The Psychology of Dementia Præcox/Chapter I

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Critical Presentation of Theoretical Views on the Psychology of Dementia Præcox.

The interpretation of the psychological disturbances of dementia præcox are found in literature only in the form of fragmentary attempts which although they at times go quite far, yet nowhere have they any clear coordination. The statements of the older authors have only a limited value as they refer now to this now to that form of mental disease which can only be indefinitely classified as dementia præcox. Hence one must not attribute to them any general validity. The first general view concerning the nature of the psychological disturbance in catatonia was that of Tschisch,[1] who, in 1886, thought that it was essentially due to inability of attention. A similar but somewhat differently conceived view was given by Freusberg.[2] He stated that the automatic actions of the catatonic are associated with a condition of reduction of consciousness which causes a loss of control over his psychical processes. The motor disturbances are only symptomatic expressions for the degree of psychic tension.

According to Freusberg the motor catatonic symptoms are dependent upon corresponding psychological manifestations. The "weakening of consciousness" points to the quite modern view of Pierre Janet. Also Kraepelin,[3] Aschaffenburg,[4] Ziehen and others affirm that there is a disturbance of attention. In 1894 we meet for the first time with an experimental psychological work on the subject of catatonia. It is the investigation of Sommer, "On the Study of 'Inhibition' of Mental Processes."[5]

The author makes the following statements which are of general significance: (1) The course of ideation is retarded. (2) The attention of the patient is frequently so fixed by pictures shown him that he can only with difficulty rid himself of them.

The frequent obstructions (the retardations of reaction time) are explained by Sommer by the visual fixation.[6] The condition of absent-mindedness among normal persons occasionally shows similar phenomena; e. g., amazement and "staring into vacancy." Because of this analogy of the catatonic condition to normal absent-mindedness Sommer affirms something similar to Tschisch and Freusberg, namely, that there is a diminution of attention. Catalepsy according to Sommer is another phenomenon closely related to optical fixation and which he considers "in all cases as a phenomenon of thoroughly psychic origin." With this conception Sommer places himself in sharp contrast to the view of Roller, to which also Clemens Neisser unconditionally adheres.

Says Roller: "The presentations and sensations which among the insane chiefly come to perception, forcing themselves into the field of consciousness, are those which have been caused by the morbid states of the subordinate centers, and when active apperception, the attention, enters into activity it becomes fixed and held by the morbid perceptions," etc.[7]

By way of addition Neisser observes: "Wherever we look in insanity we always meet with something strange which cannot be explained according to the analogy of normal psychical activity. The logical mechanisms in insanity are put in motion not through the apperceptive or associative conscious psychic activity, but by pathological irritations lying under the threshold of consciousness."[8] Neisser therefore agrees with the concepts of Roller. This view does not seem to me to be without its objections. Firstly, it is based upon an anatomical conception of the psychic processes, a view against which too much warning cannot be given. What part the "subordinate centers" play in the origin of the psychic elements, such as presentations, feelings, etc., we do not know at all. An explanation of this kind rests merely upon words.

Secondly, the Roller-Neisser view seems to presuppose that beyond consciousness the whole psyche ceases. From the French psychology and from experiences with hypnotism we learn that this is not the case.

Thirdly, if I understand correctly, by "pathological irritations lying under the threshold of consciousness" Neisser means cell processes in the cortex. This hypothesis goes too far. All psychic processes are correlates of cell processes, as well according to materialistic conceptions as according to the doctrine of psycho-physical parallelism. It is therefore not singular that psychic processes in catatonia should be correlates of a corresponding physical series. We know that normal psychical processes originate under the constant influence of numerous psychological constellations which as a rule are unknown to us. Why should this fundamental psychological law suddenly vanish in catatonia? Is it because the ideational content of the catatonic is foreign to his consciousness? Is it not the same with our dreams? And yet no one will assert that dreams originate so to speak directly from the cells without psychological constellations. Whoever has analyzed dreams according to the method of Freud knows what an enormous influence the constellations have. The appearance of strange ideas in consciousness without any demonstrable connections with former contents of consciousness is not an unheard of thing in either the psychology of the normal or the hysteric. The "pathological fancies" of catatonics have rich analogies in the normal and in hysterics (see further). What we lack is not so much comparative material but the key to open the psychology of the catatonic automatism. It seems to me in general rather daring to assume something toto cœlo new and absolutely foreign in natural science.

In dementia præcox, where numberless normal associations actually still exist, we must expect that until we shall learn to know those very fine processes which are really specific, the laws of the normal psyche will long continue to be manifest. Unfortunately to the great detriment of psychopathology, in which we are just beginning to agree upon our misunderstandings of conceptions applied, our knowledge of the normal psyche is still on a very primitive basis.

We are grateful to Sommer[9] for further fruitful studies of the associations in catatonia.

In certain cases of catatonia[10] the associations flow in a normal manner only to be suddenly interrupted by an apparently totally disconnected, peculiarly-mannered connection of ideas, as will be seen by the following example: dark—green, white—brown, black—"good day, William," red—brown.

These saltatory associations were also confirmed by Diem,[11] who conceives them as sudden "fancies." Sommer justly considers them as an important criterion of catatonia. The "pathological inspirations" as described by Breukink,[12] who follows Ziehen, can be readily found in every insane asylum where these authors have observed them. They are exclusively seen in dementia præcox, and especially play an important role in the paranoid types. Bonhoeffer's[13] "pathological fancies" probably refer to the same manifestations. The problem instigated by the discovery of Sommer is by no means settled, but until we become more enlightened we are obliged to group under the same heading the phenomena observed by various authors which are nearly all designated by almost the same name. Although from clinical experience it would seem that "pathological fancies" appear only in the realm of dementia præcox, naturally excluding the falsifications of memory which often suddenly appear in organic dementia and in Korsakow's symptom-complex, I wish to observe that in the realm of hysteria, principally in cases that never seek the asylum, "pathological fancies" often play a great part. Flournoy[14] reports the most interesting examples. Similar sudden invasions of changed psychological activity I observed in a very clear case of hysteria,[15] and recently I could again confirm it in a similar case. Finally, as I have shown, sudden disturbances of association by the incursion of seemingly strange connections of ideas also appear in the normal.[16] In the saltatory association or "pathological fancy" we are perhaps dealing with a widely disseminated psychical phenomenon, and without further discussion we can agree with Sommer that the most marked type appears in dementia præcox.

Sommer, in examining the associations of catatonics, found numerous sound associations and stereotypies. By stereotypies we mean frequent repetitions of former reactions. In our examinations we simply name it "repetitions." The reaction time showed enormous fluctuations.

In 1902 Ragnar Vogt[17] again took up the problem of the catatonic consciousness. He proceeded from the Müller-Pilzecker investigations[18] by considering mainly their observations about "perseveration." The continuation of psychic processes or their correlates, even after being replaced in consciousness by other ideas, is according to Vogt the normal analogy to catatonic perseveration, such as verbigeration, catalepsy, etc. Accordingly, in catatonia the tendency to perseveration of the psychophysical functions would be especially marked. But inasmuch as in the Müller-Pilzecker observations perseveration is manifested most distinctly only when no new content of consciousness impresses itself,[19] Vogt claims that in catatonia perseveration is only possible because no other interesting conscious process occurs. Hence it must be assumed that there is a certain narrowing of consciousness. From this we can also understand the resemblance between the hypnotic and the catatonic states.[20] The impulsive acts of catatonia are likewise explained by the narrowing of consciousness, thus preventing the intervention of any inhibition. Vogt is apparently under the influence of Pierre Janet, to whom the "narrowing of consciousness" and diminution of attention is the same as abaissement du niveau mental.[21] Here then we again meet the already mentioned view, though in a somewhat more modern and generalized form, namely, that in catatonia there is a disturbance of attention, or as I prefer to express it in a more general term, there is a disturbance of positive psychic function.[22] The reference to the similarity of hypnotic conditions is very interesting, but unfortunately Vogt gave us only a mere outline.

Kindred views are advanced by Evensen.[23] He draws a skilful parallel between catatonia and absent-mindedness. Lack of ideas in a narrowed consciousness is the foundation of catalepsy, etc.

A painstaking and detailed examination of the psychology of catatonia is the thesis of René Masselon.[24] The author first affirms that diminution of attention (distraction perpétuelle) is the main characteristic. He conceives attention in a very general and comprehensive sense corresponding to his French training in psychology. He says, "The perception of external objects, the perception of our own personality, judgment, the ideas of relationship, faith and certitude disappear when the power of attention disappears."

As shown by this citation, much depends on attention as conceived by Masselon. The more general features of the catatonic condition he summarizes as "apathie, aboulie, perte de l'activité intellectuelle." A brief consideration of these three abstractions teaches that fundamentally they mean the same thing, and indeed, Masselon in his work always tries to find that word or simile which would best express the innermost essence of his correct feeling. However, scarcely any concept of human language should be so broad; indeed, there is no one who has not already been impressed by some school or system with the biased limits of meaning. We can best find out what Masselon conceives as the essence of dementia præcox by listening to the wording of some of his statements: "The habitual state is the emotional apathy … these disturbances are intimately connected with the disturbances of intelligence: they are of the same nature … the patients do not manifest any desires … all volition is destroyed … the disappearance of desire is connected with all the other disturbances of mental activity … a veritable weakness of cerebral activity … the elements of the mind show a tendency to live an individual life not being any more systematized by the inactive mind."[25]

In Masselon's work there is a mixture of many things and views that he feels belong to one root which, however, he is unable to find without obscuring his work. Nevertheless, in spite of his shortcomings, Masselon's researches contain useful observations. Thus he finds a striking resemblance between dementia præcox and hysteria in the marked self-distractibility of the patient by everything possible and especially by his own symptoms (Sommer's optical fixation), and also in exhaustibility and capricious memory. German critics have reproached him for this discovery, but certainly unjustly when we consider that Masselon means only the reproductive ability. If a patient gives a wrong answer to a direct question it is taken by the German school as by-speaking (Vorbeireden) as negativism; in other words, as active resistance. Masselon, however, considers this as an inability to reproduce. When superficially considered it may mean both, the divergence being due to different interpretations bestowed upon this phenomenon. Masselon speaks of a "véritable obscurcissment de l'image-souvenir," he considers the disturbances of memory as "la disparition de la conscience de certains souvenirs, et l'incapacité du malade à les retrouver." The contradiction of both conceptions becomes clear without further explanation when one thinks of the psychology of hysteria. When a hysterical patient replies during the anamnesis "I do not know, I have forgotten," it simply means "I cannot or will not say it, for it is something very unpleasant."[26] Very often the "I don't know" is so awkward that the reason for not knowing is quite obvious. I have given many experimental proofs to show that the defects occurring in the association experiments, such as want of reaction, have the same psychology.[27] It is often only with difficulty that one can decide whether hysterics really do not know or whether they merely cannot or will not answer. Those who are in the habit of examining cases of dementia præcox in a somewhat detailed manner realize what exertion is often necessary to obtain the proper information. Sometimes one is certain that the patients know it, again it is an obstruction (Sperrung) which makes quite an involuntary impression upon one, and finally there are cases in which one is obliged to talk about an "amnesia" just as in hysteria, where from amnesia to unwillingness to talk is only a step. Finally the association experiment shows us that these phenomena exist in the normal person, though only in nuce.[28] According to Masselon the disturbances of memory and attention originate from the same source, though it is not clear from what source. In contrast to this the author finds ideas that obstinately persist, which he qualifies as follows: "Certain memories which were formerly more intimately connected with the effective personality of the patient tend to reproduce themselves incessantly and to continually occupy consciousness … the persisting memories assume a stereotyped form … thought tends to become clotted ('gerinnen')."[29] Without attempting to produce further proof Masselon declares that the stereotyped ideas (delusions) are associations of the complex of personality. It is a pity that the author does not linger any longer on this point. It would be very interesting to know in what way, for example, a few neologisms or a "word salad" are associations of the complex of personality, as indeed these are often the only remnants through which we become informed of the existence of ideas. That the psychic life of the adolescent dement "curdles" or "clots" seems to me an excellent simile for the gradual torpescence of the disease; it designates quite pregnantly the impressions entertained by every careful observer of dementia præcox. The author found it quite easy to derive automatism (suggestibilité) from his premises. As to the origin of negativism he offers but vague suppositions, although the French literature on impulsive phenomena afforded him many essential facts for analogous explanations. Masselon also tried association experiments. He found many repetitions of the stimulus words and frequent fancies of an apparently quite fortuitous nature. From these experiments he concluded that the patients are unable to pay attention. A right conclusion! Masselon, however, spent too little time on the "fancies."

From the main results of Masselon's work it can be seen that this author, like his predecessors, is inclined to admit a true central psychological disturbance,[30] a disturbance which sets in at the source of life of all psychic functions; that is, in the realms of apperception, feeling and desire.[31]

Weygandt in his clear elucidation of the psychology of the weak-mindedness in dementia præcox follows Wundt's terminology and calls the terminal process of the disease apperceptive dementia.[32] It is well known that Wundt's conception of apper- ception is a most general one. It embraces not only the Binet and Masselon conception of attention, but also Janet's idea of the "fonction du réel."[33] But we shall return to this. To show the universality of the apperception idea in the sense indicated I shall quote Wundt's own words: "The condition characterized by peculiar feelings which accompanies the clearer reception of a psychic content we call attention, the single process by which any psychic content is brought to clear conception is apperception.[34] The apparent antithesis between attention and apperception is solved as follows: "Accordingly, attention and apperception are expressions for one and the same psychological fact. The first of these expressions we choose by preference for the 'subjective' side of this fact to express the accompanying feelings and sensations; by means of the second we designate mainly the 'objective' results, the alterations in the quality of the contents of consciousness."[35]

In the definition: apperception is the "single process by means of which any psychic content is brought to clear conception," much is said in few words. According to this definition apperception is will, sensation, affect, suggestion, impulsive phenomena, etc., because all these are processes by means of which "a psychic content is brought to clear conception." We do not attempt to give an unfavorable criticism on the apperceptive idea, but merely to indicate its enormous extent. It embraces every positive psychic function, especially the progressive acquisition of new associations; that is, no more and no less than all enigmas of physical activity both conscious and unconscious. Weygandt's idea, therefore, of apperceptive dementia expresses that which Masselon dimly felt. Nevertheless, in this we find only a general expression for the psychology of dementia præcox. It is too general to be of any force in the deduction of all symptoms.

Madeleine Pelletier[36] examines in her thesis associations in manic flight of ideas, and in mental debility. By mental debility we understand typical cases of dementia præcox. The theoretic standpoint from which this author considers flight of ideas agrees in its essentials with that of Liepmann.[37] A knowledge of Liepmann's work is presupposed.

Pelletier compares the shallow flow of associations in dementia præcox to the flight of ideas. The characteristic of flight of ideas is "absence du principe directeur" (absence of directing principle). The same takes place in the course of the associations in dementia præcox. "The directing idea is absent and the state of consciousness remains vague without any ordering of its elements." The only state of normal psychic activity which can be compared to mania is revery, yet revery may rather be a weak-minded than a maniacal mode of thinking. Pelletier is right in finding a great similarity between normal revery and the shallow associations of maniacs, but only when the associations ire written on paper. Clinically the manic does not by any means look like a dreamer. The author evidently feels this and finds the analogy rather more fitting for dementia præcox, which condition has been compared to that of dreams since the times of Reil (e. g., Chaslin: "La confusion mentale primitive"). The richness and acceleration of presentations in manic flight of ideas differentiates it sharply from the very stagnant slowly-coursing association type of dreams and especially from the poverty and numberless perseverations in the associations of catatonics. The analogy is correct only in so far as concerns the directing idea which is absent in both of these cases; in mania because all presentations crowd themselves into consciousness with marked acceleration and with strong feeling tones,[38] therefore no attention can probably take place,[39] and in revery there is no attention to begin with, and where this is lacking the flow of associations must sink into revery. According to the laws of association there results a slowly progressive course, tending principally towards likeness, contrast, coexistence and motor-speech combinations.[40] Numerous examples can be observed daily by attentively following a general conversation. As Pelletier shows, the course of association in dementia præcox is constructed upon a similar scheme. This can best be seen by an example:

"Je suis l'être, l'être ancien, le vieil Hêtre,[41] que l'on peut écrire avec un H. Je suis universel, primordial, divine, catholique, Romaine,[42] l'eusses-tu cru, l'être tout cru, suprumu,[43] l'enfant Jésus.[44] Je m'appelle Paul, c'est un nom, ce n'est pas une négation,[45] on en connait la signification.[46] … Je suis éternel, immense, il n'y a ni haut, ni bas, fluctuat nec mergitur, le petit bâteau,[47] vous n'avez pas peur de tomber."[48]

This example shows us very distinctly the type of association in dementia præcox. It is a very shallow one and carries many sound associations. Yet the disintegration is so marked that we cannot compare it to the reveries of the normal state, but are obliged to compare it to dreams. Only in dreams is such speech observed.[49] Rich examples can be found in Freud's "Die Traumdeutung."

In the first contribution of the "Diagnostische Associationsstudien" it was proven that diminished attention produced shallow association types, motor-speech combinations, sound associations, etc., and inversely, the appearance of shallow association types always pointed to a disturbance of attention. According to our experimental proofs Pelletier is right when she refers to the shallow types of dementia præcox as the result of lowered attention. She calls this diminution by the words of Janet, "abaissement du niveau mental." From this work, too, it can be seen that the disturbance is again taken back to the central problem of apperception.

It is to be noted that the author overlooks the perseverations, but on the other hand we are grateful to her for the valuable observation on symbolism and symbolic relations so very frequent in dementia præcox. She says : "It is to be remarked that the symbol plays a very great part in the discursions of the insane. It is encountered everywhere among the persecuted and weak-minded. It is a very inferior form of thought. The symbol couid be defined as a false perception of a relation of identity or very marked analogy between two objects which in reality present only a very vague analogy."[50]

This quotation shows that Pelletier brings the catatonic symbols into relation with disordered attention. This supposition is decidedly supported by the fact that the symbol has since long been known as a usual manifestation in revery and dreams.

The psychology of negativism, concerning which numerous publications already exist, forms a separate chapter. The symptom of negativism certainly ought not to be considered as something definite. There are many forms and grades of negativism which have not as yet been clinically studied and analyzed with the necessary accuracy. The division of negativism into active and passive forms can be easily understood. The most complicated psychological cases appear under the form of active resistance. If an analysis were possible in those cases, it would frequently be found that very definite motives exist for the resistance, and it would then be doubtful if one could still talk of negativism. In the passive form, too, there are many cases which are difficult to interpret. Notwithstanding this there are numerous cases in which one may clearly point out that even simple processes of volition are always blindly converted into their opposite. According to our view negativism always ultimately depends on corresponding associations. Whether there is a negativism taking place in the spinal cord I do not know. The most general standpoint on the question of negativism is taken by Bleuler in his work on negative suggestibility.[51] He shows that negative suggestibility, that is, the impulse toward contrast associations, is not only a constituent part of the normal psyche, but also a frequent mechanism of pathological symptoms in hysteria, impulsive phenomena, and dementia præcox. The contrast mechanism is an independent function entirely rooted in "affectivity." It therefore manifests itself mainly in presentations of strong feeling as in decisions and similar things. "This mechanism protects against a rash act and forces the consideration of, for and against." The contrast mechanism is a counterpart of suggestibility. Suggestibility is the faculty of the reception and realization of strong feeling-toned ideas, while the contrast mechanism guards the opposite. It is for this reason that Bleuler appropriately calls it negative suggestibility. The fact that these two functions are so closely related readily explains why they are met with together clinically. In hysteria we have suggestibility near insuperable contrary autosuggestion; and negativism, automatism and echopraxy in dementia præcox, etc.

The importance of negative suggestibility in every-day psychical occurrences explains why contrast associations are everywhere enormously frequent. They are in the closest relationship.[52]

In language, too, we see something similar. The words which express the usual contrasts are very closely associated and therefore mostly belong to the intimate associations of language, as, white, black, etc. In primitive languages one occasionally finds only one word for contrasting ideas. According to Bleuler a relatively mild emotional disturbance will suffice to produce negativistic phenomena. Janet ("Les Obsessions," Vol. I, p. 60) shows that in persons suffering from impulsive ideas, the "abaissement du niveau mental" suffices to liberate a play of contrasts. What, therefore, can we expect from the "apperceptive dementia" in dementia præcox! Indeed, here we really find the apparently irregular play of positive and negative which is very often nicely reflected in the associations as expressed in speech.[53] Hence in the problem of negativism we have sufficient evidence that this symptom too, is in close relationship with "apperceptive dementia." The central control of the psyche is so weakened that it can neither further the positive nor inhibit the negative acts, or the reverse may be true.[54]

Let us now recapitulate what has been said. The authors thus far mentioned have essentially affirmed that diminution of attention, or more generally speaking, "apperceptive dementia" (Weygandt) is characteristic of dementia præcox. The existence of the peculiar shallowing of the associations, symbolisms, stereotypies, perseverations, command automatism, apathy, aboulia, disturbances of reproduction, and, in a limited sense, negativism, are all due to apperceptive dementia.

That neither apprehension nor retention take part as a rule in the general deterioration, seems at first sight rather singular. As a matter of fact one can find in dementia præcox during accessible moments that there exists a surprisingly good, and an almost photographic memory, which preferably takes note of the most indifferent things that unfailingly escape the notice of normal persons.[55] But just such peculiarity shows what the nature of memory is. It is nothing but a passive registration of events which take place in the nearest surroundings. But all that which requires an effort of attention passes without heed by the patient, or at most it is registered à niveau together with the daily visits of the doctor and dinner; at least so it appears to us. Weygandt (l. c.) very nicely describes this lack of active acquisition. Apprehension is generally disturbed only during periods of excitement. Apprehension and retention, or impressibility and retentiveness, are for the most part only passive processes which take place in us without the expenditure of a great amount of energy, just as mere hearing and seeing when unaccompanied by attention.

From Weygandt's idea of "apperceptive dementia" (Janet—abaissement du niveau mental) one can in a measure deduce the origin of the above mentioned symptoms (automatism, stereotypy, etc.); but we are unable from this to understand the individual multiformity of the symptoms, their capriciousness, the peculiar content of the delusions, hallucinations, etc. Many investigators have already attempted to solve this riddle.

Stransky[56] examined dementia præcox from the clinical point of view. Proceeding from Kraepelin's idea of "emotional dementia," he asserts that by this conception two things are understood. Firstly, poverty or superficiality of emotional reactions, secondly an incoordination between the same and the content of consciousness dominating the psyche.[57] In this fashion Stransky differentiates the content of Kraepelin's idea, showing that clinically one sees more than the "emotional dementia." The striking incongruity between idea and affect which we can daily observe in dementia præcox, is a more frequent symptom during the development of the disease than the emotional dementia. The incongruity between idea and emotional tone forced Stransky to accept two separate psychical factors, the noöpsyche and the thymopsyche. The former idea embraces all pure intellectual, the latter the affective processes. Both these ideas nearly correspond in Schopenhauer's psychology to intellect and will. In the healthy psyche there is naturally a constant, very fine, simultaneous, coördinated action of both factors. But as soon as incoördination steps in, it corresponds analogically to ataxia, and we then have the picture of dementia præcox with all its disproportionate and unintelligible affects. So far the divisions of the psychic functions into noö- and thymopsychic agree with reality. But it is a question whether a trite content of consciousness manifested in the patient with an enormous affect seems incongruous only to us who can only most sparingly look into his soul, or is it the same for the subjective sensation of the patient. I shall make myself clear by the following example:

I visit a gentleman in his office. Suddenly he starts up enraged and swears most excitedly at a clerk who placed a newspaper on the right instead of the left side of the table. I am astonished and make a mental note about the peculiar nervousness of this person. But after a while I learn from the other employees that the clerk has done the same thing wrongly dozens of times and hence the anger of the man was quite adequate.

Had I not received subsequent explanations I should have formed a wrong picture of the psychology of this person. We are frequently confronted with a similar condition in dementia præcox. Owing to the peculiar seclusiveness of the patients we see into them but little, a fact which every psychiatrist will substantiate. It is therefore readily understood that many excitements appear to us inexplicable because we do not see their associate causes. That may even happen to us. We are occasionally for a time in bad humor, and quite inadequately so without being conscious of its cause. The simplest responses are then uttered in a disproportionate, emphatic, and irritable tone, tc. If even a normal individual is not always clear about the causes of his ill-humor, how little can we know when confronted with the mind of a precocious dement? On account of the evident inadequacy of our psychological diagnosis, we must be very careful about the supposition of a real incoördination in the sense of Stransky. Although judging from clinical appearances there are frequent incongruities, they are by no means exclusively limited to dementia præcox. In hysteria, likewise, the incongruity is an every-day occurrence. One can see it in the very trite fact of the so-called hysterical "exaggerations," whose counterpart is the well known "belle indifférence" of hysterics. We also find violent excitements over nothing, at times over something which in no way shows any recognizable connection with the excitement. Yet psycho-analysis uncovers the motives, and we then begin to understand why the patients reacted in such a manner. In dementia præcox we are at present unable to penetrate deep enough so that the relations remain unknown, and we therefore assume an "ataxia" between noö- and thymo-psyche. Thanks to analysis we know that in hysteria there is no "ataxia," but only an oversensitiveness, which, as soon as we know the pathogenic ideational complex, becomes clear and intelligible.[58] Knowing how the incongruity is brought about in hysteria, is it still necessary that we should accept a totally new mechanism in dementia præcox? In general we know by far too little about the psychology of the normal and hysteric[59] to dare to accept in such an untransparent disease as dementia præcox, a totally new mechanism unknown to all psychology. One should be economical with new principles of interpretation. It is for this reason that I repudiate the clear and ingenious hypothesis of Stransky. As a compensation for the above, we possess a very excellent experimental work by Stransky[60] which gives us the foundation for the understanding of an important symptom, namely, the speech disorders.

The speech disorder is the product of the main psychological disturbance. Stransky calls it "intrapsychic ataxia." Whenever there is a disturbance at the points of contact of the emotional life and ideation, as in dementia præcox, producing thereby in the normal thought the lack of orientation by a controlling idea (Liepmann), there must result a stream of thought resembling flight of ideas. As Pelletier has shown, the laws of association predominate against the influence of direction. If it is a question of a process of speech there must result an increase in the purely superficial elements of connection (motor speech association and sound reactions), as was shown in our association experiments with distracted attention. Hand in hand with this there is a diminution of sensory connections. Besides these many other disturbances show themselves, such as an increase of the mediate associations, the senseless reactions, and frequent repetitions of the stimulus words. Perseverations show a most contradictory behavior during distractibility. According to our experiments they are increased in women and decreased in men. In a great many cases we could explain the resulting perseverations by the presence of a strong feeling tone. Every-day experience teaches us that a strong feeling-toned idea shows a special tendency to perseverate. By distracting the attention there results a certain emptiness of consciousness[61] in which ideas can more easily perseverate than during complete attention.

Stransky then studied the results of continuous speech association under the influence of relaxed attention. His test persons had to talk at random into a phonograph for one minute on anything or in any way they chose. At the same time they were not to pay attention to what they said. A stimulus word was given as a starting point, and in one half of the experiments external distraction was caused.

These tests brought to light interesting results. The sequence of words and sentences immediately recalled the speech as well as the writing of dementia præcox. A definite direction of speech was excluded by the arrangement of the experiment. The stimulus word at most acted for some time as a more or less indefinite "theme." Superficial connecting elements became strikingly manifest, corresponding to the disintegration of logical connections. There were numerous perseverations, or repetitions of the preceding word, almost corresponding to the repetition of the stimulus words in our experiments, and besides this there were numerous contaminations,[62] and closely connected with them neologisms or newly formed words.

From Stransky's voluminous material I should like to quote a few examples by way of illustrations : "On one leg stand the storks, they have wives, they have children, they are those who bring the children, the children, which they bring into the house, this house, an idea, which people have about storks, about the activity of storks, the storks are large birds—with a long beak and live on frogs, frogs, freegs, frogs, the frogs are froogs, in the morning (Früh), in the morning they are with—breakfast (Frühstück), coffee, and with coffee they also drink cognac, and cognac they also drink wine, and with wine they drink everything possible, the frogs are large animals, and which the frogs devour, the storks devour the birds, the birds devour the animals, the animals are big, the animals are small, the animals are human beings, the animals are no human beings …", etc.

"These sheep are … were merino sheep, from which the fat was cut out by the pound, with Shylock was the fat cut out, the pound cut out," … etc.

"K … was a K … with a long nose, with a ramnose, with a rampnose, with a nose to ram, a ram gift, a man, who has rammed, who is rammed," etc.

From these examples of Stransky's experiments it can be readily seen what laws of association the stream of thought follows. It is mainly those of similarity, coexistence, motor speech connections and combinations of sound. Besides this one is struck by the numerous perseverances and repetitions (Sommer : stereotypies). If we compare to this the sample of dementia præcox associations which we have just quoted from Miss Pelletier we find a striking similarity.[63] Here, just as there, one finds the same laws of similarity, contiguity, and assonance. Only stereotypies and perseverations are lacking in Pelletier's analysis,[64] although they can be plainly seen in the communicated material. Stransky also adds to these conspicuous similarities numerous nice examples taken from dementia præcox.

It is especially important that in Stransky's normal tests there appear numerous word and sentence-conglomerations which can be designated as contaminations.[65]

Example: "Especially a meat, which one cannot get rid of, the thoughts which one cannot get rid of, especially when one ought to persevere at it, persevere, persevere, severere, severin," etc.

According to Stransky this conglomeration contains the following condensed series of ideas:

(a) Mutton is consumed in England,
(b) This idea I cannot get rid of,
(c) This is perseveration,
(d) I am to talk at random whatever comes into my mind.

The contamination is therefore a condensation of various series of ideas. It is essentially to be considered as a mediate association.[66] This character of contamination can be clearly proven from Stransky's pathological examples:

Question: What is a mammal?

Answer (Pat): It is a cow, for example a midwife. Midwife is a mediate association of cow and shows the probable way of thought. Cow—bears living young—human beings likewise—midwife.[67]

Question: "What do you understand by the Holy Virgin?"

Answer: "The behavior of a young lady."

As Stransky rightly observes the thought probably goes as follows: Immaculate conception—virgo intacta—irreproachable conduct.

Question: "What is a square?"

Answer: "An angular quadrate."

The condensation consists of:

(a) Square is a quadrate,
(b) The square has four angles.

From these examples it should be evident that the numerous contaminations appearing in distracted attention are somewhat similar to the mediate associations which appear under distraction in the simple word reactions. It is well known that our experiments have shown that in distractibility there is moderate increase of the mediate associations.

The concurrence of three experimenters, Stransky, myself, and dementia præcox, can be no accident. It proves the correctness of our conceptions and is another confirmation of the symptom of apperceptive weakness, which of all the degenerative symptoms of dementia præcox stands out most prominently.

Stransky points out that contamination has frequently produced such bizarre word formations that they unfailingly recall the neologisms of dementia præcox. That a great number of neologisms are really brought about in this manner I am convinced. Pointing to the picture of a horse a patient remarks,[68] "This is a domestic-burden," by which he means:

(a) The horse is a domestic animal,
(b) The horse is a beast of burden.

Based on clinical observation Neisser[69] remarked in 1898 that the newly formed words, which according to the rule as well as the roots are neither verbs nor nouns, are really no words at all but represent sentences inasmuch as they always serve to allegorize (Versinnbildlichung) a whole process. This expression of Neisser indicates the idea of condensation. He even goes so far as to talk directly about the allegorization of a whole process. Right here I should like to call attention to the fact that in his work "Die Traumdeutung"[70] Freud showed that there is a great deal of condensation in dreams. Unfortunately I am unable to discuss in extenso the extent and extremely valuable psychologic material of this as yet hardly recognized investigator. It would lead too far.

A knowledge of this valuable book is presupposed. No real refutation of the ideas of Freud have to my knowledge been advanced. I confine myself to the affirmation that dreams having already many analogies to disturbance of the associations of dementia præcox, possesses also the special speech condensations in the sense of contaminations of whole sentences and situations. Kraepelin too was struck by the resemblance between the speech of dreams and of dementia præcox.[71] From the numerous examples which I observed in my own and other's dreams, I will mention only a very simple one, illustrating at the same time condensation and neologism. One in his dream wishes to express approval of a certain situation and says: "That is fimous."

It is a contamination of (a) fine, (b) famous.

The dream is likewise an apperceptive weakness par excellence, which is especially shown by its tendency towards symbolism.[72]

Finally there is still one more question which really should have been answered first, and that is: Does the state of consciousness in' Stransky's normal experiments really correspond to one of disturbed attention? Before all it is to be noted that Stransky's experiments in distractibility show no essential changes from the experiments with the normal, consequently neither the association nor the attention in both conditions could have been so very different. But what is one to think of the disturbance in the experiments with the normal?

It seems to me that the main reason is to be looked for in the forced character of the experiment. The test persons were instructed to talk at random, and that they have at times talked with great rapidity is shown by the fact that on an average they uttered from 100 to 250 words per minute, whereas in normal speech the average per minute is only from 130 to 140.[73] Now if one talks and perhaps thinks more rapidly about indifferent things than he is accustomed to, he cannot bestow sufficient attention on the associations. A second point which has to be considered is the fact that most of the test persons were unaccustomed to the situation and it consequently influenced the emotional state. This may be compared to excited orators who develop a state of "emotional stupidity."[74] In such conditions I found extraordinarily high numbers of perseverations and repetitions. Emotional stupidity causes likewise great disturbance of attention. We can therefore take it as certain that in Stransky's experiments with the normal the attention was really disturbed, although the state of consciousness is surely not clear.

We are grateful to Heilbronner for an important observation.[75] By examining a series of associations in a case of hebephrenia he found that on one occasion forty-one per cent., on another twenty-three per cent, of the reaction words referred to the patients' environment. Heilbronner considers this circumstance as an evidence for the fact that the perseverations are derived from the "vacuum," i. e., they are due to a deficiency of new ideas. I can confirm this observation from my own experience. Theoretically it would be interesting to know in what relationship this manifestation stands to the Sommer-Leupoldt symptom of "Benennen und Abtasten" (name and touch).

New and independent views on the psychology of dementia præcox are brought forth by Otto Gross.[76] He proposes the expression dementia sejunctiva for the name of the disease. The reason for this name is the disintegration of consciousness in dementia præcox, hence the sejunction of consciousness. The idea of sejunction Gross naturally takes from Wernicke. He could just as well have taken the older synonymous idea of dissociation (Binet, Janet). Fundamentally, dissociation of consciousness means the same thing as Gross's disintegration of consciousness. By accepting the idea of sejunction we have only a new term of which psychiatry has certainly enough. Dissociation according to the French school is a weakness of consciousness due to the splitting off of one or a series of ideas. They separate themselves from the hierarchy of the conscious ego and begin a more or less independent existence.[77] The hysteria doctrine of Breuer and Freud was developed on this foundation. According to the more recent formulations of Janet, dissociation is the result of "abaissement du niveau mental" which destroys the hierarchy and either favors or effects the origin of automatisms.[78] What automatisms are freed is most beautifully shown by Breuer and Freud.[79] The application made by Gross of this doctrine to dementia præcox is new and important. The fundamental idea of the author is expressed as follows: "Disintegration of consciousness in my sense signifies the simultaneous flow of functionally separated series of associations. To me the chief point lies in the conception that the activity of consciousness is to be considered as a resultant of many synchronous psychophysical processes.[80]

These citations ought to illustrate sufficiently the author's ideas. We can perhaps agree with the view that consciousness, or better, the content of consciousness, is the result of numerous nonconscious or unconscious psychophysical processes. In contradistinction to the current psychology of consciousness, in which beyond the epiphenomenon "consciousness" there immediately begins the nutritive processes of the brain cells, this aspect is really a refreshing progress for psychiatry. Gross seems to think that the psychic content (not the content of consciousness!) flows synchronously in single series of associations. This comparison seems to me somewhat equivocal. I think it more correct to assume successive conscious-becoming ideational-complexes which are constellated by antecedent association-complexes. The cement of these complexes is some definite affect.[81] If the connection between Gross's synchronous series is severed by disease, disintegration of consciousness results. Translated into the language of the French school, it means that if one or more association series are split off there results a dissociation causing weakness of consciousness. Let us not quarrel over words. Here, too, Gross returns to the problem of apperceptive disturbance; he, however, approaches this problem from a new and interesting side, from the side of the unconscious. Gross attempts to uncover the roots of the numerous automatic phenomena which break into the consciousness of dementia præcox with elemental power and strangeness. The symptoms of automatic phenomena in the conscious life of dementia præcox should be known to all psychiatrists. They are the autochthonous ideas, the sudden impulses, hallucinations, the manifestations of thought-influence, imperative ideas with the character of strangeness, the cessation and disappearance of thought (appropriately designated by one of my patients as "Gedankenentzug"—thought deprivation), and inspirations (pathological fancies), etc. Gross states that the catatonic manifestations are "changes of the will brought about by an agent which is conceived as external to the ego-continuity, and is therefore referred to as a strange power." They are a "substitution of the will of the ego-continuity by a crowding in from outside of another conscious series." We have to keep in mind that many association series can simultaneously flow in the organ of consciousness without influencing one another. From these series in consciousness one will have to become the carrier of the continuity of consciousness, while the other association series are then naturally "subconscious," or rather, "unconscious." Now at all times there is a possibility that also in these the nervous energy swells up and reaches such a stage that one of its end organs becomes endowed with attention, which means that a joint from the unconscious association series pushes itself illegitimately into the continuity of the dominant one. If these conditions are fulfilled, the accompanying subjective process can be only of such a nature as any psychic manifestation entering into consciousness in an unadjusted manner, and is therefore perceived by the conscious continuity as something entirely foreign. Ideas of explanation are almost inevitably added, the referred psychic manifestation (idea) originating not from the ego-consciousness, but thrown into it from without.[82] As aforesaid, the displeasing part in this hypothesis is the assumption of synchronous independent association series. Normal psychology does not furnish us with any facts on this point. Where we can best observe split-off series of ideas, namely, in hysteria, we find that the opposite holds true. Even where one deals with apparently totally separated series, one can find somewhere in some hidden location the bridge leading from one series to the other.[83] In the mind all stands in connection with all, the present psyche is the result of milliards of constellations.

Aside from this slight inconvenience, I believe that I may call Gross's hypothesis a rather happy one. It tells us in brief that the roots of old automatic phenomena lie in the unconscious association connections. If consciousness becomes disintegrated (abaissement du niveau mental—apperceptive weakness) the complexes accompanying it are freed from all restraint and are then able to break into the ego-consciousness. This is an eminent psychological conception, and agrees in the clearest possible manner with the doctrines of the French school, with the experience of hypnotism, and with the analysis of hysteria. If we weaken the power of consciousness by suggestion and produce thereby a split-off series of presentations, as, for example, in post-hypnotic commands, we find that this series reappears with a power inexplicable to the ego-consciousness. In the psychology of ecstatic somnambulists we have the typical breaking in of split-off ideas.[84]

Unfortunately Gross leaves one question open, and that is, which are the dissociated series of ideas and what is the nature of their content? Some time ago, long before Gross wrote, Freud answered this question very brilliantly. As far back as 1893 Freud[85] showed preliminarily that a hallucinatory delirium originates from an unfulfilled wish, and that this delirium is a compensation for unsatisfied yearnings, that the person takes refuge, as it were, in the psychosis in order to find in the dreamlike delirium of the disease that which was refused to him in reality. In 1896 Freud analyzed a paranoid condition, Kraepelin's paranoid form of dementia præcox, and showed how the symptoms were accurately determined according to the scheme of the transformation mechanism of hysteria. Freud then stated that paranoia, or the group of cases belonging to paranoia, are a defensive neuropsychosis; that is to say, that just like hysteria and obsessions, they, too, originate from the repression of painful memories, and that the form of the symptoms is determined by the content of the repression.[86]

In view of the far-reaching significance of such an hypothesis it pays to enter somewhat more fully into the classical analysis of Freud.

It was the case of a thirty-year old woman who manifested the following symptoms: She imagined that her environment had changed, she was no longer respected, she was annoyed, she was watched, and her thoughts were known. Later she thought that she was watched in the evening while undressing. She also experienced sensations in her abdomen which she believed were occasioned by an unseemly thought on the part of the servant girl. Visions then appeared in which she saw female and male genitals. Whenever she was with women alone she had hallucinations of female genitals, and at the same time imagined that the others saw her own genitals.

Freud analyzed this case. He observed that this patient behaved just like a hysteric; that is, she showed the same resistances, etc. What seemed unusual was the fact that the repressed thoughts did not appear, as in hysteria, in the form of loosely connected fancies, but in the form of hallucinations, and hence the patient compared them to her own voice. (I shall later take the opportunity to produce experimental proof for this observation.) The hallucinations here mentioned began to manifest themselves after the patient saw in the asylum a number of naked female patients bathing together. "It may be presupposed that the reason these impressions repeated themselves was because something of great interest was connected with them." She stated that she felt ashamed in the presence of these women. This is somewhat forced and altruistic modesty was striking, and pointed to something repressed. Patient reproduced "a series of scenes from her seventeenth to her eighth year, during which, while bathing before her mother, her sister and her physician, she was ashamed of her nakedness. This series, however, reached back to a scene in her sixth year, when she undressed in the children's room before going to sleep without feeling ashamed of her brother, who was present. Finally it was found that for years the brothers and sisters were in the habit of showing themselves naked to one another before retiring." At that time she was not ashamed. "She is now trying to make up in shame what she lost as a child."

"The beginning of her depression began at the time of a disagreement between her husband and her brother, on account of which the latter no more visited her. She was always much attached to this brother."

Besides this she spoke about a moment in the history of her disease during which, for the first time, "everything became clear"; that is, during which she became convinced that her assumption about being generally despised and intentionally annoyed was true. She gained this assurance during a visit of her sister-in-law who, in the course of conversation, gave utterance to the following words: "If such a thing should happen to me I would not mind it." Mrs. P. at first took this lightly, but when her visitor left her it seemed to her that these words contained a reproach, meaning that she was in the habit of taking serious matters lightly, and since that hour she was sure that she was a victim of common slander. The tone in which her sister-in-law spoke was especially convincing. It was, however, shown that the sister-in-law spoke about another subject before giving utterance to this sentence. She related to the patient that in the father's home there were all sorts of difficulties with the brothers, and added: "In every family many things happen which one would rather keep in darkness, and that if such a thing should happen to her she would take it lightly. Mrs. P. had to acknowledge that her depression was connected with the sentences uttered before the last one. As she repressed both sentences which could recall her relations with her brother and retained only the last meaningless one, she was forced to connect with it the sensation of being reproached by her sister-in-law; but, inasmuch as the contents of this sentence offered absolutely no basis for such assumption, she disregarded it and laid stress on the tone with which the words were pronounced."

After this explanation Freud turned his attention to the analysis of the voices. "It is to be noted that such indifferent remarks as 'here goes Mrs. P.'—'she now looks for apartments' were very painfully felt." The first time she heard voices was after she read the story "Heiterethei," by O. Ludwig. After reading it she took a walk on the highway, and suddenly while passing a peasant's cottage voices told her: "That is just how the house of Heiterethei looked! Here is the well and here the bush! How happy she was in all her poverty!" The voices repeated whole paragraphs of what she had just read, but the contents were of an indifferent nature. The analysis showed that while reading she at the same time entertained extraneous thoughts and that she was excited by totally different passages of the book. Against this material analogy between the couple in the romance and herself and her husband, the reminiscences of intimate things of her married life and family secrets, against all these, there arose a repressive resistance because they were connected with her sexual shyness by very simple and demonstrable streams of thought, and finally resulted in the awakening of old experiences of childhood. In consequence of the censorship exercised by the repression the harmless and idyllic passages connected with the objectionable ones by contrast and vicinity became reënforced in consciousness, enabling them to become audible. For example, the first repressed thought referred to the slander to which the secluded heroine was subjected by her neighbors. She readily found in this an analogy to herself. She, too, lived in a small place, had no intercourse with anybody and considered herself despised by her neighbors. The suspicion against the neighbors was founded on the fact that in the beginning of her married life she was obliged to content herself with a small apartment. The wall of the bedroom, near which stood the nuptial bed of the young couple, adjoined the neighbors room. With the beginning of her marriage there awakened in her a great sexual shyness. This was apparently due to an unconscious awakening of some reminiscences of childhood of having played husband and wife. She was very careful that the neighbors should not hear through the adjacent wall either words or noises, and this shyness changed into suspicion against the neighbors." On further analysis of the voices Freud often observed "a character of diplomatic uncertainty. The morbid allusions were generally deeply hidden. The continuity of some sentences was marked by strange expressions, unusual forms of speech, and, in other ways, characteristics common to the auditory hallucinations of paranoiacs. The hallucinations also showed a slight disfigurement caused by compromise formation."

I have purposely given the floor to the author of the first analysis of paranoia, a thing so highly important for psychopathology. I did not know how to abridge the ingenious demonstrations of Freud.

Let us now return to the question of dissociated series of ideas. We now see what meaning Freud gives to Gross's assumed dissociations. They are nothing other than the repressed complexes found in hysteria,[87] and last but not least also in the normal.[88] The mystery of repressed series of ideas reveals itself as a psychological mechanism of general significance and of quite usual occurrence. Freud puts in a new light the problem of incongruity between the content of consciousness and emotional tone discussed by Stransky. He shows that indifferent, even insignificant ideas may be accompanied by intense feeling tones which they take from a repressed idea. Freud uncovers a way which can lead us to the understanding of the inadequate feeling tone in dementia præcox. I need hardly discuss the significance of this. The results of Freud's investigations may be summed up as follows:

Both in form and in content of the symptoms of paranoid dementia præcox there are thoughts which in consequence of their disagreeable tone became unbearable to the conscious ego, and hence are repressed. They determine the nature of the delusions and hallucinations as well as the whole general behavior. Whenever apperceptive paralysis appears in a person the manifested automatisms contain the dissociated idea complexes—the whole army of subjected thoughts become unyoked. Thus we may generalize the result of Freud's analysis.

As everybody knows, Tiling,[89] uninfluenced by Freud, and based on clinical experience, came to conclusions closely resembling those of Freud. He, too, would contribute to individuality an almost boundless significance for the origin and formation of the psychosis. The importance of individual psychology is undoubtedly underestimated in modern psychiatry, owing less perhaps to theoretical reasons than to the helplessness of practical psychology. One can therefore cover a great distance with Tiling, at any rate, even further than Neisser[90] thought he could go. At the question of etiology, that is, at the nucleus of the problem, one must halt. The individual psychology of neither Freud nor Tiling explains the origin of the existing psychosis. In the citation from Freud's analysis we very clearly see that the "hysterical" mechanisms uncovered by him suffice to explain the origin of hysteria, why then does a dementia præcox originate? We can readily understand why the content of the delusions and hallucinations are of such a nature and of no other; but why non-hysterical delusions and hallucinations should at all appear we do not know. Here at the basis of all there should be one physical cause embracing all the psychological ones. Let us assume with Freud that every paranoid form of dementia præcox runs according to the mechanism of hysteria, but why is the paranoid unusually stable and resistive, while hysteria is characterized by the great mobility of its symptoms? Here we strike against a new phase of the disease. As Neisser[91] puts it, the mobility of the hysterical symptoms is based on the mobility of the affects, while the paranoid state is characterized by the fixation of the affects. This thought extraordinarily important for dementia præcox is formulated by Neisser as follows:[92]

"From without only a very poor assimilation takes place. The patient is able to exert less and less voluntary influence on the stream of his ideas and in this manner there originate separate groups of idea complexes of much greater volume than in the normal. These complexes are, as to contents, connected by certain inherent personal relations, but hardly coalesce in any other way, so that depending on the momentary constellations it is now this and now that one which more intensively determines the direction of the continued psychic elaboration and association, In this way there results a disintegration of the personality which becomes so to say a passive spectator of the inflowing impressions from the various irritative sources and an inanimate puppet for the freed irritations thus generated. The affects normally destined to regulate our relations to our environments and to direct our adaptation to the same, which are a protection to the organism and represent the motive powers of self-preservation, are alienated from their natural destiny. Owing to the organically strong feeling tone of the delusional stream of thought, no matter what the emotional state may be, this and this only is always reproduced. These fixations of the affects destroy the ability of feeling joy or compassion and lead to an emotional isolation of the patient which runs parallel with the intellectual alienation."

Neisser describes here the familiar picture of apperceptive dementia. Lack of new acquisition, paralysis of purposeful progress (adapted to reality), disintegration of personality and autonomy of complexes. Finally, he adds the "Fixierung der Affecte" (fixation of affects), that is, the fixation of the emotionally accentuated complexes (for affects have always regularly an intellectual content, though it is not always known). From this he explains the emotional dementia (Masselon invented for this the fitting expression "clotting"). Following Freud, fixation of affects means that the repressed complexes (the carriers of affects) can no more be disconnected from the contents of consciousness, they remain and so prevent the further development of personality.

To avoid misconceptions I must here add that the continued persistence of a strong complex in normal psychic life can lead only to hysteria. Yet the consequent manifestations of the hysterogenic affect are different from the symptom-complex of dementia præcox. For the origin of dementia præcox we must demand a totally different disposition than we do for hysteria. If a purely hypothetical supposition be permitted one could perhaps venture the following train of thought: The resultant manifestations of the hysterogenic complex are reparable, while the affect of dementia præcox gives opportunity for the appearance of an anomalous metabolism (toxine?), which injures the brain in a more or less irreparable manner, so that in consequence of this defect the highest psychic functions become paralyzed. It is for this reason that the acquisition of new complexes becomes difficult or ceases altogether. The pathogenic or rather the inciting complex remains to the last, and the further development of personality is definitely checked. In spite of an apparently gapless causal chain of psychological events leading from the normal into the pathological, one can never disregard the possibility that in certain cases a change of metabolism (in the sense of Kraepelin) may be primary, whereby the accidental newest and last complex "clots" or "curdles," and thus inherently determines the symptoms. Our experience does not as yet reach far enough to warrant the exclusion of this possibility.

Summary of the First Chapter.

This anthology from the literature, in my judgment, shows quite distinctly that all the views and investigations which among themselves hardly exhibit any apparent connection nevertheless converge to the same point. The observations and intimations plucked from the different realms of dementia præcox point above all to the idea of a real central disturbance which is designated by different names, such as apperceptive dementia (Weygandt), dissociation, abaissement du niveau mental (Janet, Masselon), disintegration of consciousness (Gross), disintegration of personality (Neisser et al.). Then there arose the idea of tendency towards fixation (Masselon, Neisser) and from this Neisser adduces the emotional dementia. Freud and Gross find the important fact of the presence of split-off series of ideas. To Freud, however, belongs the credit of being the first to show in a case of paranoid dementia præcox the "principle of conversion" (repression and indirect reappearance of the complexes). Nevertheless the mechanisms of Freud do not reach so far as to explain why there originates a dementia præcox and not a hysteria; hence it must be postulated that for dementia præcox there is a specific resultant manifestation of affects (toxins?) which causes the definite fixation of the complex by injuring the sum total of the psychic functions. However, the possibility cannot be disputed that the "intoxication" may appear primarily from "somatic" causes and seize the accidentally remaining complex and change it pathologically.

  1. Cited from Ehrich Arndt: Uber die Geschichte der Katatonie, Zentr.-f. Nervenheilk. u. Psych., Bd. XIV, p. 81.
  2. Freusberg, 1886, Archiv f. Psych., XVII, p. 758.
  3. Lehrbuch d. Psychiatrie.
  4. Allg. Ztschr. f. Psych., 1898.
  5. Allg. Ztschr. f . Psych., Bd. L.
  6. v. Leupold, who recently elaborated this symptom, names this manifestation "das Symptom der Benennung u. des Abtastens" (the symptom of naming and touching). Zur Symptomatologie der Katatonie. Klinik für psychische u. nervöse Krankheiten, Vol. I, H. I.
  7. Cited from Neisser's, Über die Katatonie. Stuttgart-Enke, 1887, p. 61.
  8. Ernst Meyer, too, leans towards this view which was then also held by Kraepelin.—E. Meyer: Beitrage zur Kenntnis der acut entstandenen Psychosen. Habilitationsschrift. Berlin, 1899.
  9. Lehrbuch der Psychopathologischen Untersuchungsmethoden, 1899.
  10. Sommer: Lehrbuch, p. 362. Recently Fuhrmann has made some association experiments in "acute juvenile dementia" without any characteristic results. Arch. f. Psych., Vol. XL, p. 817.
  11. Diem: Die einfach demente Form der Dementia Præcox (Dementia simplex). Arch. f. Psych., Vol. XXXVII.
  12. Breukink: Uber eknoische Zustände. Monatsschr. f. Psych, u. Neur., Vol. XIV.
  13. Deutsche med. Wochenschrift, No. 39, 1904.
  14. Flournoy: Des Indes à la planète Mars. Étude sur un cas de Somnambulisme avec glossolalie. Paris et Genève, 1900.—III Nouvelles observations sur un cas de somnambulisme avec glossolalie. Archives de Psychologie de la Suisse Romande, T. I, p. 102.
  15. Zur Psychologie und Pathologie sogenannter occulter Phänomene. Leipzig, 1902.
  16. Diagnostische Assoz. Stud., IV Beitrag. Über das Verhalten der Reaktionszeit beim Assoziationsexperiment. J. A. Barth, Leipzig, 1906.
  17. R. Vogt: Zur Psychologic der Katatonischen Symptome. Zentr. f . Nervenheilk. u. Psych., Bd. XIX, p. 433.
  18. Zeitschrift für Psych, u. Phys. der Sinnesorgane, Erg. B. I, 1901.
  19. In conditions of distraction there is an increase of preseveration in the association experiments. See Diag. Assoz. Stud., I Beitrag, and interesting experiments of Stransky: über Sprachverwirrtheit, 1905. Marhold, Halle. See also the excellent work of Heilbronner: Über Haftenbleiben und Stereotypie (Monatsschr. f. Psych, u. Neur., Bd. XVIII, Erg.-Heft), which accepts similar theoretical views.
  20. I call attention here to the work of Kaiser: Differentialdiagnose zwischen Hysterie und Katatonie. Allgem. Ztschr. f. Psych., LVIII.
  21. P. Janet: Les Obsessions et la Psychasthénie. Paris, 1903. Janet presents similar views in his earlier works: Névroses et Idées Fixes, and Automatisme Psychologique.
  22. According to Binet attention is "a mental adaptation to a state which is new for us." Attention et Adaptation. Année Psychologique, 1900.
  23. Die psychologische Grundlage der Katatonischen Krankheitszeichen. Zentralbl. für Neurol. Psych., etc. Edited by v. S. Kure and K. Miura, Tokio, Bd. II.
  24. Masselon: Psychologie des Déments Précoces. Thèse de Paris, 1902. (The work of Masselon "La Démence Précoce" is rather a clinical compendium of the disease.)
  25. Masselon: l. c., p. 62, 71, 135, 140.
  26. See the works of Freud, also Riklin: Zur Psychologie hysterischer Dämmerzustände und des Ganserschen Symptoms. Psych.-neur. Wochenschr., 1906.
  27. Diagnost. Assoz. Stud., IV Beitrag. Über das Verhalten der Reaktionszeit beim Assoziationsexperiment u. Experimentelle Beobachtungen über das Erinnerungsvermögen. Zentr.-Bl. f. Nervenheilk. u. Psych., Jahrgang XXVIII, p. 653.
  28. Cf. Diagnost. Assoz. Stud., IV Beitrag.
  29. Masselon: l. c., p. 69, 261, 263.
  30. Séglas (Leçons cliniques), 1895, says the following about the uncertainty of catatonic accomplishments: There is nothing surprising when one reflects that all movement requires the previous synthesis of a crowd of mental representations—and it is precisely the power to make this mental synthesis which is defective in these individuals.
  31. Kant: Kritik der praktischen Vernunft.
  32. W. Weygandt: Alte Dementia Præcox. Zentr.-Bl. f. Nervenheilk. u. Psych., Jahrgang XXVII, p. 613.
  33. Obsessions et Psychasthénie, Vol. I, p. 433. The fonction du reél can also be expressed in other words as psychological adaptation to the environment or acting up to reality. It corresponds to the "adaptation" of Binet, which represents a special side of apperception.
  34. Gundriss der Psychologie, 1902, p. 249.
  35. Grundzüge der Physiol. Psychologie, 1903, p. 341.
  36. L'Association des idées dans la manie aiguë et dans la débilité mentale. Thèse de Paris, 1903.
  37. Liepmann: Über Ideenflucht, Begriffsbestimmung u. psychologische Analyse. Halle, 1904.
  38. It is true that Aschaffenburg found a certain prolongation of the association time in manic cases. It should, however, not be forgotten that in acoustic-speech experiments attention and speech expression play a great rôle. One observes or measures expression of speech only, and not connections of ideas.
  39. Acceleration and emotional strength of ideas are at least that which we can verify by observation. This, however, does in no way exclude the fact that there are other essential moments to consider which are, at present, inaccessible to our cognition.
  40. Diagnost. Associationsstudien, I Beitrag, Einleitung.
  41. Assonance.
  42. Contiguité.
  43. Assonance.
  44. Assonance.
  45. Assonance.
  46. Assonance.
  47. Resemblance and contiguity, immense suggested to him the ocean, then the bâteau and the aphorism which forms the shield of the city of Paris.
  48. Pelletier: l. c., p. 142.
  49. Kraepelin: Arch. f. Psych., Vol. XXVI, p. 595, and Stransky: Über Sprachverwirrtheit, 1905, point out the same thing.
  50. Pelletier : l. c., p. 129.
  51. Bleuler: Die negative Suggestibilität ein psychologisches Prototyp des Negativismus, der contraren Autosuggestion und gewisser Zwangsideen. Psych.-Neurol. Wochenschr., 1904.
  52. The following express themselves in a similar manner: Paulhan: L'activité mentale et les élements de l'esprit, 1889.—Svenson: Om Katatonie. Hygiea, 1902.—Janet: Les Obsessions, 1903.—Pick: On Contrary Actions. Journal of Nervous and Mental Disease, Jan., 1904.—An instructive case is given by Josiah Royce: The Case of John Bunyon. Psychological Review, 1894, p. 143. [Jelliffe: Pre Dementia Præcox, Am. Jour. Med. Sc. 1907. Ed.]
  53. Compare the analyses of Pelletier, l. c., as well as the experimental examinations of Stransky: Über Sprachverwirrtheit.
  54. Further works on negativism have already been criticised by Bleuler: l. c.
  55. Kraepelin, too, is of the opinion that the apprehension is not more intensively damaged; it is only an increased inclination to an arbitrary production of incoming ideas. Lehrbuch, VII Aufl., p. 177.
  56. Stransky: Zur Kenntniss gewisser erworbener Blödsinnsformen, 1903. Jahrb. f. Psych., Vol. XXIV, p. 1.
  57. Jahrbuch. f. Psych., XXIV, p. 28.—Idem: Zur Lehre von der Dementia præcox. Zentr.-Bl. f. Nervenheilk. u. Psych., XXII Jahrg.—Idem: Zur Auffassung gewisser symptome der Dementia præcox. Neurol. Zentr.-Bl., 1904, Nr. 23, u. 24.—Idem: Über die Dementia præcox. Wiener mediz. Presse, 1905.
  58. An hysterical woman, for example, one day merged into a deep and persistent depression "because the weather is so dull and rainy." The analysis, however, showed that the depression set in on the anniversary of a very sad and important event in the life of the patient.
  59. Binet (Les altérations de la personnalité, p. 89) approximately remarks: Hysterics are for us only subjects of choice, exagerating phenomena that one must necessarily find in some degree among a crowd of other persons who are not at all tainted, even slightly, by the hysterical neurosis.
  60. Stransky: Über Sprachverwirrtheit.
  61. Comp. Diagnost. Associationsstudien, I Beitrag. B. Durchschnittsberechnungen, Abschnitt III.
  62. Comp. Rud. Meringer and Karl Mayer: Versprechen und Verlesen. Eine psychologisch-linguistische Studie. Stuttgart, Göschen, 1895.

    By contamination we understand the condensation of many sentences or words into one sentence or into one word; e. g., "I will soon him see home" is a contamination of "I will go home," "I will soon see him."

  63. We must, however, mention that the speeches of Stransky show the unmistakable character of precipitation which is generally lacking in dementia præcox. What gives the impression of precipitation is hard to say.
  64. As mentioned above, Sommer has already shown the sound associations and stereotypies in simple word reactions.
  65. By contamination we understand the condensation of many sentences or words into one sentence or into one word; e. g., "I will soon him see home" is a contamination of "I will go home." "I will soon see him."
  66. See the analysis of mediate associations. Diagnost. Associationsstudien, Beitrage I, Introduction.
  67. According to Professor Blueler, the following combination is more probable:
    cow——— ———————— bears living young
    is an example midwife
  68. Given by translators as play of words, in author's example can not be translated.
  69. Neisser: Über die Sprachneubildungen Geisteskranker. Vortrag. 74. Sitzung. d. Vereins Ostdeutsch. Irrenärzte in Breslau. Allgem. Zeitschr. f. Psych., LV, p. 443.
  70. Based on a large empirical material, Kraepelin, in his work, Über Sprachstörungen im Traume (Psychol. Arbeiten, Bd. V, H. I), also occupies himself with these questions. In reference to the psychological genesis of the phenomena in question, Kraepelin's assertions show that he does not differ much from the views developed here. Thus he says on p. 10: "The appearance of speech disturbances in dreams is certainly very closely dependent upon the obnubilation of consciousness and the diminution in clearness of ideas conditioned by it."

    What Paul Meringer, Mayer and others designate as contamination, and Freud as condensation, Kraepelin names "ellipse" ("mixture of different series of ideas," "en elliptical concentration of several simultaneous series of thoughts"). Here I wish to call attention to the fact that as early as in the 80's Forel used the expression "ellipsis" for the condensations and new word formations in paranoid states. It escaped Kraepelin that Freud had already, in 1900, treated dream-condensations in a detailed manner.

    By condensation Freud designates the blending together of situations, pictures, and elements of speech. The linguistic expression "contamination" concerns only the blendings of speech, and is, therefore, a special idea which is subordinate to Freud's idea of condensation. The retention of the term contamination is to be recommended for condensation of speech.

  71. Arch. f. Psych., XXVI, p. 595. Compare also Psych. Arbeiten, Bd, V, H. I, p. 79, where Kraepelin says: "It should perhaps be kept in mind that the peculiar expressions of the patients (dementia præcox) are not simple 'nonsense,' nor still less do they represent intentional productions of overbearing moods, but they are the expression of a peculiar disturbance of word findings which must be nearly related to those found in dreams." Kraepelin also expresses the view that "in confusion of speech, besides disturbances of word selecting and the speech expression of thought, there are even such disturbances of the process of thought which in part resemble those of dreams."
  72. Compare above the excellent observation of Pelletier, l. c., Über das Symbol.
  73. Stransky: l. c., p. 14.
  74. Jung: Über Simulation von Geistesstörung. Journ. f. Psych. und Neur., II, p. 191, und Wehrlin in Diagnost. Associationsstudien, Beitrag II.
  75. Monatsschr. f. Psych, und Neur., Bd. XVIII, Erg. Heft, p. 324.
  76. Gross: Über Bewusstseinszerfall. Monatschr. f. Psych, und Neurol. p. 45.—Idem: Beitrag zur Pathologic des Negativismus. Psych.-neur. Wochenschr., 1903, Nr. 26.—Idem: Zur Nomenklatur "Dementia sejunctiva." Neurol. Centr.-Bl., 1906, Nr. 26.—Idem: Zur Differentialdiagnostik negativistischer Phänomene. Psych.-neurol. Wochenschrift, 1906, Nr. 37, und 38.
  77. See the fundamental work of Janet: L'automatisme psychologique.
  78. Janet: Les Obsessions.
  79. Studien über Hysteric.
  80. Gross: Zur Nomenklatur, etc.
  81. The pure laws of association play quite an insignificant rôle when confronted with the unlimited power of the emotional constellation, just as in real life where the logic of thought has no significance when confronted with the logic of feeling.
  82. Gross: Zur Differentialdiagnostik, etc., l. c.
  83. Just this point I have thoroughly proved (depending on Flournoy) in a case of somnambulism. Zur psychologie und pathologie sog. okkulter Phänomene. Leipzig, 1902.
  84. See especially the magnificent script examples of Helene Smith, Flournoy: Des Indes, etc.
  85. Über den psychischen Mechanismus hysterischer Phänomene. Neurol. Centr.-Bl., 1893, H. 1 and 2.
  86. For further remarks on Defensive Neuropsychoses, see Neurol. Centr.- Bl., 1896
  87. Compare Diagnost. Associationsstudien, Beitrag V, VI, VII, VIII.
  88. Diagnost. Associationsstudien, Beitrag IV.
  89. Tiling: Individuelle Geistesartung und Geistesstörung.—Idem: Zur Aetiologie der Geistesstörungen. Centr.-Bl. f. Nervenheilkunde u. Psych., 1903, p. 561.
  90. Neisser, Individualität und Psychose. Berlin, 1906.
  91. Neisser, Individualität und Psychose, p. 29.
  92. To be sure Neisser only does that for paranoia, under which he can hardly include original paranoia (Kraepelin). His representations fit mainly the paranoids.