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LECTURE X.

PRIMARY DELUSIONAL INSANITY.

Mode of Development--Contrasted with those of Melancholia and Mania

Patients not much Excited or Depressed by the Presence of Delusions-
Chief Symptoms of the Disorder— Delusions Arise de novo, and are not
the Result of any Antecedent Mental Disease-- Ætiology-A Neurosis
Inherited or Developed— Imperfect Development of the Bones of the
Skull-Meningitis, Injuries, etc. -

:-It more often Appears during the Epochs of Lise-Symptoms—In the Prodromatous Stage-Tendency to Solitude-Distrust-Eccentricities– Irritability and Brooding-Tendency to Reverie and Subjectivity— The Primary Stage may Cover Months or Years--The Essential Element of fully Developed cases is Delusions – Hallucinations of General Sensation–Often Present in the Back, Sides, and Genital Organs—The Character of Delusions may Partake of Exaltation or of Pseudo-Depression-Memory—Illustrative Case—Letters of the Patient- Personality Overwhelmed by the Strange Concepts and Dominant Ideas, etc.

Mode of Development.-We have now traversed the two great fundamental departures from the standard of what may be assumed to be healthy mentality.

The first of these was in a line of diminution of functional activity, attended with mental suffering; the second in the opposite line of increased functional activity, and attended with exhilaration. Both of these conditions, you will bear in mind, have been shown to be accompanied or followed by delusions, illusions, or hallucinations, insistent ideas, and, in some instances, all of these. Further; in the condition of both mania and melancholia, the symptoms which gave names to them constituted the underlying and principal features of the disorder, while the hallucinations and delusions assumed a secondary position, apparently growing out of, and depending upon the former, and they faded away largely in proportion as the conditions from which they arose and upon which they depended improved. This, however, was not the result in all cases. A very considerable percentage, after the conditions of mania and melancholia had passed away, remained still affected with delusions of different kinds, and also with hallucinations. These peculiar phantom-like creations which had been projected into the conscious sphere of thought, while its mechanism was burdened by a supersensitive or neurasthenic condition, made so profound an impression, or became so fully imbedded, as to remain long after the condition itself, which was the indirect cause of them, had improved, thus constituting a secondary, sequential, or chronic form of abnormal mental activity.

We now enter upon the consideration of a third line of departure from the assumed standard of healthy mind, the general trend of which leads away from that of either of the above forms, and, indeed, rarely crosses or intersects with either of them, except in an incidental way. It is a mental state or condition by no means as common as the first two, and yet is frequent enough to be found in all large asylums, and in some of them in considerable numbers.

In this form of mental disorder neither of the two principal mental conditions which we term mania and melancholia is found to exist in any marked degree. While some cases are attended by such mental changes as would ordinarily indicate a condition of depression, or, at least, a physiological basis for it, yet the individual does not pass into a state of melancholia. He may be mentally burdened, and be constantly apprehensive of evil about to happen to him, but he does not on that account suffer in mind as the melancholiac does; he is never overwhelmed; he never despairs; he never speaks of not becoming well, or of troubles which he anticipates for his friends or family; he seems to be profoundly unconscious that there is anything the matter with him, and converses about his delusions of persecutions as a matter of fact, and troublesome, but something to be escaped from by using the proper means.

Again, he may be never so sanguine as to his future prospects and his present fortune; he may be confident he is an emperor, for a little while debarred from his rightful throne; or Paul the Apostle, or Jesus Christ even; that he is worth untold millions, and has missions of the highest importance to fill; and yet he never becomes excited about it; he does not become incoherent or maniacal, or deduce illogical conclusions from the assumed premises. The failure in his reasoning consists largely in the assumption of premises which do not exist. If these were true, the inferences and conclusions which he reaches in a very straightforward and consistent way would not be so far wrong or highly improbable. No very marked degree of mental enfecblement or dementia or of mental inactivity appears for several years after the disorder has become fully developed.

Hallucinations and delusions of different kinds and characters appear to constitute the permanent characteristics of this form of mental disorder. And it should be noticed that these are not the residue of any antecedent attacks of systematized insanity, nor due to the after effects of such, nor do they constitute the after effects of either excitement or depression. Whatever of the latter may have existed in the earlier stage, is not more than is compatible with

mental integrity and ability on the part of the personality to distinguish properly and interpret all sensations and experiences.

That peculiar supersensitive condition of certain portions of the central ganglia, or certain cortical areas of the brain, which constitutes the basis of hallucinations, is not in this variety due to an extension of disease which formerly existed in other portions of the grey substance, but, on the contrary, appears to arise de novo, and to become the point d'appui, whence it is radiated to other limited sections of the cortex, thus furnishing a basis for delusions of a primary character.

The emotional system, which contributes so important an element and the disturbance of which plays so large a part in some other forms of mental disorders, remains mostly unaffected in this. Whatever of excitement may appear seems to depend upon the morbid beliefs of the patient, and may become considerable during short periods in connection with delusions of persecution.

Ætiology.-A neurosis—either inherited or developed from experiences incident to early life, such as infantile convulsions, delirium, or the disorders of childhood; imperfect or arrested development of the bones of the skull; meningitis occurring in childhood from falls, blows, or other contusions to the skull; injuries affecting the nervous system from frights and over-study at this period; or, finally, from impressions received while still in utero,-usually manifests itself at an early period of life, and generally during adolescence.

The proximately exciting causes of the development of this form of disease are less pronounced than in many others. In those cases which have come under my observation it has been connected more often with the advent of

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puberty, adolescence, and the climacteric; or, again, with masturbation and systemic diseases occurring in the early period of life, and profound impressions and injuries.

The environments have been favorable; educational advantages and positions in society good, and those unfavorable influences which arise from poverty, over-work (except in cases of study), anxieties and disappointments, have not existed.

Symptoms.-The disease appears generally to develop in connection with the growth of the system, though, as already remarked, it may arise at later epochs in life in some cases. In the prodromatous stage there may be an increased tendency to solitude and a growing distrust toward those who have been friends for years, combined with an exaggerated degree of self-importance, and still the individual appears so natural, and, when once engaged in actual intercourse, converses so nearly as he always has done, that no suspicions arise as to the oncoming of disease. Its primary indications may consist in eccentricities; singularity in general conduct; too little inclination to participate in the sports and experiences common to childhood; peculiar fancies, and a tendency to indulge dream-like states and reveries, while half unconscious of what may be passing about him; a state of abnormal irritability and supersensitiveness if disturbed; an inclination to solitude and introspective periods at that age when normally constituted children are expending the surplus of nervous energy in outward activities and the motor centres are especially sensitive and active. Such conduct is characteristic of and normal to the individual, as ordinary conduct is to persons in general, thus indicating how profound is the impression of the inheritance, or accidental experience, upon the organization of the nervous system. It is so potent an

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