Complete Text (Part 16)

mother tongue sounding to him like those of an unknown language (word -deafness). There is also more or less inability to recall words, especially nouns, although the corresponding ideas are distinct (verbal amnesia). The word-deafness and verbal amnesia sometimes exist alone but in a typical case, while some words are correctly spoken, wrong words of similar sound or meaning are often substituted for the right ones (paraphasia) and others are mutilated so that speech becomes a jargon without the patient being aware of it. Writing suffers in the same way as speech (paragraphia) but to a greater degree and may be entirely abolished. Reading aloud is changed in the same way (paralexia) and the comprehension of written or printed words is generally lost. Auditory Aphasia, Lesion of posterior part of jirst temporal convolution, B. There is no evidence of organic intracranial disease. 1 . Owing to deafness occurring in early life the patient has not learned to talk or has forgotten how. Deaf -mutism, 2. The loss of words and voice is generally absolute, yet the patient is intelligent and writes readily. In very rare cases writing may be lost or recurring utter- ances occur so as to cause a strong resemblance to organic motor aphasia. Other evidence of hysteria always present. Hysterical Mutism, 3. The aphasia takes one or more of the forms described as due to organic disease, most commonly motor aphasia or a mild degree of auditory aphasia. a. There is motor aphasia following the stammering DISORDERS OF SPEECH. 203 of severe chorea. Disappears as the chorea im- proves. Choreic Aphasia, b. The aphasia is one of the phenomena of epilepsy or migraine, lasting from a few minutes to a few- hours. Epileptic or Migrainous Aphasia, c. The aphasia appears in the state of profound ex- haustion toward the end of an infectious fever, especially typhoid, but disappears as strength re- turns. Aphasia of Infectious Fever, d. The aphasia is due to a toxic state of the blood, most frequently uremia or narcotic poisoning, oc- casionally diabetes, gout or snake-bite. Toxemic Aphasia, 204 NERVOUS AND MENTAL DISEASES. INSANITY. The patient's mind is so undeveloped or so changed from its normal condition as to unfit him for the domestic, social or business relations appropriate to his age and station. The delirium and stupor of acute fevers and acute intoxi- cations are not included, unless unusually prolonged. I. The mental defect is due to arrested development of the mind caused by disease or injury of the brain in early life. All the later acquired powers, such as sustained attention, ab- stract reasoning, self-control and observance of the social proprieties, are strikingly defective and in all but the slightest cases it is easy to show a marked defect in memory. Results or accompaniments of the cerebral disease are often conspicuous, such as cranial malformation, hemiplegia, monoplegia or paraplegia of the spastic type, disorders of speech, epilepsy and various stigmata of degeneracy. A history of difficult birth or of convulsions in infancy is com- mon. If the arrest occurs at or before birth or in early in- fancy and the defect is very great, so that the patient is unable to take proper care of his person or to express his wants intelligibly, it is always called idiocy ; but if the arrest occurs later or is incomplete, so that the mental defect is not so great, it is often called imbecility or merely feeble- mindedness, although it is really a milder degree of idiocy. Imbeciles can generally care for the person and talk fairly well and most of them are capable of considerable improve- ment by education, while a few show exceptional power in certain limited fields, such as music or arithmetical calcula- tions. Idiocy, On account of its convenience for clinical purposes the following classification of idiocy is taken from Frederick Peterson with but slight modification. The same case may be in more than one class. A. The arrest of development is caused by hydrocephalus. Hydrocephalic Idiocy. B. The cranium is abnormally small. Microcephalic Idiocy. C. The disease arresting mental development has caused hemiplegia, paraplegia or monoplegia. Paralytic Idiocy. D. The arrest of mental development is due to repeated epileptic attacks. Epileptic Idiocy. E. The arrest is caused by iniury to the head. Traumatic Idiocy. F. The arrest is caused by meningitis. Meningitic Idiocy. G. The arrest is caused by scarlatina, measles, diphtheria or other infectious fever. Post-febrile Idiocy. K. Arrest of physical and mental development is caused hy disease of the thyroid gland which is generally enlarged. The disease is common in the mountainous regions of Europe and Asia, but rare elsewhere. The patients are dwarfs having the characteristic appearance of cretins, the skin being thick, coarse and yellow, the hair scanty, eyelids puffy, eyes small, nose flat, lips thick, tongue large, teeth deficient and limbs deformed. The admin- istration of thyroids causes improvement which, in some cases, is very great. Myxedematous Idiocy. I, Degeneration of the retinal neurons, causing blindness, and degeneration of the neurons of the cortes and cen- tral nervous system generally, causing idiocy, occur together in young infants of certain families. Amaurotic Idiocy. J. The patients show a special aptitude in some limited field, such as music, arithmetical calculations, drawing or buffoonery, which is far in excess of their other powers and may greatly exceed that of the average normal individual. Idiots Savants. K. The lack of mental development is due to deprivation of 2o6 NERVOUS AND MENTAL DISEASES. sight and hearing and may be remedied by appropriate education as in the cases of Laura Bridgman and Helen Kellar. Sensorial Idiocy, II. The disease occurs in a mind already developed and consists in either a perversion or a loss of faculties. A. There is a state of emotional exaltation or depression, accompanied by a corresponding acceleration or re- pression of ideation, speech and action. There is no real failure of memory, although it may be impossible to secure the patient's attention sufficiently to test it. Delusions, if present, are secondary to the emotional change and in harmony with it and are not systematized. There are no signs of organic disease. 1 . After an initial stage of mental depression the patient becomes excited and exhilarated. His talk is rapid and shows a ready, though superficial, association of ideas. There is an excessive tendency to act in accor- dance with any idea that may occur and all the ordinary restraints on speech and action are absent or are ef- fectual for a few moments only. Appetite and the animal instincts generally are excessive. Delusions, if they occur, are of a pleasant, often of an ambitious nature and are inconstant and often incoherent. In general, the patient appears as though in the excited stage of alcoholic intoxication. All gradations exist from the slightest noticeable exhilaration to furious madness, marked by incoherent raving and blind destructiveness. Mania. 2. The patient gradually passes into a state of mental depression, in which the association of ideas is re- tarded. Delusions or hallucinations, if they occur, are painful and include the idea of personal disrepute or guilt. As a general rule food is refused and speech and action repressed or almost abolished, the patient staring ahead in profound dejection, perhaps automatically performing some destructive action such as picking clothing to pieces. Exceptionally INSANITY. 207 there are frantic efforts to escape from imaginary evils (melancholia agitata). The tendency to suicide is strong and attempts at suicide may be preceded by homicide, under the delusion that the victim is bene- fited by being removed from a wretched world. Melancholia, 3. Attacks of mania and melancholia alternate with each other, with or without a normal interval, so as to form a regularly recurring cycle. Incurable. Circular Insanity, B. The patient is subject to delusions which are logically coherent or systematized and are mainly limited to one subject. There is no such profound emotional change as in mania or melancholia and memory is not impaired, being exceptionally accurate for occurrences associated with the delusions. There is an hereditary predisposi- tion to insanity and stigmata of degeneracy are common. In a typical case, after a period of morbid introspec- tion, there gradually develops a delusion of persecution, based partly on hallucinations, especially of cutaneous sensibility and hearing, and partly on misinterpretation of actual occurrences. The means believed to be em- ployed by the persecutors varies with the environment, education and imaginative power of the patient; elec- tricity, hypnotism, mind-reading and X-rays being com- mon now, while witchcraft and demoniac possession were the common means a couple of centuries ago. The imaginary persecution becomes more persistent and systematic and is usually supposed to be carried on by some powerful organization, such as the Free-masons, the Catholic Church or a political party. Later, ap- parently as an explanation of the persecution, there gen- erally appears a delusion of g^eat personal importance, such as being the heir to a throne, a political or religious reformer, a great inventor or even Jesus Christ. The delusions may vary from the typical form (para- noia quenilans, paranoia erotica, paranoia hypochon- 208 NERVOUS AND MENTAL DISEASES. driaca, etc.), and hallucinations may be especially prom- inent (paranoia hallucinatoria), while in many cases the disease is but partially developed (cranks), but systema- tization is characteristic of all cases. The patient can give elaborate reasons for his beliefs, however absurd, and can exercise his mental faculties normally on sub- jects not connected with the delusions. Formerly called monomania. Incurable. Some cases end in a mild de- mentia. Paranoia, C. There is an intellectual loss shown most readily by a failure of memory for recent events, but always involv- ing impairment of the judgment, attention, abstract rea- soning and esthetic, social and ethical feeling. Emo- tional changes, hallucinations and delusions may occur, but they are secondary and delusions are never systematized. 1 . There has been no preexisting mental disease or epi- lepsy and there is no evidence of organic cerebral disease. The patient, a youth or young adult with an hereditary predisposition to insanity and perhaps given to masturbation, rapidly becomes depressed, stupid and apathetic, often reaching an extreme de- gree of degradation. As a rule recovery takes place, leaving no recollection of the period of stupor, but death may occur or true dementia supervene. Most nearly related to melancholia, from which it is dis- tinguished by greater impairment of consciousness and memory and absence of the profound depression with sense of guilt and of delusions. Originally called acute dementia, but differs from true dementia in the absence of organic cerebral disease and the possibility of recovery. Stuporous Insanity. 2. The mental defect is caused by some form of organic cerebral disease and is permanent. Dementia. a. There is coarse organic disease of the brain, such as tumor, abscess or a vascular lesion. Dementia of Coarse Organic Disease, Special diagnosis as in Hemiplegia, INSANITY. 309 1. The dementia is preceded by mania or melancholia or, rarely, by paranoia and at first is mixed with the exaltation, depression, or delusions character- istic of the aiuse. Later these vestiges of the original disease vanish and the dementia may reach aji extreme degree of mental degradation. Terminal Detneniia. :. The faculties are lost as age advances. Differs from the normal loss of mental vigor in old age only in degree. Senile Dementia. . The dementia is preceded by prolonged excess in the use of alcohol, often by attacks of delirium tremens and by delusions of snspicion and fear, based on mental depression and hallucinations, somewhat resembling the delusion of paranoia, but less systematized. Onset may be very g;radiial or rapid during an attack of delirium tremens. Alcoholic Dementia. i. The dementia gradually supervenes in epilepsy. No other cause. Epileptic Dementia. :. The patient is almost always a man, in early or middle adnlt life, who has been syphilitic or al- coholic or who is nervously exhausted by a fast life or some prolonged strain. After a neuras- thenic stage there is a gradual alteration of char- acter and loss of mental power. Along with the mental defects common to all forms of dementia there are various signs of degenerative cerebral or cerebro -spinal disease. Speech is marred by stumbling and perhaps stuttering, especially in words containing I and r. The effort to speak or to protrude the tong;ue is often accompanied by a facial twitch. The writing is badly formed and more or less incoherent on account of repetitions and omissions. Tremor of the liands and a fine fibrillarj' tremor of the tongue and lips are com- mon. The pupil-, are generally unequal but the 2IO NERVOUS AND MENTAL DISEASES. difference is inconstant. Argyll-Robertson pupil may be found. Weakness or incoordination of any or all of the limbs may supervene and the knee-jerks, although usually exaggerated, may be lost, so as to cause a strong resemblance to tabes. Epileptiform and apoplectiform attacks are com- mon. In most, but not all cases, the neurasthenic depression is succeeded by a stage in which there are monstrous, unsystematized delusions of wealth, power or personal excellence. Remissions, even apparent cures, may occur, but the disease always advances again and ends fatally, generally within two or three years from the onset of symptoms. Paretic Dementia. D. The insanity presents a superficial resemblance to mania but differs from it in the more rapid onset and greater violence of the symptoms, absence of the characteristic exhilaration, greater impairment of consciousness and absence of any subsequent recollection of the attack. 1 . The patient is almost always a man in early or middle adult life. There is no prodromal period and the onset is exceedingly rapid. There is a swift succes- sion of incoherent ideas, revealed by words, shouts or inarticulate cries, and accompanied by uncontrollable rage. There is intense and general motor excitement which culminates in a blind destructive fiiry. The face and conjunctivae are flushed, the circulation and respiration accelerated and the temperature raised. The symptoms rapidly subside within a few hours to a few days of the onset, generally within twelve hours, and end in sleep, from which the patient awakes with no recollection of the attack. Recovery is complete and the attack does not recur. Rare. Transitory Frenzy. 2. The patient is of neurotic inheritance, more frequently a woman. The exciting cause may be a fever, alco- holic excess, puerperal disease or emotional shock. INSANITY, 211 1 After a prodromal period of not more than a few days which is marked liy depression, hcadachi insomnia and irritability, a violent delirium sets ii Under the influence of constantly changing, inc( herent hallucinations and delusions the patient sing; shouts or swears and, if unrestrained, attacks atten- daiUs and smashes furniture. Anger or dread usually predominate ; exaltation is rare. Pulse and respira- tion are rapid and feehle and temperature irregularly elevated. Food is generally refused. Involuntary evacuations occur. Ends within a few weeks, some- times within a few days, in extreme prostration, which is followed by coma and death, by dementia, or rarely by recovery without recollection of the attack. Second attacks do not occur. Acute Delirium, . The insanity is caused by injury to the brain or by a definite constitutional condition. The mental symptoms generally differ from the typical forms of insanity in being of an incomplete, mixed or inconstant type and are better described as delirium than as mania, melan- cholia or paranoia. If maniacal excitement occurs the typical exaltation is apt to be lacking, while unpleasant hallucinations, incoherence and confusion are more prominent than in true mania. Although there is often a marked depression it is not likely to be so constant or to involve so great a sense of guilt as in melancholia. Delusions of suspicion or persecution frequently occur but they are neither so constant nor so coherent and systematized as in paranoia. Temporary stupor may simulate dementia and genuine dementia is not an un- common termination. I. Insanity is caused by a blow on the head and consists in confusion with hallucinations and delusions which ore generally of an UJipleusant chiiracter. Headache, vertigo, irritability and various physical defects are common. May end in recovery or in dementia. Traumatic Insanity, 212 NERVOUS AND MENTAL DISEASES. ri 2. Insanity is caused by sunstroke, the symptoms being like those of traumatic insanity. Insanity of Insolation, 3. Insanity results from the excessive consumption of alcohol, not necessarily causing drunkenness, but eventually causing some of the signs of chronic alco- holism, such as gastric catarrh, cirrhosis of the liver, morning vomiting, characteristic odor of the breath, bloated face, tremor, etc. a. After an unusual excess or on the occuiTence of some local inflammation or injury, or perhaps without any exciting cause, the patient becomes dejected, timid and restless. Sleep is at first dis- turbed by horrible dreams and w^ithin a few days these are replaced by insomnia with illusions and hallucinations, especially of seeing loathsome and dangerous animals, accompanied by corresponding terrifying dehisions. For a time the visions may be dispelled and the patient reassured, but they return in constantly changing forms and he be- comes continuously delirious, talking and acting as though at his ordinary work, reaching for imaginary objects or trying to escape or to pro- tect himself. Hallucinations of touch, hearing or smell may also occur. Speech becomes more and more incoherent and may be reduced to an unin- telligible muttering. The temperature is elevated, the pulse rapid and soft and there is tremor, especially of the hands, face and tongue. Within a week convalescence begins or there is increasing prostration which generally leads to coma and death. May be complicated by pneu- monia, hepatic or renal disease, alcoholic eclamp- sia or neuritis. Delirium Tremens, b. The mental symptoms are a complication of alco- holic multiple neuritis and are less acute than de- INSANITY. 213 tiriiim tremens, consisting mainly in loss of mei.i- ory for recent events and a corresponding delnsion of living in the past. The patient usually