PATHOLOGY
543
PATHOLOGY
the most important causes of mental disease, it is also
certain that a great proportion, even the majority, of
habitual drinkers are severely burdened by heredity,
and start as psychopathic inferiors. They are not
degenerate because they drink, but they drink because
they are degenerate, and alcohohsm merely destroys
an already ailing nervous system. The true cause of
drunkenness lies primarily in the individual's constitu-
tion, and may frequently be traced to the ancestors.
The sins of the fathers are visited upon the sons, even
to the third and fourth generation. In so far as illegiti-
mate intercourse is a sin, syphilis and its attendant
paresis may be regarded as one's own fault. It should
not, however, be forgotten that syphilis can be ac-
quired in other ways (e. g. by drinking from an infec-
ted glass). One finds the accusations of conscience
and self-reproach in wholly irresponsible melancholic
patients, and unrepentant criminals often live a long
hfe without developing insanity. In short, the ques-
tion whether the soul through its passions or burdens
can make itself diseased must in general, according to
modern experience, be answered negatively, or the
possibility of such causative combinations may be
acknowledged only with important reservations and
the greatest restrictions.
III. Varieties of Insanity. — The forms that men- tal disease may assume, according to their symptoms, their course, and their results, are extraordinarily complex. Only those of most importance will be touched upon.
(1) Melancholia. — The most important feature here is a primary {sc. not induced by external events), sad, and anxious depression, with retardation of the thought processes. The patients feel themselves deeply unhappy, are tired of life, and overwhelm themselves with self-reproaches that they are unable to work, are lazy, stupid, wicked, or unamiable. In many cases the patients themselves can give no reason for their depression; they often cite in explanation long-forgotten sins of youth, all kinds of more or less unimportant occurrences and circumstances, the cares of daily life %vhich are treated as a matter of course in times of health, or the very symptoms of their illness. Because they take no pleasure in anything, in prayer or in the presence of their families, they accuse them- selves of impiety and want of affection. In other instances pure delusions arise. The patients accuse themselves of crimes which they have never commit- ted: they have made everybody unhappy, have dese- crated the Host, and have given themselves up to the Devil. Many cases of da?monomania of the Middle Ages and of the times of the Reformation belong to this category, as was clearly recognized by many eccle- siastics. Regino, Abbot of Priim (892-99), Gregory VII (1074) etc. protested energetically against the execution of witches; the Jesuit Friedrich von Spee (d. 1675), in his "Cautio criminalis", condemned the trying of witches as an institution opposed to human- ity, science, and the Catholic Church.
The patients often feel a terrible anxiety, fear a cruel martyrdom; sleep suffers, bodily nutrition fails, and painful centres of pressure are often found in dif- ferent nerve tracts. The danger of suicide is extremely great. The greater number of all suicides occurs as a result of recognized melancholia; other conditions, such as an intense state of anxiety, may often render such patients dangerous also to others. The self- accusations are uninfluenced by any words of com- fort; a hundred times confessed, they return again and again. The severest cases end in a condition of inability to speak or to move (stupor).
(2) Mania. — By this we understand a primor]/ (i.e. not caused by external influences), happy, elated mood subject to very rapid variations, especially to impulsive, wrathful emotions. Self-conscious- ness is increased, the flow of ideas is precipitate and rambling; there is over-talkativeness and excessive
restlessness. The severest cases end in flighty ideas,
confusion, and frenzy. But even the mild cases are
disastrous for the patients and for their surroundings.
Abnormal sensuality shows itself; individuals of pre-
viously high moral standards give themselves up to
violent alcohohc excesses, and practise all kinds of
sexual crimes. The patients are senselessly lavish,
are guilty of deceits and thefts, and, by reason of their
irritabihty, quarrel with their associates, superiors
etc., insult them, and disturb the public peace, commit
violence, are arrogant, quarrelsome, contentious, and
delight in intolerable hair-splitting. Sleep is badly
broken, the eyes shine, the play of the countenance is
full of expression and vivacious; many patients re-
semble persons slightly intoxicated. Very frequently
maniacal and melancholic states occur with character-
istically regular alternations, and repeat themselves in
one and the same individual, who during the intervals
is mentally normal (circular insanity with lucid
intervals).
(3) General Paresis. — This disease leads with gradually increasing mental and physical decay to dementia, paralysis, and death. Frequently, in the early stages maniacal states, antecedent to severe dementia, are already observable. The patients are not only distracted and forgetful, but above all irritable, sleepless, brutal, shameless, sensual, lavish, extravagant etc., exactly like true maniacs, only in a still more coarse and unrestrained fashion, because of the simultaneously appearing dementia. Very often one finds the most grotesque and changeable ideas of grandeur (megalomania) ; the patients believe themselves immeasurably rich, are emperors, opera- singers, even God Himself; they have discovered per- petual motion, know all languages, have thousands of wives, etc. In other cases there are hypochon- driacal delusions (the patients complain they are dead, or putrescent, etc.). Not infrequently the delusions are permanent, and the patients simply grow less rational from day to day. On the physical side, one observes most frequently a characteristic difficulty in speech; the speech becomes stutter- ing, uncertain, and finally an unintelligible babble. The pupils of the eyes lose their circular form, are often unequal (e. g. the right narrow, the left very wide), and do not contract on exposure to light (Argyll-Robertson pupil). Very frequently transi- tory apoplectic or epileptic attacks occur. In the last stages the patients are quite insane, prostrated, con- fined to bed, and pass their excretions involuntarily until death intervenes. In the earlier stages, almost at any stage in fact, marked and continued improve- ment and stationary periods may take place at any moment.
(4) Juvenile Insanity {Dementia proecox). — This disease process usually sets in after the years of pu- berty, and gradually leads to a condition of dementia. Quite frequently only the ethical side of the psyche is at first affected. Boys and girls who have been active will suddenly develop a dislike to work, become irritable and headstrong, give themselves up to coarse excesses, go about in bad company, lose every family sense, etc. After a year or more the loss of intelli- gence becomes unmistakable. At times the initial stages take on a hypochondriacal colouring. Natures previously healthy and full of the joy of life begin to observe themselves with anxiety, go from physician to physician, have recourse to quacks, etc. They found their complaints on all kinds of foolish notions; there must be an animal, or a sore, in their stomachs, etc. Very frequently in the further course of the disease (occasionally at the beginning), hallucinations of hearing and of sight occur. Conditions of con- fusion, delusions of persecution, of poisoning, of megalomania of varying types occur. Peculiar so- called catatonic states of muscular tension develop, in which the patients remain expressionless and motion-
