The second kind of Occasion demanding introspection, is the autochthonous emanation of feeling of unaccustomed character. Such feelings occur at the physiological epochs;-but at these times they are readily explained in a familiar and simple way, and hence no supernatural agency is usually invoked. A similar explanation is made readily enough in cases of evident bodily disease, even where mental symptoms are prominent, for it is no longer the custom to speak of demon-possession even in the acute deliria. But even where no physiological epoch or clearly defined physical disease stands forth, unusual feelings are no uncommon phenomenon, and they demand explanation. Such occur conspicuously in the psychopathological syndrome so completely described by Janet under the term psychasthenia. Persons thus afflicted feeling an incapacity and an impediment to their free activity and not recognizing that they are sick, endeavour to interpret their feelings. Of course, the interpretation varies somewhat in accordance with the nature of the feelings, and with the person's information about the world and his psyche. But quite apart from modifications of this type, I have found it very common for patients to declare "I feel as if there was another person in me," or "I feel compelled as if by another agency to act thus." The explanation of a supernatural agent weighing upon them becomes very easy. For the purpose of this discussion, it is not important whether psychasthenia arises purely from degeneration of structure, or from faults in the chemistry of the plasma which bathes the nerve structures, or whether it is a purely psychopathological condition to which the physical phenomena are secondary, as some would have us believe. Our object is merely the setting forth of the fact that it is a diseased condition which disposes its victim towards metaphysical explanations.
It is a sort of uneasiness which prevents comfort in the feelings of certainty, in the operations of the intellect and decision of action. The patient finding himself abulic, and perhaps too critical minded to accept the mundane supports in his vicinity, seeks a solace in that which to him seems powerful because incomprehensible, that is to say in something supernatural.
For this, it is not essential that the victim's mind be pervaded by the infantine cosmogony which parades often as religious truth. Without anything of the sort, there may arise naive interpretations, hardly even having explicit reference to supernatural agents. For example, a patient may say "If I begin on Friday, a certain undertaking will fail," "If I do not turn my vest twice, misfortune will occur," "It is incumbent upon me to turn round in my chair, or the negotiations will fail." The enumeration of expedients would be useless. The above are from three different patients, one a boy of fourteen now completely cured; the second from the son of a prominent public man now quite restored to health; the third from a case still under care. In none of these was the bodily state of importance, the psychological reactions were the sole object of therapeutic effort, and their ordination was accomplished by purely psychological means.
DATA CONCERNING DELUSIONS OF PERSONALITY WITH NOTE ON THE ASSOCIATION OF BRIGHT'S DISEASE AND UNPLEASANT DELUSIONS.[*]
[*] Presented in abstract at the Sixth Annual Meeting of the American Psychopathological Association, held in New York City, May 5, 1915. Being Contributions of the State Board of Insanity, Whole Number 47 (1915. 13). The material was derived from the Pathological Laboratory of the Danvers State Hospital, Hathorne, Massachusetts, and the clinical notes were collected by Dr. A. Warren Stearns, to whom I wish to express my indebtedness but to whom no one should ascribe the somewhat speculative character of the present conclusions. (Bibliographical Note.-The previous contribution was State Board of Insanity Contribution, Whole Number 46 (1915.12) by D. A. Thom and E. E. Southard entitled "An Anatomical Search for Idiopathic Epilepsy: Being a First Note on Idiopathic Epilepsy at Monson State Hospital, Massachusetts," accepted by Review of Neurology and Psychiatry, 1915.)
E. E. SOUTHARD, M. D.
Pathologist, State Board of Insanity, Massachusetts; Director, Psychopathic Hospital, Boston, Mass., and Bullard Professor of Neuropathology, Harvard Medical School, Boston, Mass.
ABSTRACT
Previous work on somatic delusions. Suggestion that allopsychic delusions are as a rule in some sense autopsychic. A genetic hint from general paresis (frontal site of lesions in cases with autopsychic trend.) Mental symptomatology of general paresis. Work on fifth-decade psychoses. Statistical summary. Group with pleasant (or not unpleasant) delusions. Three cases of senile dementia, delusions of grandeur, and frontal lobe changes. Three cases with religious delusions. Remainder of pleasant-delusion group. Group with unpleasant delusions. Nephrogenic group.
THE suggestions here put forward concerning personal (autopsychic) delusions are based on material of the same sort as that previously analyzed for a study of somatic and of environmental (allopsychic) delusions. Our conclusions are also influenced by two analyses of the types of delusion found in general paresis. Moreover, at a period subsequent to the analysis presented here, some work on fifth-decade insanities had been completed, and the delusional features constantly found in the functional cases of insanity developing at the climacteric, entered to modify our general point of view.
The situation may be summed up as follows:
The accessibility to analysis of the clinical and anatomical data at the Danvers State Hospital was such as to prompt the use of its card catalogues for statistical work upon delusions. The more so, because in a period of enthusiasm over the Wernickean trilogy (autopsyche, allopsyche, somatopsyche) of conscious phenomena, the Danvers catalogue had attempted to divide the delusions recorded into the three Wernickean groups. Putting these clinical data side by side with the anatomical data, we were speedily able to single out those cases with normal or normal-looking brains and thus to secure a group approximately composed of functional cases of insanity.
It shortly developed, as to the CONTENT of delusions, that somatic delusions were exceedingly prone to parallel the conditions found in the trunk-viscera and other non-nervous tissues of the subjects at autopsy.) A subsequent study has confirmed this conclusion for the distressing hypochondriacal delusions found in climacteric insanities, which delusions, however distressing, are often far less so than the true conditions found at autopsy. And it may be generally stated that the clinician can get very valuable points concerning the somatic interiors of his patients by reasoning back from the contents of their somatic delusions.
But how far can we, as psychiatrists, reason back from the contents of environmental delusions, e. g. those of persecution, to the actual conditions of a given patient's environment? In a few cases it seemed that something like a close correlation did exist between such allopsychic delusions and the conditions which had surrounded the patient-the delusory fears of insane merchants ran on commercial ruin, and certain women dealt in their delusions largely with domestic debacles. But on the whole, we could NOT say that, as the somatic delusions seemed to grow out of and somewhat fairly represent the conditions of the some, so the environmental delusions would appear to grow out of or fairly represent the environment.
Thus, however brilliant an idea was Wernicke's in constructing the allopsyche (or, as it were, social and environmental side of the mind) for the purpose of classification, our own analysis promised to show that for genetic purposes the allopsyche was much less valuable. These delusions having a social content pointed far more often inwards at the personality of the patient than outwards at the conditions of the world. And case after case, having apparently an almost pure display of environmental delusions, turned out to possess most obvious defects of intellect or of temperament which would forbid their owners to react properly to the most favourable of environments. Hence, we believe, it may be generally stated that the clinician is far less likely to get valuable points as to the social exteriors of his patients from the contents of their social delusions than he proved to be able to get when reasoning from somatic delusions to somatic interiors. Put briefly, the deluded patient is more apt to divine correctly the diseases of his body than his devilments by society.
Our statistical analysis, therefore, set us drifting toward disorder of personality as the source of many delusions apparently derived ab extra and tended to swell the group of autopsychic cases at the expense of the allopsychic group,
In the statistical analysis of a group of cases corresponding roughly with the so-called functional group of diseases, we find false beliefs about the some on a somewhat different plane from those about the patient's self and his worldly fortunes. We can even discern through the ruins of the paretic's reaction that his false beliefs concerning the body are often not so false after all, and that his damaged brain of itself is not so apt to return false ideas about his somatic interior as about his worldly importance and plight. There then seems to be more reality about somatic than about personal delusions: the contents of somatic delusions are rather more apt to correspond with demonstrable realities than the contents of personal delusions. Accordingly our analysis of delusional contents includes a hint also as to genesis. Taken naively, the facts suggest a somatic genesis for somatic delusions exactly in proportion as these delusions are not so much false beliefs as partially true ones.
What genetic hint have we for the delusions concerning personality? One genetic hint was obtained from a correlation of delusions with lesions in general paresis,[2] in which disease perhaps the most profound and disastrous of all alterations of personality are found. Amidst the other alterations of personality found in paresis, autopsychic delusions are characteristic: indeed allopsychic delusions are conspicuously few in our series. And, as above, the somatic delusions, fewer in number, can be fairly easily correlated with somatic lesions, or else with lesions of the receptor apparatus (thalamus) of the brain.
Now it was precisely the cases with autopsychic delusions, as well as with profound disorder of personality in general, that showed the brunt of the destructive paretic process in the frontal region. The other not-so-autopsychic cases did not show this frontal brunt, but were less markedly diseased at death and had a more diffuse process.
Our genetic hint from paresis, therefore, inclines us to the conception that this disorder of the believing process is more frontal than parietal, more of the anterior association area than of the posterior association area of the brain. And if we can trust our intuitions so far, the perverted believing process is thus more a motor than a sensory process, more a disorder of expression than a disorder of impression, more a perversion of the WILL TO BELIEVE than a matter of the rationality of a particular credo.
Again we may appear to burst through from an undergrowth of statistics into the clear field of truism. False beliefs are more practical than theoretical, more a matter of practical conduct than of passive experience, more a change of reagent than a reaction to change. The man on the street or even many a leading neurologist would perhaps accept this formula as his own.
Certainly in general the least satisfactory of these chapters on the nature of delusions was the chapter on environmental effects,[3] and this perhaps because the results seemed so nearly negative.
A further contribution to delusions of environmental nature was somewhat unexpectedly derived from a piece of work on the general mental symptomatology of general paresis.[4] Dichotomizing the paretics (all autopsied cases) into a group with substantial, i. e., encephalitic, atrophic or sclerotic lesions of the cortex and a group without such gross lesions or else with merely a leptomeningitis, I found the latter (or anatomically mild) group to be characterized by a set of symptoms which were all "contra-environmental," whereas the former (or anatomically severe) did not thus run counter to the environment. The conclusions of that paper, so far as they concern us now, are as follows:-
The "mild" cases showed a group of symptoms which might be termed contra-environmental, viz. allopsychic delusions, sicchasia (refusal of food), resistiveness, violence, destructiveness.
The "severe" cases showed a group of symptoms of a quite different order, affecting personality either to a ruin of its mechanisms in confusion and incoherence, or to mental quietus involved in euphoria, exaltation, or expansiveness.
The most positive results of this orienting study appear to be the unlikelihood of euphoria and allied symptoms in the "mild" or non-atrophic cases and the unlikelihood of certain symptoms, here termed contra-environmental, in the severe or atrophic cases. Perhaps these statistical facts may lay a foundation for a study of the pathogenesis of these symptoms. Meantime the pathogenesis of such symptoms as amnesia and dementia cannot be said to be nearer a structural resolution, as these symptoms appear to be approximately as common in the "mild" as in the "severe" groups.
But in both papers dealing with paresis [2,4] we rest under the suspicion that the delusions are possibly of cerebral manufacture. Of course, a lesion somewhere outside the brain is not unlikely to be projected through the diseased brain, and SOMATIC delusions in the paretic are rather likely to represent something in the viscera.
It was desirable to get back to normal-brain material, to learn how the INTRINSICALLY NORMAL brain[5] could perhaps produce delusions from a particular environment. Could a particularly "bad" environment actually PRODUCE delusions?
By chance, at about this stage in our studies of delusions, some work on fifth-decade insanities[6] was completed. This work seemed to show that the most characteristic (non-coarsely-organic) cases of involutional origin were much given to delusions (each of 24 cases studied), somewhat more so than to the hypochondria and melancholia which we commonly ascribe to the involution period. But this result is equivocal as to the environmental (i. e. allopsychogenic) power to produce delusions, since one could not rid oneself of the suspicion that the delusions were due to the degenerating brain.
To return to our former results with the normal-looking brain:
Case after case of the quasi-environmental group proved to be more essentially personal than environmental, until at last it almost seemed that the environment could seldom be blamed for any important share in the process of false belief. In short, we seemed to show that environment is seldom responsible for the delusions of the insane.
Be that as it may, we secured several lines of attack on the delusions of personality by our study of quasi-environmental delusions. First, we were irresistibly led to a consideration of the emotional (pleasant or unpleasant) character of the delusions. We heaped up a large number of unpleasant delusions in that (quasi-environmental, but actually) personal group. It is interesting to inquire, accordingly, whether our more obviously autopsychic cases will also be possessed of an unpleasant tone. Secondly, we came upon the curious fact that cardiac and various subdiaphragmatic diseases were correlated with unpleasant emotion as expressed in the delusions. It was therefore important to inquire whether similar conditions prevailed in the new group. Thirdly, we found ourselves inquiring whether our patients were victims of what might be termed a spreading inwards of the delusions (egocentripetal) or a spreading outwards thereof (egocentrifugal delusions). But this difference in trend, clear as it often is from the patient's point of view, remains to be defined from the outsider's point of view.
Again, it remains to determine, if possible, how far delusions are dominated respectively by the intellect or the emotions, or even by the volitions.
As before, I begin with a brief statistical analysis.
SUMMARY
Danvers autopsy series, unselected cases 1000 Cases with little or no gross brain disease 306 Cases listed as having autopsychic delusions 106 Cases listed as having only autopsychic delusions 50 Cases for various reasons improperly classified 13 Cases of general paresis in which gross brain lesions were not observed 15 Residue of autopsychic cases 22 The group of 22 cases thus sifted out can be studied from many points of view. We may recall that our former study of allopsychic delusions proved that a large proportion of delusions concerning the environment were in all probability not essentially derived from the environment. Their contents might relate to the environment, but their genesis could better be regarded as autopsychic (intrapersonal). In fact we really found only 6 out of 58 cases of pure allopsychic delusions, which could be safely taken as showing so much coincidence between anamnesis and delusions that a correlation could be risked.
Following the method of our former work on somatic and on environmental delusions, we sought in the first instance PURE cases of autopsychic delusion-information. For a variety of reasons, more than half of the original list, namely, 28 cases, had to be excluded. Many of these exclusions were due to the strong suspicion that the cases were really cases of general paresis, despite the normality of the brains in the gross. The residue of 22 cases include, we are confident, no instance of exudative disease of the syphilitic group, though general syphilization cannot safely be ruled out in all cases.
There are two groups of cases, a group of eleven cases with delusions of a generally pleasant or not unpleasant character (in which group there is a small sub-group of three cases of octogenarians with expansive delusions reminding one of those of general paresis) and a group of eleven cases with delusions of an unpleasant character.
I. CASES HAVING DELUSIONS OF A NATURE PLEASING OR NOT UNPLEASING TO THE BELIEVER
The true emotional nature of the beliefs placed in this group cannot fairly be stated to be pleasurable. But, if not pleasurable, they may perhaps be stated to be complacent, expansive, or of air-castle type. The criteria of their choice have been largely negative: the patients are not recorded as expressing beliefs of a painful or displeasing character: in the absence of which we may suppose the beliefs to be either indifferent or actually pleasing in character.
Of the 11 cases whose delusions were supposedly of an agreeable nature or at least predominantly not unpleasant, there were 3 with delusions reminding one of general paresis. The ages of these three were 80, 84, and 87 respectively. They did not show any pathognomonic sign (e.g. plasma cells) of general paresis. They all showed in common very marked lesions of the cortex, including the frontal regions (in two instances the extent of the frontal lesions was presaged by focal overlying pial changes) .999 was a case of pseudoleukemia with marked cortical devastation but without brain foci of lymphoid cells. Two of the cases showed cell-losses more marked in suprastellate layers; in the third there was universal nerve cell destruction, with active satellitosis caught in process.
Condensed notes concerning the cases with pseudoparetic delusions follow. Two of them, it will be noticed, yielded some delusions also of an unpleasant nature.
CASE I. (D. S. H. 10940, Path. 999) was a clever business man, Civil War veteran, who began to lose ground at 75 and died at 84. He was given during his disease to boasting and perpetual writing about elaborate real estate schemes and said he owned a $100,000 concern for the purpose.
The case was clinically unusual in that the picture of a pseudoleukemia was presented, with demonstration at autopsy of great hyperplasia of retroperitoneal lymph nodes and grossly visible islands of lymphoid hyperplasia in liver and spleen. The brain weighed 1390 grams and showed little or no gross lesion, if we except a pigmentation of the right prefrontal region under an area of old pias hemorrhage. There was also a chronic leptomeningitis, with numerous streaks and flecks along the sulci, especially in the frontal region. There was little or no sclerosis visible in the secondary arterial branches and but few patches in the larger arteries. Microscopically the cortex proved to be far from normal: every area examined showed cell-loss, perhaps more markedly in the suprastellate layers than below.
CASE 2. (D. S. H. 11980, Path. 1024) was a Civil War veteran who failed in the grocery business, was alcoholic, was finally reduced to keeping a boarding-house and grew gradually queer. Mental symptoms of a pronounced character are said to have begun at 75. Death at 80. Delusions reminded one of general paresis: worth $5,000,000 a month, 108 years old, was to build a church: also, a woman was trying to poison him.
Autopsy showed caseous nodules in lung, coronary and generalized arteriosclerosis (including moderate basal cerebral), mitral and aortic stenosis (the aortic valve also calcified). The frontal pia mater was greatly thickened and, although no gross lesions were noted in the cortex, the microscope brings out marked lesions in the shape of cell losses (especially in suprastellate layers) in all areas examined. There were no plasma cells in any area examined.
CASE 3. (D. S. H. 12767, Path. 1185) was a widowed Irish woman, who died at 87. Previous history blank. Extravagant delusions of wealth were associated with a fear of being killed.
The autopsy showed little save chronic myocarditis with brown atrophy, calcification of part of thyroid, non-united fracture of neck of left femur, moderate coronary arteriosclerosis. The brain was abnormally soft (some of the larger intracortical vessels showed plugs of leucocytes possibly indicating an early encephalitis-Bacillus cold and a Gram-staining bacillus were cultivated from the cerebrospinal fluid.) Though the convolutions were neither flattened nor atrophied and absolutely no lesion was grossly visible, the cortex cerebri and also the cerebellum were found undergoing an active satellitosis with nerve-cell destruction in all areas examined.
The following three cases (IV, V, VI) present a certain identity from their delusions concerning messages from God (V thought he was God). It is very doubtful whether VI should be placed in the present group of Pleasant or Not Unpleasant Delusions, since the patient appears to have been "theomaniacal" as the French say, in a rather passive and unpleasant manner (God occasioned foolish actions!) Placed on general statistical grounds at first in the Not Unpleasant group, Case VI should be transferred to the Unpleasant group. Case V's delusion (identification with God, expression of atonement?) was in any event episodic in a septicemia. Case IV ("happiest woman in the world"), was phthisical (cf. VII) Notes follow:
CASE 4. (D. S. H. 4019, Path. 218) Housewife, 37 years always cheerful, became the happiest woman in the world, hearing God's voice and being specially under God's direction. "Acute mania." Death from bilateral phthisis with numerous cavities and bilateral pleuritis. There were no other lesions except a small sacral bed-sore, a small fibromyoma of the uterine fundus, small slightly cystic ovaries, a slight dural thickening, and possibly a slight general cerebral atrophy. (wt. app. 1205 grams, marked emaciation.)
CASE V. (D. S. H. 11742, Path. 852) was a victim of streptococcus septicemia (three weeks) who said he was God. Patient was a Protestant iron-worker of 59 years, who had lost an eye and had become unable to work about three months before death. Aortic, cardiac, renal lesions at autopsy. Prostatic hypertrophy. Dr. A. M. Barrett found few changes in nerve cells, except fever changes. One area in left superior frontal gyrus showed superficial gliosis.