THE ALIENIST AND NEUROLOGIST. VOL. XXIII. ST. LOUIS, APRIL, 1902. No. 2. OUTLINES OF PSYCHIATRY IN CLINICAL LECTURES.* By DR. C. WERNICKE, Professor in Breslau.† Definition of the acute psychoses with respect to the chronic-Presentation of a case of acute psychosis almost recovered-Conditions and color of the explanatory ideas-A few new sources for the forma THE tion of delusions; from analogy, defective atten tion, pathological formation of associations. LECTURE EIGHTEEN. HE acute psychoses are primarily characterized by their mode of origin; we will have to regard all those mental disorders acute, in accordance with the use of the term in other diseases, which develop symptoms of significant intensity within a few hours or days. Besides it is to be stipulated as to the further development of the disease whether and how long it retains the acute character, or whether it recovers or passes into a chronic state. In the latter instance the acute psychosis becomes the acute initial stage of a chronic psychosis. With the same right, acute stages of the chronic psychoses occurring in other than the initial period will have to be included among the acute psychoses. *Continued from the ALIENIST and NeurologIST, Vol. XXI, No. 2. +English by Dr. W. Alfred McCorn. Still it would little accord with the complex actual conditions and the use of words based thereon, if we would regard the length of course alone as the decisive indication in designating a psychosis acute or chronic. Rather the quality of the disease type, the "acute character," which adheres to it, owing to a rapid development, an indication of such independence, that even on longer duration of the disease, or, where the condition of a rapid development does not exist, it will decide in favor of an acute psychosis. This shows the special position, that diseases of the nervous system must be given: a sciatica or other neuralgia of years standing, an old tabes may be attended by the most intense lacerating pains, the extremely chronic trouble of brain tumor is attended at well specified periods by the most acute brain symptoms, i. e. a combination of headache, vertigo, vomiting and general convulsions. Thus the acute reactions of the nervous system are seen to be very generally dependent on irritation, which very often has no perceptible connection with the gross disease processes-the anatomical tissue changes. In our efforts to more definitely define the acute psychoses, we are consequently referred to other, more exhaustive criteria. I refer to my remarks* on the mutual relation of content and action of consciousness and then to the result, that the pathological changes in the content of consciousness must form the chief topic of our consideration, as they were in the chronic psychoses. We must now add, where this province is entrusted to us; the permanent or fixed changes in the content of consciousness. But we will not hesitate to further conclude, the pathological changes in the content of consciousness form the domain of the acute psychoses. If you will now call to mind the schemet I have given for the derivation of the symptoms, you will at once observe, that it is also a scheme of the pathological changes in the action of consciousness, changes, which in their totality we have known as disorders of secondary identification. It would be the task of an independent theory of *See ALIENIST AND NEUROLOGIST, Vol. XX, p. 548. symptoms of mental disease to discuss those derived from the scheme, to put their occurrence and significance in the different mental diseases in the proper light. Still any attempt of the kind would take us too far from our real task of becoming acquainted with actual causes of disease, so I will confine myself to speaking somewhat fully of only the most important theoretically, of these disorders of identification, which are indispensable to the general pathology of mental diseases. They are chiefly those symptoms, which come within the province of false sensations or intimately connected with them. Besides I will have to confine myself each time in presenting patients to elucidating the symptoms, that are new in their significance with respect to our scheme. Simple reflection will verify, that the symptomatology of the acute mental diseases cannot be exhausted by the symptoms derived from our scheme. Still we had seen that the action of consciousness produces the content of consciousness, so that a changed action of consciousness must of necessity result in changes in the content of consciousness, and we could define the acute mental disorders as the changes in the content of consciousness, we see effected within a certain time.‡ We are now often able to assume a priori, that these changes in the content of consciousness will be less fixed or of shorter duration in the acute mental diseases than in the chronic. Nevertheless the clinical significance of the disorders of the content of consciousness in the acute mental diseases is so essential and decisive for the fixation of a definite disease type, we feel that any theory of disease, which would neglect this point of view, must be biased and incomplete, insufficient for the great amount of clinical data. If in the chronic psychoses or paranoiac states we could confine ourselves in the main to the changes in the content of consciousness, you will now understand how much more complicated is our task in the acute psychoses, where the changes in the action of consciousness are equally as significant as those in content. So it is that the sequelae, which in the chronic psy See ALIENISt and NeurolOGIST, Vol. XX, p. 548. choses we say follow a number of elementary symptoms, are in great part manifested in the acute psychoses, even find there a broader application, e. g. the principle of explanatory delusions. And as explanatory delusions do not in themselves represent a pathological action of the organ of consciousness, we will become acquainted in the acute mental diseases with new sources of delusion formation, which are connected with normal mentality. The experiences we have had in this respect, form in a certain measure a supplement to the theory of the paranoiac states and therefore most properly follow them here. A patient selected for discharge, who has been free from psychotic symptoms for three months, offers a favorable opportunity. K. is a mechanical engineer of twenty-seven, with an academic education, who is to be regarded as recovered from an attack (the second) of a severe complicated mental disease, even to the defective insight for a few of the symptoms at the time of the acute onset. His well retain ed memory of the whole period of his illness amounting to about 11⁄2 years, his intelligence and training in scientific observation render him peculiarly suited to afford information as to certain symptoms. I will say merely that the patient fully describes the voices and autochthonic ideas at the time of his illness. We gather from this merely the lesson, that these elementary symptoms of the paranoiac state generally occur also in the acute mental diseases. The explanatory ideas, the patient has added are more important for our actual purpose. He was always fully aware, that the voices, whose material embodiment he did not see, were not to be explained physically, and so there was only left to him the assumption of supernatural action of "spirits," as much as he at first resisted the evidence of his senses. He then explained the strange thoughts as inspired by these spirits; that it did not here result in a delusion of physical persecution is certainly to be ascribed to the man's scientific training. We also see from the example, that the explanatory delusions are no less important in the acute mental diseases than in the chronic. A certain degree of retained intellectual power is necessary to the hypothesis: logical requisites and logical ability must be present for an explanation of the strange manifestations. In general this hypothesis corresponds to a certain degree with retained self-possession as it was usually present in our patients. Besides the content of the explanatory delusion is shown to depend on the patient's individuality. How much this is the case can be seen from a second example. Among the thoughts inspired in him, our patient has also stated, that he has been in the world at different times as Wotan and Alfred the Great. He has therefore believed in transmigration. From my question if he had regarded it an act of resurrection, he developed the idea, that every person in his personality is to be looked upon as a definite arrangement of material part, and that he has considered it possible for the same arrangement of molecules to be repeated at different times and so the same persons be produced. As much as he now laughs at the assumption, it must be admitted that only a person with a scientific mode of thought would be able to formulate such an explanatory idea. For the occurrence of complex explanatory ideas, as well as for the estimation of the autochthonic thoughts as such, a certain degree of self-possession must be inevitably presumed. If we accept that these false judgments, like those mentioned of having lived twice before at different times, could have been formed in this way, the smallest degree of retained power of judgment is necessary for such thoughts to be recognized as not originating according to the normal type. We will not then be astonished, if the acute insane, who lack self-possession, are sometimes in a state of complete confusion, strange ideas are obtruded and manifested, without their criticising them or attempting an explanation. In this way I recognize the occurrence of primordial delirium (Griesinger) in the acute insane, as I have formerly stated in speaking of Friedmann's book on delusions. Although this author has adhered to his stand. *See ALIENISt and NeurolOGIST, Vol. XXI, p. 315. |