirium tremens , 173, 335, 340, 346, 377, 391, 490 in acute hallucinosis , 170 aetiology , 175 altruistic , 170 chronic , 179 based on need for explanation , 56 chronic, protracted , 294 hypochondriacal , 83 combination with epilepsy , 183 physical , 70, 75 diagnosis , 176, 409, 413, 418 primary , 106 fi rst-person description of , 440 Delusions of reference, 394–395, 410, 416, 435, 438, 445 insomnia in , 377, 412 Delusions of relatedness , 378, 394, 395, 411, 418, 445 pathological fi ndings in , 177 in acute psychoses , 82 symptoms in , 173, 412, 418 allopsychic , 83 treatment of , 176 autopsychic , 82 Delusional disorder (‘monomania’) , 105, 360, 398, 436 in healthy people , 82 Delusional mood , 433 retrospective , 87 Delusions (general), 55 et seq ,113 et seq. , 392–396, somatopsychic , 83 412, 445 Delusions, specifi c content Affective concomitants , 395 belittling , 336, 445, 448–449 allopsychic , 394, 396, 410 fantastic hypochondriacal , 272, 282 by analogy , 114 grandiose , 378, 394, 412, 446, 448 associative spread of , 395 hypochondriac , 394 autopsychic , 394, 396, 410, 448 of infestation , 389, 390 belief in reality of , 377, 430 lycanthropic , 439 bizarreness of , 388 of pregnancy , 411 belief in reality of , 377, 430 religious , 76, 395, 411 bizarreness of , 388 Dementedness . See Paranoia changed sensory input and , 394 Dementia , 72, 314, 337, 352, 357, 399–400, 411, 443 confi rmation bias and , 396 acquired , 314, 337 corrective explanations and , 368, 423 aetiologies of , 317 defi nitions of , 367 alcoholic , 319 diagnostic non-specifi c nature of , 382 combination of stressors and , 400 differentiation from delirium , 394–395 congenital , 314, 337 empirical testing of , 401 context of occurrence , 337 epistemological assumptions in , 367 diagnosis of , 314 explanatory , 333, 345, 379, 395, 396, 416 epileptic , 319 as ‘falsifi cation of consciousness’ , 332, 360, 367, grades of , 337, 400–401 381, 392 hebephrenic , 303, 319 formed by learning-like process , 393, 430 mentally chaotic rather than systematised , 400 habitual style of thinking and , 396 not irreversible , 400 as half-serious ‘make believe’ , 430 paralytic , 284, 318 history of understanding of , 367 post-apoplectic , 519 impact of social milieu on , 342 processes leading to , 349 as interpretations of motor abnormality , 394 senile , 320 as interpretations of symptoms of medical disorders, 407 Dementia praecox , 399, 436 lapses of attention and , 394 Bleuler and , 387 parable, metaphor, analogy and , 395 hebephrenia and , 399–400 ‘physiological’ , 451 Kraepelin and , 359, 360, 389–390, 399, 408, 421, as rational interpretations , 333, 343, 344, 392–393, 430, 434 395, 423 Dengue fever , 356, 369 464 Index

Depression/depressive disorder , 335, 430, 445, 448 E Description in psychiatry , 362 E ating disorders , 335, 410 inseparable from interpretation , 362 anorexia nervosa , 381, 390, 410 interdependent with explanation , 362 ‘Eburnisation’ , 445 Determinism , 361, 370 Echolalia , 282 Diagnosis , 335, 409 Education level (of patients) , 368, 382, 394, 419, conventions for, lack of in Wernicke’s day , 339 420, 423 critique of , 350–351, 408 ‘Ego’, the, (das Ich ) , 404 differential , 333, 356, 412, 418 Affective overlay of , 429 Diagnostic and Statistical Manual (American Psychiatric complex dynamic structure of , 368–370 Association), 383, 408, 409 ‘Ego complex’ , 404–405 Didactic principles , 332, 347 fragmentation of , 368 tension with practical realities in teaching , 347 held together by logical coherence , 423 Diphtheria , 339, 355 history of concept , 404–405 toxin , 355 motor mechanisms and , 372 Discharge (from hospital) origin in sense of corporeality , 351, 414, 438 criteria for , 341 ‘primary’ (Meynert) , 351, 368, 404 obstacles to , 56, 60, 98 ‘shame’ and , 429 planning , 342 ‘soul’ and , 370, 404 Disarray , 134, 275, 334, 410, 418, 423, 445, 451 Einstein, Albert , 364, 365 allopsychic , 135, 414 Electra complex , 390 autopsychic , 135, 385, 416 Electrical treatment , 428 motor , 137 Electroencephalography , 425 non-appearance of , 137 Emminghaus, Hermann , 351, 432 somatopsychic , 135, 396, 414, 416 Emotions , 370, 445 translation issues (Ratlosigkeit ) , 385–386 ‘emotional incontinence’ , 319, 445 treatments of , 136 James/Lange theory of , 384 Disease use of terms in Grundriss , 384–385 clinico-pathological correlations and , 380, 420 Empiricism , 338, 361, 362, 382 ‘cortical’ , 380 evidence-based medicine and , 361 ‘entities’ , 334, 419 Encephalitis (a.k.a. ‘Phrenesia’) , 75 general vs. localised , 338 Energy , 424, 445 history of debate over concept of , 380, 406–407 conservation of , 425, 445 infectious , 336, 355–356, 380 history of concept , 425 diseases not primary concepts for Wernicke, specifi c, of sensory elements , 338, 362 66, 125 translation issues , 380 Ependymitis granulosa , 288 Disease curve . See Course (of mental illness), ‘Epigenetic’ , 445 depiction/graphical plot of Epilepsy , 335, 341, 412–413, 431, 444 Disorientation , 133, 334, 385, 406, 411, 418, 445 differentiation from hysteria , 357 allopsychic , 391, 411, 413, 416, 418 focal symptoms and , 379 autopsychic , 411, 413, 416 pseudo-seizures , 357 somatopsychic , 411, 416 psychoses in , 297, 337 Dissimulation , 321 seizures in , 357, 429 Dissociation , 360, 369, 381 stigmatization of , 341 Dissociative Identity Disorder , 387 twilight states of , 341, 376, 452 Dizziness , 48 Esquirol, Jean-Étienne , 350, 363, 431, 432 Doppelgänger , 387 Ethology , 370 Dorsal column disease in paralysis , 281 Eugenics , 359, 431, 432 Duchenne (de Boulogne) , 332, 356, 431 Euthanasia , 342 inhibition and , 371 Exner, Sigismund , 432, 444 Dynamic tradition (in psychiatry) , 403–406 Experiment , 423, 446 ‘Ego’ , 404 thought (Mach) , 354, 361 individual analysis in , 419 vs. theory , 332 neurosis and , 405 Explanation in science subconscious/unconscious mental activity , 393, and defi nition, as interdependent , 362 403–404, 405 and patients’ explanatory delusions , 422 ‘symptom complex’ in , 404 relation to classifi cation , 421 Dyskinesias , 356 Eye movements , 18, 28, 35 Index 465

F Geisteskrankheit , 333, 379, 380, 448 Facial expression , 11 Geistesstörung , 333, 379, 380, 407, 448 Falret, Jean-Pierre , 432 General Paralysis of the Insane (GPI). See Progressive Falsifi cation of consciousness/memory , 53, 333, 357, paralysis 371, 411, 450 Genetics , 358–359 allopsychic , 59, 333, 410, 416 interaction with social factors , 359 autopsychic (personal identity) , 333, 381, 410 pre-disposition without overt psychotic illness , 430 chronic worsening , 64 Gestalt psychology , 362, 367 residual , 54, 87 Glial cells , 353, 436 secondary , 333 astrocytes , 291, 353 somatopsychic (bodily awareness) , 60, 62, 333, phagocytic role of , 353 381, 410, 416 proliferation of, after neuronal damage , 291, ‘Faradisation’ , 446 328, 353 Fechner, Gustav , 338, 352, 364, 365, 366, 369, 424, 432 ‘Globus pharynges’ , 446 Feeblemindedness . See Dementia Goldstein, Kurt , 346 ‘Fibrae propriae ’ (Meynert) , 446 Golgi, Camille , 353 Fit of rage, epileptic , 298 Goltz, Friedrick , 371, 432 Flechsig, Paul , 337, 434 Gowers, William , 432 Flight of ideas , 215, 236, 237, 349, 384, 399, 430 Grandiosity, ideas of , 349, 394, 417, 430, 436, 446 Focal symptoms , 4, 66 , 358, 374, 375, 379 consecutive , 56, 102 in progressive paralysis , 7, 290 emergence of , 106 Foerster, Otfrid , 347 maniacal , 219 Food refusal, paralytic , 219 in akinetic conditions , 76, 249 religious , 76 in melancholia , 209 Granule cell , 447 in somatopsychoses , 154 Griesinger, Wilhelm , 332, 349, 351, 359, 365, 385, 388, Forel, Auguste , 359, 369, 432, 435 394, 431, 434, 435, 448 Forensic psychiatry , 335 Grundriss, as a lecture series , 345, 412 Forster, Edmund , 347 accompanying class discussions , 345 Foucault, Michel , 403 clinical generalizations within , 412–419 Franco-German rivalry , 339, 350 lectures in tandem , 345–346 Franco-Prussian war , 335, 360, 441 profi les of class members , 346–347 Frankl, Victor , 402 progression of ideas developed in , 348 Freud, Sigmund , 350, 355, 360, 397, 425, 435, 437, 444 as research presentations , 346 the ‘Ego’ and , 404 Gudden, Berhard von , 432, 436 interactions with Wernicke , 403, 404 Guillain–Barré (–Strohl) syndrome , 357, 434 neurosis and , 405 repression and , 406 teleology and , 370 H Freund, Carl , 432 Habitual forms of mental illnesses , 242 Fritsch, Gustav , 337, 432, 433 Haeckel, Ernst , 401, 436, 438, 439 Functional change Haemoglobin , 433, 437 abnormality of , 13 Hagen, Friederich , 433 excess of , 13 Halle , 339, 351, 412 loss of function , 13 Hallucinations , 72, 73, 117, 333, 334, 361, 381, 384, Fundamental concepts , 333 388–392, 393, 396, 412–413, 426, 446. See also mass, force (physics, Newton) , 338, 362 Illusions sensation (Mach) , 338, 362 abnormal sensory input and , 390 symptoms (Wernicke) , 332, 412, 421 changed in disorders of the projection fi elds , 126 Charles Bonnet syndrome and , 392 combining sensory modalities , 121 , 334 G dependence on affect , 142, 402 G anglion cells. See Cerebral cortex, pyramidal cells in diagnostic non-specifi c nature of , 382 Ganser, Sigbert , 432 differentiation from illusions , 334 Gastric feeding tube, use of , 257 dreamlike , 114, 122, 125, 167 , 377, 390, 416 Gastroenterology , 389–390 (see also Twilight states) Gastroenterostomosis , 437 ‘elementary’ , 127 Gaupp, Robert Eugen , 347 Esquirol and , 431 Gehirnkrankheit , 379, 448 explanatory delusions for , 69 466 Index

Hallucinations (cont.) Holism , 343, 378, 401–403, 421 functional , 119 based on brain science , 401 genuine in content, deceptive in appearance , 142 ‘binding problem’ and , 401–402 incorrigibility of , 79, 119 , 389 incompatibility with medical concepts of mental kinaesthetic , 431 illness, 419 localization of (in brain) , 126 integration of mental faculties and , 402 as major elementary symptom , 388 ‘personal wholeness’ and , 344, 402, 403, 419, 421 meaningful images in , 390, 420 relation of elementary to secondary symptoms and , 422 ‘memory image becomes a visual image’ , 391 ‘resonance’ metaphor and , 402 multimodal , 389 unifi cation of Affect and cognition , 402, 421 non-verbal auditory , 389 unifi cation of percepts and concepts , 402 progressive paralysis and , 390 Wernicke’s clinical style and , 402 reduced sensory input and , 391 Hôpital de la Salpêtrière , 350, 431, 433 re-enactments of past trauma and , 389 Hume, David , 364 refl ex (Kahlbaum) , 390 Hydraulic metaphors , 392, 425 release from inhibition and , 365 Hydrocephalus , 422 as sensory deceptions , 333, 388 externus , 288 sejunction theory and , 72, 123, 386, 388, 391–392 internus , 288, 294, 295, 352, 422 by suggestion in Delirium tremens , 172 Hyoscine , 234, 427, 428 tactile , 69, 121, 389, 416 Hyperaesthesia of the sense organs , 130, 332, 334 of taste and smell , 119, 389 psychosensory , 13, 117, 162 theory of , 122, 334, 389–392, 433 Hyperkinesia , 366, 374, 384, 397, 400, 410, 427 by ‘top-down’ control of sensory regions , 390, 392 intrapsychic , 13, 216 unimodal , 334 psychosensory , 13, 376 verbal auditory (see ‘Phonemes’) Hypermetamorphosis , 128, 227, 334, 379, 418, 423, visual (see Visions) 429, 435, 447 when falling asleep , 391 Hyperthermia , 369 Hallucinosis , 333, 388 Hypnosis , 403, 431, 434 acute , 166, 294, 335, 385, 410, 417 animal , 397 acute progressive , 170 bridgehead for dynamic psychiatry , 403, 431 aetiology , 169, 281 Hypochondria , 374, 405, 410, 416, 417 418 422, 434. course , 170, 310 See also Somatopsychosis chronic , 106, 268, 334 abnormal sensations in , 416 diagnosis of , 169 hypochondriacal anxiety , 335 prognosis , 170 palsies of , 397 residual , 74, 82, 99 without Affective component , 416 treatment , 170 Hypoglossal paresis in Delirium tremens , 174 Happiness, unusual feeling of , 373 Hysteria , 187, 335, 350, 357, 361, 370, 377, 385, 431, hypochondriacal , 107, 142, 198 435, 437 perceptions of , 316 abnormal sensations in , 383 Head shape , 442 absences and , 337, 410 Heavy metal poisoning , 336 fugue, as male equivalent of , 369 Hebb, Donald , 366 hystérie traumatique (Charcot) , 360 neural assembly concept , 366, 373 ‘hystero-epileptics’ , 357 Hebephrenia , 107, 303, 337, 345, 359, 381, 399–400, 411 in men , 360, 369 Heboid , 193, 303 psychosis in , 301 Heboidophrenia , 193, 303 Hysterical paralysis , 264 Hecker, Ewald , 359, 399, 434, 448 Hegel, Georg Friedrich Wilhelm , 370 Heilbronner, Karl , 346 I Helmholz, Hermann von , 354, 363, 425, 430, 433 Identifi cation , 7, 22, 373 Helplessness. See Disarray (Ratlosigkeit ) disturbance of , 7, 12, 128, 173, 378, 413 Hemiplegia in paralysis , 286 Idiocy , 314, 447 hypochondriacal , 264 ‘Illness’ (as an individual affl iction) , 380, 411, 419 Hering, Heinrich , 433 Illusions , 69, 117, 140, 334 Heubner, Johann , 433 Affective states and , 402 Hidden variables , 332 Imagery, mental , 377, 430 Hippocampus , 373, 389, 403, 412 Imaging, functional , 352, 418 Hitler, Adolf , 347 Imbecility , 314 Hitzig, Edouard , 337, 432, 433, 435, 439 Imitation, drive to , 44 Index 467

Impulsive action , 143, 231 Jactation , 230, 401, 418, 447 Inanition delirium , 307, 337 James, William , 332, 369–370 Inanition psychoses , 293 Janet, Pierre , 350, 370, 388, 403, 406, 431, 445, 449 Incapacitation in paralysis , 287 Jaspers, Karl , 367, 380, 383, 397, 421, 450, 451 Incurability , 54, 67 Allgemeine Psychopathologie , 380 Indecisiveness , 315 Jealousy, drinker’s delusion of , 295 ‘Individual’ (translation issue) , 332 Jolly, Friedrich , 434 Individuality . See Personhood ‘Jumpiness’ in epileptics , 130 Inductive inference , 368 Jung, Carl Gustav , 402, 403, 424 Infl uenza , 293 Inhibition , 447 cognitive , 430 K mutual (reciprocal), in CNS , 371 K ahlbaum, Karl Ludwig , 349, 351, 352, 356, 358, 359, release from and positive symptoms , 358, 365 378, 382, 385, 387, 390, 397, 433, 434, 437, 444 neuronal , 371, 388, 390, 426 Kant, Immanuel , 369, 422 spinal , 371 Critique of Pure Reason , 366, 388 thought, and , 371 form vs. content , 348–349, 366, 382, 421 Initial perception , 1 neo-Kantian revival , 421 Insight into illness , 38, 333, 348, 377 psychological concepts , 382, 421 lack of , 55 , 394 synthetic a priori statements , 367, 372 loss of, as psychological reaction , 400 Kepler, Johannes , 426 recovery of , 343, 408 Kinaesthetic word images , 6 Instinctive behaviour , 376 Kleist, Karl , 336 Institutionalisation , 343 Kleptomania , 260 ‘Insuffi ciency’, subjective feeling of (melancholia) , 207 Koch, Robert , 356 Insurance (health) , 405 Kolk, Jacobus van der , 434 Interactions, internal (psychological) , 343, 383, 402, 403 Korsakoff, Sergei , 335, 358, 434, 435, 451 ‘Interest’ , 207 Kraepelin, Emil , 344, 348, 353, 356, 358, 359, 360, 362, Intermissions (in illness course) , 310 390, 397, 430, 431, 433, 435 International Classifi cation of Causes of Death (ICD) , approach to classifi cation , 362, 378, 408, 409, 421, 422 339, 408 military research and , 422 International Statistics Institute , 339 paraphrenia and , 358 Intestine, large , 332, 335, 390 textbook of , 399, 407 Intestinal sensations (‘gut feelings’) , 29 Wernicke’s attitude to , 353, 399 Intoxication , 377 Krafft-Ebing, Richard , 435 delirious states in , 175 Krankenvorstellungen aus der psychiatrischen Klinik in pathological state of, 175, 29, 184 Breslau , 346, 412 Intrapsychic function Krankheit (translation issues) , 380, 407 excess of , 18, 205 Kretschmer, Ernst , 360, 376, 402, 403 loss of , 13, 205, 261 ‘death feint’ and , 397, 444 Intrapsychic pathway , 13 delusions of reference and , 394 Introspection (‘internalization’) , 332, 345 recovery and , 401 used to develop hypotheses about brain , 366 L Involution, senile , 304 L andry’s paralysis. See Guillain–Barré (–Strohl) syndrome Irradiation Language , 332, 345 of refl exes , 31 Chinese script and , 382 of stimuli , 126 not the only way to organize consciousness , 345 of ‘will impulse’ , 263 semantic vs. phonetic organization in , 379 Irritable Bowel Syndrome , 390 Lateral column disorder in paralysis , 280 Isolation of mental patients , 324 Lateral column symptoms , 448 ‘Law of Effect’ , 373 ‘Law of Isolated Conduction’ , 435 J ‘ Law of Specifi c Energies ’ (Müller) , 354, 435 J ackson, John Hughlings , 350, 355, 398 Laws, on mental health classifi cation of epilepsies , 357 across Bundesländer , 341 hierarchy of functions in brain , 351, 355, 358, 336 British Mental Treatment Act (1930) , 341 his work not known to Wernicke , 357 Lead poisoning, subsequent psychosis , 296 ‘march of epilepsy’ , 357 Learning (acquisition of memory) , 332 separation of positive from negative symptoms , 358 synaptic plasticity and , 371–372 468 Index

Leeches , 428 course , 218 Leonhard, Karl , 397 diagnosis , 219 Liepmann, Hugo , 346 differentiation from schizophrenia , 399 Linnaeus, Carl , 359, 377, 406 excessive association in , 336, 399 style of nomenclature , 359 expatiating , 196 taxonomy of diseases , 359 heredity , 430 Lissauer, Heinrich , 347, 429, 434, 447 as intrapsychic hyperfunction , 13, 205 , 336, 349 Load, inherited , 219, 293 as intrapsychic loss of function , 13, 205, 243 Local signs of retina , 18, 27 ‘levelling of ideas’ in , 336, 398 Localization (of function in brain) , 127, 331, 370, neural basis of , 398 373–375, 425 periodic , 191, 236, 239, 417 classiﬁ cation of mental disorders and , 375 prognosis , 230 electrical stimulation and , 432, 374 progressive paralysis and , 336 lesion location and symptoms , 339, 373–374, 379, 432 puerperal , 233, 306 mental illness and , 375 pure , 215 motor symptoms and , 374 recurrent , 353, 452 orderly connectivity and , 374 relation to Affective melancholia , 399, 426 orderly topographic representation and , 355, 398 secondary , 379 relation to general clinical concepts , 357 symptoms , 215 Localization of sounds , 355, 420 temporal lobe lesions and , 379 Locke, John , 366, 393 treatment , 221 Lombroso, Cesare , 359 Manic-depressive illness , 408, 421 Lorentz, Hendrik , 364 Mann, Ludwig , 347 Lorenz, Konrad , 370 Marasmus , 448 Lotze, Hermann , 363, 436 Medical concepts and terminology for mental disorders , Lucid intervals in mania , 218 381, 403, 419–422 ‘Lunatic’/’lunacy’ , 448 incongruent with holistic concepts , 419 Luys, Jules , 434 prognosis and , 419 tension between mechanism and meaning , 420–421 Medical ethics statutes , 339, 407 M Medical practice in Wernicke’s day , 331 M ach, Ernst , 338, 339, 362–364, 365, 367, 422 emphasis on longitudinal course , 410 anti-metaphysical , 361 international developments , 339 ‘causality’ and , 364 military implications , 422 conservation of energy , 425 statistics on prevalence, lack of , 339, 408 Fechner and , 338 Medical records (at Breslau, Halle) , 378, 412 form vs. content in , 366–367 Medical technology , 427, 428 ‘local sign’ and , 363 infusion , 428 natural philosophy and , 338, 361, 362 intravenous injection , 428 personhood, complexity of , 368–369 ophthalmoscopy , 428 primary experience as foundation , 363, 382 Medulla oblongata , 448 psycho-physical parallelism and , 364 Medullary pyramid , 448 rejecting ‘absolute space’ concept , 363 ‘Medullary strips’/‘Medullary degeneration’. sensory physiology and , 338, 364 See White matter teleology and , 370 Megalomania , 448. See also Grandiosity, ideas of; thought experiments and , 362, 423 Delusions (speciﬁ c content), grandiose Magnan, Valentin , 350, 435 Melancholia , 335, 383, 398, 445, 448 Magnetic treatment , 428 agitated , 148, 414 Magnetism, animal , 352 attonita , 254 (see cum stupore ) Maladie du doute , 199 combined with mania , 336 Mania , 335, 336, 379, 397, 398–399, 411, 416, 417, depressive , 103, 208, 261, 336, 398, 422 430, 447 heritability , 431 aetiology , 219 hypochondriacal , 162, 422 agitated confusion, and , 336, 349 rebound of mania in , 342 choleric , 274, 278, 306, 418 recurrent (proxy) 213 , 220 chronic , 221 , 336, 353 seizures in , 429 combination with melancholia , 220, 336 vicarious , 452 compulsive activity in , 217 Melancholia, Affective , 207 , 359, 361, 378, 398, 408, confused , 236, 336, 349, 384, 387, 411, 417, 418 410, 417, 418, 422, 428 cortical overactivity in , 336, 398 aetiology , 210, 281 Index 469

decision making in , 376 residual , 333, 448 diagnosis , 211 sensory processing and , 413 hospital admission for , 340–341 separation of acute from chronic , 334, 354, as impairment of ‘will’ , 336, 398, 426 409–410, 419 mood change in , 335, 398 simulation of , 337, 346 prevalence of , 339 terminology for , 380 prognosis , 210 transitional periods of life and , 337, 349, 358, 400, 434 relation to mania , 399, 426 ‘unusual experiences’ and , 381 secondary changes in , 336, 398 Mental processes , 333 suicide risk in , 342 similarities to normality in psychiatric patients , 334, symptoms , 207 343, 344 treatment , 212, 427, 428 Metaphysics , 361 Memory Meyer, Adolf , 435 cells , 17 Meynert, Theodor , 336, 338, 348, 351, 352, 354, 355, consolidation of , 444 358, 365, 366, 368, 403, 409, 414, 424, 427, 434, continuity of , 366 435, 436, 438, 443, 446, 449 episodic , 412, 414 analogies, metaphors of , 351, 424 long-term , 348, 358 attitude of Wernicke to , 337, 351–352 loss of , 46, 180, 182, 283 , 340, 357 cerebral blood fl ow and associative processes , 352 ‘manipulation’ within , 332 hallucinations and , 390 of one’s own body , 332, 333, 412 inhibition and , 370, 371 of outer environment , 332, 333, 412 Parkinson’s disease and , 354 of personal life experiences , 332, 333, 412 primary Ego and , 352, 368, 404 as ‘remembered images’ , 331 Micromania , 415, 418, 445, 448–449. See also retention , 48, 348, 417 ‘Delusions of belittlement’ retrieval of , 332, 406 Mill, John Stuart , 365 semantic , 412 Mitgehen , 397 Mendel, Gregor , 359 Monakow, Constantin von , 435 Meningitis , 293 Monatsschrift für Psychiatrie und Neurologie , 3338, delirious states in , 176 351, 404 Meningoencephalitis , 288 Monomania , 105. See also Delusional disorder Menopause , 305 Moral insanity , 39, 193, 335, 340 Menstrual psychoses , 219, 305 Morbid self-reference (Neisser) , 394, 435 Menstruation , 336, 400, 412, 417, 428, 429, 448 Morphine . See Opium Mental illnesses Mortality in acute psychoses (asylum statistics) , acute syndromes of , 334, 409 313, 339 Affective impact of , 384–386 Motility psychoses , 336, 372, 381, 396, 399, 410, 413, bacteriological toxins and , 356, 389–390, 407 415, 430, 449 ‘brain diseases’, compared with , 331, 379 aetiology , 256 chronic , 334, 347–348, 381, 408 akinetic , 243, 336, 348–349, 352, 378, 400, 408, 411 combining impairments with advantages , 419 catatonic symptoms in , 399–400 confl ict between cortex and subcortex , 355 combination with other psychoses , 274 content vs. activity of consciousness in , 409 complete , 260 continuity vs. separateness from normal composite , 275, 276 psychology , 381 course , 255 criteria for declaring a person mentally ill , 340 cyclic , 259 defi nitions of , 381 diagnosis , 256 disease process , 407 as form of somatopsychosis , 418 as ‘diseases’ , 407, 419 hyperkinetic , 336, 366, 391, 400, 410, 417 disruption of associations in , 354 prognosis , 257, 260 dissimulation of , 337 relation to Dementia praecox , 400 distinguished from ‘mental disturbance’ , 334 symptoms , 249 dreaming and , 376 theory of , 268, 336 family history of , 359 therapy , 257 general vs. focal , 339 Motility psychoses, hyperkinetic , 224 internal vs. external causes , 407 aetiology , 226, 233 loss of sense of personal wholeness in , 344, 381, akinetic phases in , 259 402–403, 421–422 combination with other psychoses , 274 relapse prevention, principles of , 401 course , 233 relation to problems of general medicine , 340 diagnosis , 233 470 Index

Motility psychoses, hyperkinetic (cont.) ‘Nature’ , 362, 377, 406–407 prognosis , 234 Negativism , 249, 265 , 397, 449 symptoms , 226, 227 Neisser, Clemens , 394, 435 treatment , 233 Nerve current (nerve ‘stream’), 73, 79 Motionlessness , 249 ‘Nervous exhaustion’. See Neurasthenia Motor impulse , 449 Neumann, Heinrich , 352, 365, 427, 435, 447 Motor (motility) symptoms. See Names for specifi c Neurasthenia , 360, 431 symptoms Neuroglial cells , 353, 436 rarity of, today , 397 phagocytic role of , 353 Movement (motility) disorders , 411 astrocytes , 291, 353 compound , 336 proliferation of, after neuronal damage , 353 driven by abnormal sensations (hypermetamorphic) , Neurohistology , 339, 353 378, 336 Nissl method , 353, 431, 435 fragments of purposeful actions , 397 staining methods , 339, 353 heredity and , 337 Weigert methods , 353, 436 parakinetic , 336, 366 Neuroleptic (antipsychotic) medicines , 379, 393–394, of speech , 334, 336, 366 415, 444 Movement sensation , 32 Neurology , 356, 420 absence of (see Akinesia) disorders of , 379 restless , 233 relation to psychiatry , 379, 397, 422 stereotypical , 251 used to explicate mental disorders , 334, 379 Movements ‘Neuromythology’ (Jaspers) , 334 attack , 11, 33 Neurone classifi cation of (Meynert) , 11, 351 activation threshold , 430 defensive , 11, 33 theory , 339, 353, 432 disturbances of , 12 Neuropathology , 339, 375, 381, 383, 420, 429 exploratory , 332 correlation with clinical syndromes , 336, 358 expressive , 11, 12 neurone loss and , 384 eye , 374 processes of, in mental illnesses , 334, 337 385, 420 initiative , 11, 12, 75 random vs. constrained by meaning , 420 pseudospontaneous , 136, 226. 251 Neuropsychology , 334 reactive , 11 Neuroscience , 331 rhythmic , 268 as foundation for Grundriss , 338, 378 signifi cance of, for psychoses , 10 Neurosis , 405, 449 spontaneous , 33 compared to psychosis , 381, 444 Müller, _Johannes Peter , 354, 435, 436, 450 ‘epileptic’ , 405 Multiple (‘split’) personality, 369. See also ‘Second state’ history of use of term , 405, 444 Muscle hypochondriacal , 161, 381, 405 activation sensation , 32 obsessive , 199, 297 , 335, 405 coordination , 33 ‘railway neurosis’ , 405 electrical stimulation of , 332 Newton, Isaac , 338, 361, 365 pains , 349 Nietzsche, Friedrich , 437 relaxation , 377 Nissl, Franz , 347, 353, 435, 436 sensation , 29, 31, 389 Nothnagel, Hermann , 355 sensitization to pressure , 377 Nursing spasms , 340 care in institutions , 339, 427, 429 Mutacismus . See Mutism homes, advantages for recovery , 342 Mutism , 6, 321, 360, 381, 397, 437 nurses (see Asylum, staff (warders)) in akinesia , 246 religious or secular basis , 342 in hyperkinesia , 226 Nutrition , 400, 427 initiative , 263 reactive , 267 Myelin , 353, 357, 383, 436, 437, 447 O Obsession , 68, 73, 91, 384, 397, 405, 411 Obsessive-compulsive disorder , 379, 398, 429, 431 N Obsessive psychosis , 199, 297 N atural history , 378 Occipital lobes, diseases of , 28 Natural philosophy , 332, 361–362, 378, 427 Opinion, psychiatric , 105 European vs. English style , 361–364 Opium/morphine , 427, 428 Natural sciences , 334, 337, 406, 421, 424 in movement disorders , 427 Index 471

psychosis due to , 296 hallucinatoria , 101 Organ of Corti , 355 originaria (‘original craziness’) , 107 Organ sensations , 331, 365, 376, 384, 390–391, 446, primaria (‘ primordial delirium’) , 105 449–450 querulous , 87, 94 hyperaesthesia of , 130 Paranoid states , 54, 65, 333, 348, 360, 398, 407, 448 abnormal infl uence of on motility , 131 after acute psychoses , 102 Overvalued idea , 87, 92, 334, 361, 367, 393, 395, 397, after motility psychoses , 256 398, 410 classifi cation , 104 amnesia and , 406 course , 102 as basis of illusions , 140 mono-delusional variety (see Delusional disorder) delusional elaboration of , 393, 403 nomenclature , 65 infl uence of , 87 Paraphasia , 127, 269 in melancholia , 94, 212 Paraplegia, hypochondriacal , 264 as primary abnormalities , 334, 388 Paraphrenia , 358 Parietal lobe, disorders of , 28 Paris, as medical centre , 339, 350 P Parkinson’s disease , 355 Pachymeningitis haemorrhagica , 288 Pathology Pain sensation , 48, 340, 349, 404, 448, 450 correlation with symptoms , 379 Parabadie [in Wernicke’s index, but not in his text, in mental illness, limited to ‘whole person’ level , 421 defi nition uncertain, probably a form of Wernicke’s use of the term , 381, 426, 450 paraphasia; Ed] 269 Patients Paraesthesia, psychosensory , 13, 181, 269 complaints by , 343, 389 Paragraphia jargon of , 343 in Delirium tremens , 174 long-stay in-patients , 333, 343 in paralysis , 286 mental content of , 343 Parakinesia , 13, 251 , 367, 374, 397 violence by , 341 Paraldehyde , 428 Pattern completion , 373 Paralexia [misreading of printed words; Ed], in Pavlov, Ivan Petrovich , 356, 373 Delirium tremens , 173 Perception Paralysis, progressive , 336, 340, 347, 352, 357, 381, ‘apperception’ and , 377, 443, 451 402, 409, 410, 424, 437 cells (‘perception elements’) , 17, 29, 30 abnormal excitation and , 386 compared to sensation , 331, 366, 373 advancing , 285 compared to thoughts , 373 aetiology , 279, 280, 281 , 336, 356 distortions of sense of space and time in , anatomical fi ndings in , 287, 288, 289 , 336, 434 363–364 anatomical fi ndings in, macroscopic , 287 elaborated by exploratory movements , 333, 363 anatomical fi ndings in, microscopic , 289, 429, 434 form vs. content of , 366 atypical , 285 generalization of , 374 clinical condition , 7 illusions, as distortion of , 334 dementia and , 400 ‘perceptual elements’ (cells) , 331, 391 diagnosis , 285 relation to memory images , 355, 372, 374, 391 disease concept , 279 solid bodies and , 363 fever in , 357 of space , 363 focal symptoms of , 285 tactile , 332, 363 372 galloping , 282 of time , 363 hypochondriacal , 265 visual , 331, 332, 372 hysterical , 264 Perceptions localization of degeneration process , 290 localization of , 1, 15 paranoid form of , 219 normal value of , 49 passive limb manoeuvrability, alteration of , 280 Perceptual image , 17 pointer to future of psychiatry , 336, 375 Periencephalitis , 288 prodromal symptoms , 280 Peripheral neuropathy , 357 remission , 284 fl accid paralysis and , 357 spinal symptoms in , 280 Perplexity (Ratlosigkeit ). See Disarray stereotypical movements in , 282 Persecution, ideas of , 349 syphilis, relation to, in Wernicke’s view , 356, 429 Perseverance in postures , 250 Paranoia , 65. See also Paranoid states Persistent genital arousal disorder , 390 chronica simplex , 101, 351, 360 Perseveration , 298, 495 complete , 104 Personality . See Individuality 472 Index

‘Personhood’ (‘Individuality’) , 37, 186, 332, 368–369, Polyneuritis , 181 431, 450 Positive feedback , 373 breakdown of , 57, 71, 87, 134 Potassium bromide in drunkards , 192 constructed by assimilating components of memory , Prague , 380 332, 402, 413, 422 Presbyophrenia , 182, 335, 359 contribution from physical education, 438 aetiology , 182, 281, 304 episodic memory and , 414 symptoms , 182 interaction of all body systems and , 402 Progressiva divergens , 219, 280 multimodal convergence as substrate for , 402 Prognosis , 339, 344 ‘personal identity’ , 335, 404 Dementia praecox and , 399, 421 re-integration after mental illness , 344, 402 determined by ‘natural course’ , 339, 419 two-fold nature of (Ball) , 370, 387 education level of patient and , 419 unique vs. common features , 377 importance given to , 344 unity of , 363, 369 indicators of , 401, 419 viewed as complete logical coherence , 388 psychological factors in , 401 Persons, failure to recognize , 141 social environment and , 341, 401, 419 Pfl egeanstalt (‘Nursing home’) , 342 specifi c syndromes and , 401, P fl üger, Edouard , 436 Projection fi bres of the retina , 36 Phenacetin , 428 Projection fi elds in the cortex , 2, 26 Phenazisms , 117, 141 of speech , 6 Philosophy of the viscera , 29 dualism of mind and brain , 365–366 Projection system (Meynert) , 4, 354 German idealist , 370 Pseudoapoplectic attacks in senescence , 320 materialism , 331, 365, 366, 370, 404, 434 Pseudofl exibility , 252, 266 of mind/brain relationships , 365–366 Pseudomelancholia , 262 psycho-physical parallelism , 364, 365, 371, 432 Pseudoparalysis, alcoholic , 295 of science , 338, 361 Psychiatry theory of knowledge (epistemology) , 366–368 backward compared to other specialties , 331, 343 Phonemes (auditory verbal hallucinations) , 80, 117 , criticism of by service users , 344, 422 361, 388–389, 391, 414, 415, 418 developed through precedents of general medicine , 344 compelled repetition of , 127 dynamic tradition in , 403–406 cultural acceptance of ‘hearing voices’ , 403 ethology and , 370 disorientating , 118 guidelines for training in , 347, 358 ‘explanatory’ , 395 history of , 334, 418, 451 localization of voices , 420 hopes for future of , 337 in mania , 218 legal control of , 340–341 in melancholia , 211 literary cross-overs with , 400 narrow defi nition of , 408 professional standing of , 331, 343, 351 as primary abnormalities , 334 public attitudes to , 340 projection of, on the surroundings , 81, 118 reasoning in , 422 relation to uttered speech , 391 relation to neurology , 379–380, 422 site of , 127 research and routine practice inseparable , 358 Phrenesia . See ‘Encephalitis’ role of theory in , 377–379 Phrenic nerve insuffi ciency of , 75, 374, 416, 450 ‘science of’ , 338, 412, 421 Physicality. See ‘Corporeality’ three traditions within , 403 Physics, theoretical , 337. See also Natural philosophy to be based on most fundamental premises , 361 hidden variables in , 361 ‘Psychiker’ , 350, 365, 433, 435 Pia mater, behaviour of in progressive paralysis , 288 Psychomotor pathway , 13 Piaget, Jean , 424 disturbance of , 226 Pick, Arnold , 350, 359, 436 Psychopathology , 368, 397 Pinel, Philippe , 362, 432 Wernicke’s rejection of term , 380, 381, 426, 451 Plato , 365 ‘Psychophysical’ , 451 theory of ideas , 366 Psychophysical movement , 46 Pleasurable sensation , 49 ‘Psychophysiology’ , 451 Poincaré, Henri , 364 Psychosensory pathway , 13 Politzer method , 451 Psychoses Polyneuritic psychosis , 180, 357, 411, 451 active vs. ‘residual’ or ‘memory effect’ , 380–381, 419 aetiology, 295, 296 acute , 111 prognosis , 182 aetiology , 293, 307 symptoms , 180 as consequence of sejunction , 85 Index 473

course , 309 etymology of , 386 ‘exhaustion’ , 408 meaning of word , 385–386 expiry of , 97 previously translated as , 386 as falsifi cation of contents of consciousness , 381, 407 term used by patients , 386 familial loading , 430–431 Rationality, as universal human norm , 368, 403 history of word/concept , 381, 405 Raving madness , 233 insomnia as a precursor to , 377 Reasoning Korsakoff (see, Psychosis, polyneuritic) by analogy , 332, 333, 424–426 manic-depressive (Kraepelin) , 421 from elementary to secondary symptoms , 422 outcome , 313 ‘framework’ (a priori context) needed for , 388 position of, in relation to organic brain diseases , 4 individualised clinical , 419, 421, 422, 423 possible neuropathology of , 336 from neurobiology to psychology , 382, 421, 423 relationship of the acute to chronic , 111 over-inclusiveness of , 333 separation from neurosis , 405 by psychiatric patients , 333, 423 social factors and , 402, 419 in psychiatry , 382, 421 as ‘too much thought’ , 402 in science , 361 ‘transitory’ , 452 (see also Epilepsy, twilight states in) by reductio ad absurdum , 422 treatment for , 428 reverse of deduction , 423 ‘unitary’ , 453–454 types of , 128 Psychoses, acute, basic forms of , 271 unstated premises in , 367 acute progressive sensory , 273 Wernicke’s , 422–427 acute total sensory , 272 Recovery (from mental illness) , 333, 401, 402 alcoholic , 336, 381 dependence on patients’ habits of thought , 368, 423 chronic , 65 of disturbed Affect , 385 circular/cyclic , 220, 399 natural ‘healing’ and , 401 compound , 275, 336, 411 sequence of, for different symptoms , 385, 393–394, 413 course , 102 translation issues , 401 epileptic , 297, 336 Recognition, process of , 16, 18 functional ( vs. organic) , 328, 337, 404–405 Refl ex(es), arc, psychic , 12 hebephrenic (of adolescence/puberty) , 303, 337, axon fl are refl ex , 334, 355 359, 387, 399 congenital refl ex movements , 27, 131 hereditary , 297 consciousness and , 376 hypochondriacal (see ‘Somatopsychosis’) hallucinations , 83, 119 hysterical , 301, 381 movements , 11, 31 menopausal , 305, 337, 358 ‘organ sensation’ and , 384, 450 menstrual , 305, 337, 411 protective , 355 mixed , 271, 336, 411 psychic , 355, 375–376 obsessive , 335 pupillary , 348 periodic , 309 ‘short-circuit’ through cortex, and , 376 polyneuritic , 335, 358, 429, 434 tendon , 357 ‘prison’ (Ganser) , 432 tendon refl exes, alterations of , 280 puerperal , 306, 337 Reinforcement (psychological) , 373, 376, 392, 429 senile , 304, 337, 358, 359, 449 as both consequence and cause of association , 430 symptomatic , 13 psychotic symptoms and , 392 total , 411 Reminiscence , 48 Psychotherapy , 428 Remission , 311 Public attitudes to mental illness in paralysis , 284 concern over custodial practices , 340 Renshaw cell , 371 diffi culties for psychiatrists , 340 Representation (by brain) disputes with lawyers , 340 assimilation of perceptions into concepts , 331, 424 diversity of views , 340 assimilation of sensory images into perception , 331, 424 need for public education , 340 of body , 331, 367, 414 (see also Corporeality) Public health system of the time , 342 of concepts , 331, 366 Puerperal disorders , 336 diffuse , 374 Pupillary rigidity . See Argyll-Robertson pupil of external world (allopsychic) , 331 Pursued persecutor , 95 of eye movements , 18 of goals (‘destination’, ‘execution’) , 10, 12, 44 of language , 331 R of movement , 332, 421 R askolnikov (Dostoievsky) , 395, 438 of personhood (autopsychic) , 332, 367, 374–375, Ratlosigkeit , 385 . See also ‘Disarray’ 402–403 474 Index

Representation (by brain) (cont.) Self-blame delirium . See Micromania potentially fallible , 367 Self-generated ideas. See Autochthonous ideas of sensation , 421 Self-reference, morbid , 81 of verbal thoughts , 382 Senescence , 304 Respiration type, defective , 75 Sensation Restless Legs Syndrome , 336, 380, 427 auditory , 373, 394 Restructuring of words , 102 biases imposed by brain , 363, 367 Retina , 363, 374 compared to perception , 331 images , 18 content vs. ‘tone’ of , 331, 363 ganglion cells in , 355 distinguished from ‘feeling’ , 366 stimulation, form of , 17 intestinal , 335, 351, 389, 417 visual after-images and , 422 localization of , 61 Rigidity (muscle) , 250 , 336, 340, 355–356, 397 of movement , 363, 366 Romberg test , 356 position sensation , 32 Rother (named patient) , 368, 386, 388, 411 sensory content of , 26 taste and smell , 394 threshold , 413 S visceral , 331, 384 S achs, Heinrich , 347 visual , 355, 363, 373 Schäffl e, Albert , 437 ‘Sense of self’. See also ‘Personhood’ Schizophrenia , 341, 349, 373, 383, 384, 387, 400, 421 exaggeration of , 59 associative processes in , 430 in manic patients , 216 disorganised (hebephrenic) subtype , 75, 399 ‘Senseless rage’ , 376 gender/age incidence , 430 Sensory cortical regions , 391 Schneider, Kurt , 367, 383 connections from other cortical areas , 391, 426 Schoppenhauer, Arthur , 437 somatosensory areas , 374 Schroeder, Paul , 347 Sensory perception , 29 Schüle, Heinrich , 359 Sequence of sensory impressions , 23 Science (natural) Severity (of illness) , 397, 408, 409, 410, 414 balance between experiment and theory , 377–378 Affective states and , 414 birth of , 378 grading of , 414 common language of , 381 graphical depiction of , 230 concise description rather than explanation , 365 Sexual abstinence , 437 Scopolamine. See Hyoscine Sexual pathology’ , 382, 435 Scurvy , 340 Sexually-transmitted diseases , 339, 356, 357 Sechenov, Ivan , 356 Shakespeare, William , 350 Seclusion , 429 ‘Shell shock’ , 335, 361 Sécond état (Second state/‘dual personality’) , 188, Sherrington, Charles Scott , 371 295, 299, 335, 340, 349, 357, 369, 378 409 410. Simulation , 322 See also Dissociative Identity Disorder Simultaneity , 363 ‘levelling’ of ideas in , 190, 193, 217 Skin sensation, disturbances of , 28 relation to epilepsy , 369 Sleep , 30 Sedative medicines , 377 as an active process , 377 ‘Seizures’/‘attacks’ , 451 disturbance of , 350, 377 diagnosis of , 286 insomnia and , 377, 416 paralytic , 284 pressure for dreaming sleep , 377 Sejunction theory , 71, 333, 334, 338, 368, 378, 382, REM dissociation and , 377, 412 386–388, 391–392, 393, 399, 425, 430 symptoms during , 380 autochthonous ideas and , 393 therapeutic role of , 427 backfl ow of nervous energy and , 391, 426 Sleeping drugs , 350, 428 fl aws in , 387, 391–392, 426 Snell, Ludwig , 394, 436 hallucinations and , 386 Social class , 359 illogical statements of patients and , 386, 391, 423 Social milieu ‘microanatomical’ basis for , 387 rejection of discharged patients by , 342 ‘mutually contradictory memories’ and , 384 ‘Somatikers’ , 331, 365, 404, 405, 433 negative vs. positive symptoms in , 384 Somatization , 335, 360, 390 origins in Meynert , 387 related to lay understanding of body/mind , 389 as primary pathological process , 386, 388, 407, 420 Somatopsychoses , 336, 381, 410, 417, 418 symptoms of activation and , 386 acute , 163 Self-awareness , 41 aetiology , 160 Index 475

body dysmorphic disorder and , 415 Symptoms. See also Delusions, Hallucinations, and circumscribed intestinal , 153, 156 specifi c named symptoms differentiation from hypochondriacal neuroses , 161 arising from aberrant excitability , 331 localization of pathological sensations in , 160 arising from excesses of excitability (see Symptoms, motor behaviour in , 154, 161 positive) paralytic , 162, 282 arising from loss of excitability (see Symptoms, prognosis , 161 negative) symptoms , 160, 162 allopsychic , 333, 334, 410, 414, 415, 417 worsening , 154, 304 autopsychic , 333, 334, 410, 414, 416, 417 Somnolence , 48 of breakdown, in brain diseases , 72 Space, concept of classifi cation of , 331 acquired rather than innate , 363 ‘symptom complex’ , 404–405, 444 Spatial sense ‘ deduced from features of diseased organ’ , 362, 406 of ear , 29 depend on person’s mental faculties , 382 of retina , 28 detailed analysis within Grundriss , 336, 358, 362, of skin , 35 382, 383, 397, 398, 408 Speech dimensions of, in schizophrenia , 359 articulation vs. content , 366 disappearance during singing (motor symptoms) , 392 centre, sensory , 80 elementary , 333, 362, 383–384, 388, 389, 393, 398, comprehension , 45 416, 446 development of , 33 entirely defi ned by motor behaviour , 396 disturbance, paralytic , 280 functional neurological , 360 excess of , 397 grouping of experiences as , 362, 378, 382 hallucinations , 80 internal connections between , 361, 382 importance for diagnosis , 323 intrapsychic , 331, 336, 410 pathology , 173, 424 as major focus in Grundriss , 333 pathways , 6 manner of expression depends on life event , 383 projection fi elds of , 6 motor abnormalities , 334, 336, 374, 379, 410 schema for , 10 negative , 331, 350, 358, 384, 415 social signifi cance of , 38 ‘over-pathologising’ of , 403 sounds, representation of , 373 as patient’s movements , 331 Spencer, Herbert , 355, 436 positive , 331, 350, 358, 384 Spinal cord , 366 psychological mechanisms of , 382 Spinal miosis. See Argyll-Robertson pupil psychomotor , 331, 410, Spindle (‘fusiform’) cells , 23 psychosensory , 331, 332, 410 Spinoza, Baruch , 364, 366, 367, 369 quasi-neurological , 335, 360 Spirochete , 336 relation between positive and negative , 358, 384 discovery of , 336, 340, 356, 407 relation to specifi c disorders , 409 Statistical analysis/inference , 361, 424 secondary , 333, 383, 384 Stengel, Erwin , 384 sequence of appearance , 413 Stereoscopic image of the retina , 28 somatopsychic , 333, 335, 410, 413–414, 416, 417, 418 Stereotyped movements , 397 as starting point for understanding (Wernicke) , 333, Stimulation effect , 72 362, 382–383, 406 electrical, of muscle , 332 speech , 336 localization of , 126 translation issues , 451 Storch, Ernst , 346 Synapses, chemical transmission in , 354 Stroke , 346, 379, 443 Synaptic plasticity in , 371 Stupor long-term potentiation , 371 alcoholic , 295 long-term depression , 371 paralytic , 281 temporal precision of , 371 post-epileptic , 298 Syphilis , 336, 337, 339, 412 Subconscious. See Psychiatry, dynamic tradition in brain softening and , 443 Suicide , 359, 416 diverse forms of , 340, 355–356 in mania , 218 relation to progressive paralysis , 336–337, 356–357 in melancholia , 207 social factors and , 402 risk of , 336, 342, 345 spirochete as cause of , 336, 340, 356, 407 Suggestion , 90, 139 tertiary (neurosyphilis) , 340, 375, 400, 407 Sydenham’s chorea. See Motor (motility) symptoms, treatments for , 429 chorea Synchronism of sensory stimuli , 21, 22 Syllable stumbling , 173, 280 Systematization of delusions . See Delusions (general) 476 Index

T symptomatic relief , 339 T abes dorsalis , 356, 438 for syphilis , 428 relation to syphilis in Wernicke’s view , 356 Trional , 428 taboparalysis , 285 Tuberculosis (phthisis) , 337, 340, 355–356, 452 Tactile movement , 28, 33 meningitis due to , 340 Tactile organ , 34 Turning in circles , 379, 392 Tactile paralysis , 15 Twilight states Tactile hallucination , 69, 121 in Delirium tremens , 176 Taxonomy , 359 hysteric , 303 Georges Buffon and , 377 in transient psychoses , 157 as ‘natural types’ , 359, 377, 407, 436 paralytic , 283 purposes of , 407–408 pre-epileptic , 189 Telegraphy , 424 post-epileptic , 176, 297 Teleology , 370 Temporal lobe, stimulating symptoms of , 130 Tetanus , 339, 356, 444 U discovery of clostridium tetani , 339, 356 U nconscious. See Psychiatry, dynamic tradition Thalamus , 351, 376, 391 Urge to move atrophy of , 289 choreatic , 231 Theory (in science) , 332, 200 hypermetamorphic , 232 Thiamine defi ciency , 337, 357, 429 jacktatoid , 250 polyneuropathies due to , 357 psychiatric sequelae and , 340 Third Reich , 342, 359 V Thought V asomotor symptoms , 335 audible (‘thought echo’) , 335, 389 Verbigeration (‘loquacity’) , 6, 227, 251, 268, 381, compared to perception , 373 384, 397 disappearance of , 335 Vetoing a decision to act , 376 disorder , 399, 400, 417, 421 452 impairment of vetoing , 376, 379 experiments (Mach) , 354, 362 Vienna, as medical centre , 339, 350, 404 ‘laws of’ , 427 Virchow, Rudolf , 436 processing analogous to overt behaviour , 376 Visions (Visual hallucinations) , 120, 126, 377, 389, 391 role of, as agent controlling behaviour , 370 dependence on affect , 143 ‘thought withdrawal’ , 343 projection of in space , 121 ‘train of ’ , 352 Visiting rights in hospitals , 343 Threshold of perceptions , 47 Visual agnosia , 16, 347, 429, 434, 452 ‘Three-way split’ of symptoms (Wernicke) , 333, 410, Visual cortex , 331 411, 418 Visual fi eld, concentric constriction of , 47, 204 associations between domains , 415 Visual fi eld defects , 28 clinical value of , 411, 413–414 Visual memory , 15, 29 correlation structure of , 411, 415–418 association of , 21 differential diagnoses and , 418 localization of , 5, 15 dissociations between domains , 417–418 relation to hallucinations , 126 integrated to create ‘personal wholeness’ , 421 relation to perceptual images , 17, 29 sequence of recovery and , 413–414 relation to olfactory images, 16 scientifi c validity , 411, 412–413 relation to optic images , 16 strength of associations and , 414 relation to tonal images , 127 Tinbergen, Nikolaas , 370 Visual perception , 19 Tone, psychic , 205 Vitalism , 352, 434, 451 Touch Vitamin C defi ciency , 430 active , 374 Voices, hearing , 79, 117 concept , 33, 34 Voices, imperative and prohibitive , 76, 79, 143 Transitivism , 137 Treatments , 335, 339, 415, 427–429. See also Specifi c named treatments W adverse effects of , 339, 427, 428 W agner-Jauregg, Julius , 435, 436 for anxiety , 427, 428 Wahn (translation of) , 394–395 herbal medicines , 427 Ward, James , 436 in hospital, importance of , 336 Wasserman test (for syphilis) , 336, 357, 339–340 psychotherapy , 401, 428–429 Waxy fl exibility (fl exibilitas cerea ) , 336, 397, 446 Index 477

Weigert, Karl , 353, 437 natural philosophy and , 338 ‘Well-worn’ pathways, principle of , 10, 23 neuroscience, knowledge of , 353–355 Wernicke, Carl neuroscience, gaps in knowledge of , 333, 424 academic disputes and , 350, 352 not ‘distancing himself’ from patients , 344 ambivalence about ‘reformists’ , 340 openness about his own mistake , 345 anonymous acknowledgment (1894) , 337–339, 351, overinclusiveness , 426–427 352, 365 ‘Pathologie’ in Grundriss , 381–381 applying his scientifi c concepts to himself , 344 ‘person’ concept and , 369–370 approach to classifi cation , 332, 343, 362, 382, 421 professional rivals and , 350–353 approach to ‘symptoms’ , 333, 382–383, 410–419 psychosis, concept/defi nition of , 382, 396, as a ‘lone voice’ , 353 413, 451 as neurologist 336, 374–375, 384, 397 420 quantitative data and , 424 ‘associationism’ of , 352, 370, 373–374 rapport with trainees/students , 344, 345 attitude to philosophy , 369, reasoning by , 338, 361, 382, 420, 423–427 ‘causality’ vs. ‘aetiology’ , 364 rejects ‘alien’ status for patients , 344 clinical style , 333, 343–345, 382, 402, 422, 441 rejects personal authority , 422 comments on national differences , 350 search for symmetry , 425–426 comparison with Kraepelin , 421–422 signs of haste in writing of Grundriss , 349 concept of mental illness , 380–381 single case analyses by , 382 (see also Symptoms) competence as general physician , 340 specifi c diagnoses of , 408–409 competence as surgeon , 340 teaching style , 345–346 confi dentiality, concern about , 344 tension between medical training and clinical consistency of use of terms in Grundriss , 348, 422 experience , 421 Fechner and , 338 theory, importance in Grundriss , 378 fl aws in reasoning , 333, 426–427 theory of knowledge and , 366–369 hidden variables in , 361 trainees in his class , 346–347 holism and , 378, 383, 384, 401–403 validation of concepts in , 362 Hirnmythologie (‘neuromythology’) and , 380, 386 written style , 348, 422 humour in Grundriss , 350 Wernicke–Kleist–Leonhard tradition , 346 inconsistencies in Grundriss , 365, 426 Westphal, Carl Friedrich Otto , 351, 432, 436, 437 idiomatic language in Grundriss , 348–349, 350 White matter (hemispheric) , 355, 444, 446 ineptness in child psychiatry , 345 degeneration of (‘medullary’) , 448 interviewing style , 345 Willful activity, diminution of , 207 learning and memory , 371 Will (‘ das Wille’ ) , 46, 206, 335, 371 ‘local sign’ of sensory experience and , 363 defi cit of (melancholia) , 207, 383, 398 localization of function and , 370, 373–375 facilitation of (mania) , 426 meaning sometimes unclear in Grundriss , 349 loss of, in specifi c muscle areas , 397 medical concepts/terminology and , 381, 409, World Health Organization , 384 426–427 method of analysing clinical data , 378 mind/brain relationships in , 365–366 Z mixing psychological and biological language , 370, 426 Ziehen, Theodor , 338, 351, 361, 405, 408, 423, 424, 438