CASE VI. (D. S. H. 5345, Path. 867) was a "primary delusional insanity," a salesman of 37 years, whose beliefs concerned impressions direct from God, in consequence of which he habitually knelt and prayed. Yet many of the actions which he felt he must perform were foolish actions. The patient died of pneumococcus septicemia during a lobar pneumonia. The brain showed a few changes suggestive of fever (A. M. Barrett). There were a few flecks of atheroma in the aorta. There was an acute parenchymatous nephritis with focal plasma cell infiltrations suggesting acute interstitial nephritis. This case appears to have shown one of the most nearly normal brains in the whole Danvers series.
The remainder of the Pleasant or Not Unpleasant Group as originally constituted consists of VII, a phthisical case (cf. IV), VIII, probably feeble-minded romancer, not deluded in the sense of self-deception (probably best excluded from present consideration); IX, probably not safely to be assigned to the Pleasant or Not Unpleasant Group, feeling passive in somewhat the same sense as Case VI (see above), suffering from auditory hallucinosis (superior temporal atellitosis, data of the late W. L. Worcester); X, delusion of birth to superior station, possibly the object of mixed emotions, probably not pleasant; and XI, manic-depressive exaltation with grandiose utterances, long prior to death (if there had been lung tuberculosis at the basis of the ileac ulcers, it had long since healed).
Notes follow (VII-XI) and at the end a brief summary of the entire group (I-XI).
CASE 7. (D. S. H. 8878, Path. 521) It is questionable whether the delusions classified in this case entitle it to inclusion in the present study. e.g. "I was baptized in the Catholic Church (patient a Protestant housewife) with holy water, ink, and Florida water." Patient was variously designated, as "dementia" and as "acute confusional insanity." Death in second attack at 26 (first attack at 22). Father also insane. Death due to bilateral ptthisis with tuberculosis of intestines and mesenteric glands, emaciation. It is noteworthy that the brain weighed but 1038 grams. Dr. W. L. Worcester's microscopic examination showed acute nerve cell changes probably of the type of axonal reactions.
CASE 8 (D. S. H. 8807, Path. 556) very probably a feeble-minded subject. At all events patient had done no work in his life, had been given to spells of restlessness and excitement, and had talked disconnectedly. Symptoms were thought to have dated from the tenth year. It is questionable whether a statement that he was managing the Electric Railway and Shipbuilding Company can be regarded as delusional, that is, as believed by the patient. Death was due to (perhaps septicemia from one abscess of jaw and to hypostatic penumonia), the brain appeared normal but Dr. W. L. Worcester found, besides certain acute changes, also satellitosis. The question remains open whether the case should be regarded as defective or as belonging to the dementia praecox group.
CASE 9. (D. S. H. 8605, Path. 568) had an ill-defined attack of mental disease and was in D. S. H. at 29. Thereafter, lived in Gloucester Almshouse, but at 51 became excited and was returned to D. S. H. where she died at 59. Possibly hallucinated: someone called her mother (single woman). Delusion: the spirit is here (Protestant). Patient was given to a stream of muttered, vulgar and incoherent talk. Possibly the case was residual from hebephrenia. Dr. W. L. Worcester found cell changes in the superior temporal gyri (finely granular stainable substance in practically all nerve cells) and not elsewhere. The correlation is suggestive with the probably auditory hallucinosis. The brain weighed 1190 grams. Death due to bronchopneumonia. Heart and kidneys normal.
CASE 10. (D. S. H. 10145, Path. 928) a Danish fisherman possibly manic-depressive, victim of three attacks at 40, 50, and 69 years. The first attack followed loss of wife, and delusions concerning being born again developed. The last attack showed few well-defined delusions, as patient was in a bewildered and incoherent state. One statement is characteristic: if patient had remained in Denmark, he might have inherited the throne. The autopsy showed most extensive arteriosclerosis, including basal cerebral. Death from general anasarca and jaundice. (cholelithiasis). There was some question of an acute encephalitic lesion in the tissues lining the posterior half of the third ventricle. Various chronic lesions (splenitis, endocarditis, diffuse nephritis), malnutrition.
CASE 11. (D. S. H. 7767, Path. 792) was a case possibly of manic-depressive type (previous attacks Hartford Retreat and Danvers State Hospital) who worked as machinist between attacks and died at 70, having been in D. S. H. 8 years. Patient was greatly emaciated and anemic from chronic ulcers of ileum. There was also cholelithiasis. There was a mild coronary atheroma and slight mitral valve edge thickening.
The delusions expressed were those of great wealth. Patient also thought he was a great poet. No brain changes were found (A. M. Barrett).
Having attempted on the basis of certain statistical tags to constitute a group of cases having relatively normal brains and pleasant (or not unpleasant) delusions, we are forced to reconstruct our group upon viewing several cases more attentively.
Case VIII should be excluded as probably not delusional.
Case X might perhaps be transferred with propriety to the unpleasant-delusion group.
Certain cases of felt passivity under divine influence separate themselves out from the group; indeed VI and IX probably belong in the unpleasant-delusion group (see below).
These subtractions leave seven cases to deal with. Three of these seven, viz. I, II and III, are apparently best regarded as examples of frontal lobe atrophy, and their grandiosity may resemble that of certain cases of general paresis.
Of the remaining four, two, Cases IV and VII, are phthisical; one, Case VI, showed an episodic identification with God (incident in fatal septicemia), and one, Case XI, uttered manic-depressive exalted statements about wealth and poetical power.
I turn to a consideration of the unpleasant-delusion group, which as first constituted was to contain eleven cases (XII-XXII) but to which must be added three more (VI, IX, X).
Case XII should be at once excluded from present consideration on account of its microscopy.
CASE 12. (D. S. H. 12282, Path. 942) died in a second attack of depression (manic-depressive insanity?). Catholic, always of a quiet and reserved disposition, happy in married life. Delusional attitude concerning an abortion which she said she had induced. "Soul lost," "I'll see hell."
Autopsy: Death from gangrene of lung and acute fibrinous pericarditis. Erosion of cervix uteri. The edema of the brain, irregular pink mottlings of white substance, and an exudative lesion of one focus in the pia mater of the right side suggested an encephalitis more marked on the right side. Microscopically a few small vessels showed plugs of polynuclear leucocytes. The nerve cells were affected by various acute changes. The visuo-psychic portion of an occipital section (right) showed suprastellate cell-losses of a somewhat focal character
Of the remaining ten (XIII-XXII), one, Case XIII is another of mixed emotions ("am Eve and have to suffer;" "in Purgatory;" etc) of a religious type. It is the only case in the unpleasant group with phthisis pulmonalis, (combined, however, with abdominal tuberculosis and nephritis).
CASE 13. (D. S. H. 7361, Path. 499) was a somewhat defective Catholic woman (mother insane) always of a melancholy and reserved temperament. She had been ill-treated by husband, child had died, another had followed soon. She developed a belief that she was Eve and had to suffer. At hospital decided that she was in purgatory and expressed a variety of other religious beliefs. She also thought she was ill-treated at hospital. Her head was asymmetrical: skull thick and eburnated. Brain (1130 grams described as normal). Chronic interstitial nephritis. Pulmonary and mesenteric tuberculosis.
Of the remaining nine (XIV-XXII) all had grossly evident kidney lesions except two (XIV and XV). Of these two, XIV probably had renal arteriosclerosis and was in any case very gravely arteriosclerotic in general and suffered from cystitis. Case XV died apparently of starvation with hepatic atrophy; it is a question whether "poverty" was or was not a delusion. Notes of XIV and XV follow:
CASE 14. (D. S. H. 8741, Path. 500) was a German teacher, college-bred, of a reserved and melancholy turn of mind (mother insane). An attack at 39, another at 70. "Both poor wife and son will starve." "Perhaps they should be put out of reach of poverty," later felt he "had caused death of wife and son on account of his expensive living." Autopsy: chronic internal hydrocephalus, cerebral arteriosclerosis. Brain weight 1180 grams. Coronary sclerosis with calcification throughout, aortic and pulmonary valvular calcification hypertrophy of heart. Cystitis.
CASE 15. (D. S. H. 4454, Path. 237) was presumably a manic-depressive case, had in all four attacks, and died in the fourth attack (66 years). The day he arrived at the hospital, having not eaten for several days at the end of several months of delusions of poverty the case was called "acute melancholia," and the cause of death assigned was starvation. The liver weighed 1102 grams and was fatty. There was a diffuse thickening and clouding of the pia mater, and the dura was firmly adherent everywhere to the skull.
Notes follow of seven cases (XVII-XXII) which show many lesions, are in a number of instances cardiorenal and in all instances renal. If it is permitted to count XIV also as renal, a list of eight cases out of the original list of eleven unpleasant-delusion cases is obtained in which nephritis of some type has been found. Case XIII, nephritis and phthisis, belongs also in the renal group.
CASE 16. (D. S. H. 4168, Path. 226) feared death and refused food on the ground that she should not eat. Patient had always been of a despondent and reserved nature (sister also insane) and, after her husband's death, when she was 53, grew unable to carry on her house, dwelt constantly on griefs, entered hospital at 61, and died at 64 ("chronic melancholia"). Death from internal hemorrhagic pachymeningitis. The liver of this case weighed 1074 grams and was fatty. There was chronic interstitial nephritis.
CASE 17. (D. S. H. 4707, Path. 498) originally cheerful and frank, lost her situation as companion, grew despondent at failure to get employment, had a "hysterical" attack at 52. It is doubtful whether her beliefs were delusional: "can never be better," "will not be taken care of," "no place for her." "Subacute melancholia. "The autopsy showed gastric dilation (over 3000 cc.), and an atrophic liver and pancreas, and slightly contracted kidneys. The heart was normal. Death from ileocolitis. Moderate chronic internal hydrocephalus. Dr. W. L. Worcester's microscopic examination showed rather unusual degrees of nerve cell pigmentation (precentral and paracentral).
CASE 18. (D. S. H. 8898, Path. 570) was an unmarried daughter of a fire insurance company president. Both her mother and she developed mental disease after the company failed (Boston and Chicago fires). Both mother and father died, and patient was in several hospitals after 36, obscene, denudative, onanist. Delusions concerning crimes committed. Satyriasis. Could hear fire kindled to burn her. Diagnosis, "secondary dementia."
Death at 54 from bilateral bronchopneumonia. Atrophic uterus. Cystic right ovary with twisted pedicle: atrophic left ovary: contracted kidneys. The brain was not abnormal in the gross- but showed (Dr. W. L. Worcester) some acute changes (also larger cells pigmented).
CASE 19. (D. S. H. 10106, Path. 663) a cheerful Irish house-wife (mannerism of drawling words) underwent a maniacal attack at 41, and another at 44. Delusions: "sorry she had lived": "broken her religion" Given to self recrimination.
Autopsy: Death from hypostatic penumonia. Healed gastric ulcer. Moderate arteriosclerosis, slight cardial hypertrophy. Granular cystic kidneys. Mucous polyp and subperitoneal fibromyoma of uterus. The brain was macroscopically normal, but showed superficial gliosis (frontal and precentral) and thinning out of medullated fibers superficially (frontal).
CASE 20. (D. S. H. 8963, Path. 679) an epileptic shoe-maker, 50 years, was of the belief that he was sent to Hospital for hitting a boy and was to be executed.
Autopsy: Aortic and innominate aneurysm, hypertrophy and dilatation of heart. Interstitial nephritis. The brain, normal macroscopically, proved microscopically to show, in all areas examined, superficial gliosis. There was gliosis in parts of the cornu ammonis, but no demonstrable nerve cell loss (interesting in relation to the epilepsy).
CASE 21. (D. S. H. 4584, Path. 861) cabinet-maker of melancholy temperament, Civil War veteran. Said to have been feeble-minded after six months in rebel prison. Violent at times for twenty years. Did no work, thought "soul lost."
Death from pneumococcus and streptococcus septicemia. Chronic diffuse nephritis. The brain was described grossly as normal: but microscopically there was marked superficial gliosis in all areas examined and considerable cell loss in suprastellate layers of precentral cortex. The calcarine sections show little or no cell-loss. But one section from the frontal region is available (right superior frontal). This shows little cell-loss except in the layer of medium-sized pyramids.
CASE 22. (D. S. H. 8250, Path. 909) an unmarried woman without occupation, two attacks of "melancholia" at 36, and 40. Always of a retiring and shy disposition. Mental disease began after father's death. Delusions (if such): has been selfish and wicked. Constant self condemnation. Suicidal. Exophthalmic goiter.
Autopsy: Thyroid glandular hyperplasia. Mitral sclerosis. Aortic sclerosis with ulceration. Chronic endocarditis. Chronic diffuse nephritis. Scars of both apices of lungs, with small abscess of left apex. Emaciation. Brain weight 1050 grams. No gross lesions described; microscopically profound alterations; extreme or maximal cell-losses in small and medium-sized pyramids in both superior frontal regions. Smaller somewhat less marked cell-losses elsewhere.
Upon reviewing the unpleasant-delusion group, then, we exclude one (XII) altogether. It is questionable whether XV actually exhibited delusions at all. We then discover that eight (in all probability all) of our nine remaining cases are renal in the sense of grossly evident lesions at autopsy.
But it will be remembered that we transferred three cases originally thought to entertain "not-unpleasant" delusions to the unpleasant group, because their constraint, although conceived to be of divine origin, seemed to be unpleasant (VI, IX, X). Of these VI and X were renal cases; but IX is expressly stated by a reliable observer (the late Dr. W. L. Worcester) to have had normal kidneys as well as heart. In point of fact, however, Case IV had hallucinations and religious delusions ("spirit is here") probably derived therefrom, and Dr. Worcester found an isolated brain lesion correlatable with the hallucinosis; and in any event the emotional state of the patient is in grave doubt.
Accordingly if we take the unpleasant-delusion group to be constituted of Cases VI and X (transfers from the first group), XIII, XIV, and XIV to XXII, that is eleven cases, we come upon the striking fact that virtually all of them are renal cases.
Of course, as (with Canavan) I have been at some expense of time to prove, virtually ALL cases of psychosis (as autopsied) are in a microscopic sense abnormal as to kidneys.[7] But only about a third exhibit GROSS interstitial nephritis, arguing a certain severity of process. The above cases, it will be observed, fall into the GROSS class in respect to renal lesions.
Without laying too much stress on such results, it is worth while to say that, whereas most workers might be willing to surmise that metabolic or catabolic disorder must affect the sense of well-being, I must confess that the discovery of so much gross kidney disease in a group selected on other grounds filled me with a certain surprise.
The literature is not without suggestions as to the possible correlation of renal and mental disorder. Ziehen,[8] for example, remarks that nephritis brings about mental disease in two ways,-through vascular changes which very frequently accompany chronic nephritis and other uremic changes in the blood. Inasmuch as we know that creatin, creatinin and potassium salts irritate the animal cortex, Ziehen notes that psychopathic phenomena may occur in man as a result of slight uremic changes. According to Ziehen, most of these nephritic psychoses run the course of what he calls hallucinatory paranoia (it may be remembered that Ziehen counts among paranoias a number of acute diseases and even so-called Meynert's amentia). Chronic nephritis, as well as acute diabetes and Addison's disease are thought by Ziehen to produce certain chronic forms of mental defect which he terms autotoxic dementia, but he regards most of these cases as really cases of arteriosclerotic dementia.
It does not appear that Wernicke[9] has considered renal correlations systematically.
Kraepelin[10] mentions the epileptiform convulsions of uremia as well as delirious and comatose conditions, especially those in advanced pregnancy. These uremic conditions may be both acute and chronic. But Kraepelin has not been able to convince himself of the existence of a clearly defined uremic insanity unless the delirious condition just mentioned may be regarded as such
Binswanger[11] states that the mental disorders occurring in acute and chronic nephritis are either toxemic psychoses on uremic bases, or due to arteriosclerosis. In the latter cases, he states that the disease pictures are as a rule characterized by grave disturbances of emotions, chiefly of a depressive character. He adds that these are all too frequently the forerunners of arteriosclerotic brain degeneration.
A brief mention of renal disease in the general etiology of mental disease is made by Ballet.[12] Ballet states that Griesinger's opinion that renal disease had little importance in the etiology of mental disease and that no one would count the cerebral symptoms of Bright's disease as mental is no longer held. Ballet enumerates a number of works upon so-called folie brightique which tend to prove that acute or chronic Bright's disease gives rise either to melancholic disorder or alternately to maniacal and melancholic disorder. How the mental disease is produced is doubtful. Ballet holds that all the various psychopathic disorders resulting from Bright's disease are autotoxic. Renal disease like heart disease is only capable of awakening a latent predisposition or liberating a constitutional psychosis, unless it is merely effecting a species of intoxication.
It cannot be doubted that the relation of kidney disorder to mental disorder is worth intensive study, of which the present communication is merely a fragment. Progress will be of course impeded by the fact that upon microscopic examination, practically all cases of mental disease coming to autopsy show renal disease of one or other degree; in fact, it is perhaps possible to show a higher correlation of renal disease with mental disease than of brain disease to mental disease. Perhaps something can be obtained if we limit ourselves to a study of cases with pronounced somatic renal symptoms and signs, cases with the renal facies and the like.
As to the question of phthisis and mental disease, Ziehen remarks that the tuberculous are often observed to be optimistic but that other cases show a hypochondriacal depression with egocentric narrowing of interests. He speaks of a sort of rudimentary delusional disorder looking in the direction of jealousy in certain cases. Pronounced mental disorder occurs rarely in tuberculosis, according to Ziehen, and leads either to melancholia or to hallucinatory states of excitement, resembling the deliria of exhaustion or inanition. Acute miliary tuberculosis may produce the impression of a general paresis or of an amentia in Meynert's sense. The inanition delirium of tuberculosis resembles that of carcinosis and malaria.
Kraepelin regards tuberculosis as of very slight significance in the causation of insanity, despite the fact that slight changes in mood and in voluntary actions frequently accompany the course of the disease. Irritability, depression and sensitiveness, incomprehensible confidence and desire to undertake various tasks, pronounced selfishness, sexual excitement and jealousy are the traits of mental disorder in tuberculosis.