Emil Kraepelin.

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^Wanderversammlung d. suedwest Neurolog. u. Irrenraetse an
Baden-Baden, 1897.

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tions, rhjrmes, and repetitions, which may be sung as well
as spoken. Numerous delusions are expressed which are
incoherent, changeable, and both exalted and depressive.
In emotional attitude patients are much exalted and some-
times erotic ; depression with anxiety, however, may pre-
dominate the emotional tone. Occasionally there is irrita-
bihty with exhibitions of passion.

The motor excitement is very pronounced; patients re-
move their clothing, race about the room, overtiun furni-
ture, and pound the door. They are both destructive and
imtidy, and often exhibit the most reckless and impulsive
movements. They prattle away incessantly, sometimes in
a whisper, now at the top of their voice, and again gesticu-
lating and clapping their hands. The attention cannot be
attracted and questions are rarely answered. They will not
obey requests, but almost always exhibit a purposeless
resistance to everything, even to bathing and dressing.

Physically. — There is great insomnia. If the patients
sleep at all, it is only for short intervals. Likewise they take
but Uttle nourishment, and in many cases require mechani-
cal feeding. The condition of nutrition is wretched, and
there is a marked loss of flesh and physical weakness. The
skin is pale and clammy, the temperature usually subnormal,
and the pulse weak and irregular. The reflexes are usually
exaggerated. Tremor is sometimes present and there is a
tendency to acute decubitus.

Course. — The duration of the disease is brief, sometimes
of only a few hours or days, and rarely lasting over one to
two weeks. The retimi to consciousness is usually sudden,
often following a sound sleep. When the patients awaken,
the hallucinations and illusions have disappeared; they are
conscious of their surroundings and ask for nourishment.
They may continue talkative, perhaps showing a flight of

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ideas, some exaltation, grumbling, and fretful manners for
several hours and even days. Brief relapses sometimes occur.
As soon as nourishment is freely taken, the weight increases

Diagnosis. — The differentiation from infection delirium
has aheady been considered (see p. 130). The epileptic be-
fogged states are distinguished by the greater clouding of
consciousness, a more uniform emotional tone which is
mostly anxious or ecstatic, and the fact that the activity
does not conform to the thought or the emotional expres-
sions. The catatonic excitement is recognized by the clearer
orientation, and the characteristic catatonic movements.
The delirious excitement of dementia paralytica can be dif-
ferentiated only by the history of preceding mental deteriora-
tion and the presence of characteristic physical signs. The
delirious mania of manic-depressive insanity, in the absence
of a history of previous attacks, can be recognized only t)y
a greater disturbance of apprehension and the very vivid
hallucinosis. Amentia is differentiated by the longer course
and distractibiUty of the attention.

Prognosis. — Recovery from the mental disorder is usual
if the patients do not die from collapse.

Treatment. — The important indications are first to main-
tain nutrition and next to alleviate the excitement. The
patients must, therefore, receive a suflBcient quantity of
liquid nourishment, in the accomplishment of which it is
often necessary to resort to forced feeding by stomach or
nasal tube. A little alcohol (one to two ounces) added to
the milk and egg is extremely valuable. Broths and pep-
tonized meats may be given in small quantities. Where
mechanical feeding is contraindicated, because of vomiting or
abrasion and hemorrhage of the mucous membrane, nutrient
enemata can be substituted. Faihng in this one can always

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resort to the hypodennoclyBis of normal saline solution, one
to two pints, with the expectation of securing excellent re-
sults, especially if there is impending collapse. The infu-
sion should be given under low pressure in the back, rump,
or breast.

In the alleviation of the excitement, by far the most eflB^-
cient remedy is the prolonged warm bath, into which the
patient should be placed at once and kept there imtil the
excitement subsides. The bath should be maintained at
ninety-five to ninety-eight degrees F. all the time. The
patients may remain in the bath without fear of harm for
hours and even days at a time, but usually they become
quiet in less than an hour, when they should be retiuned
to bed. As soon as the excitement reappears, they should
again be placed in the bath. If the patients exhibit fear
in entering the bath and require holding, the bath can do
but little good. In such cases, one may give a hjrpodermic
injection of hyoscine hydrobromate, -t^ to ^ grain, or
trional, 15 grains, shortly before the bath for the first few
times. As soon as the patients become accustomed to the
bath they usually Uke it, and some even fall asleep in it.
If the bath is not available and one must resort to hyp-
notic and sedative drugs, hyoscine hydrobromate -^ to ^
grain and paraldehyde forty-five minims to one drachm
may be relied upon for the best results. One should not
be persuaded to overload the system with sedatives in an
effort wholly to subdue the excitement in the hope of secur-
ing quiet for others. Excitement, of itself, is by no means
the most serious ssrmptom. It is sufficient if you succeed in
procuring even a few hours' sleep and prevent the patients
from wholly exhausting themselves. Prolonged warm baths
properly applied usually render unnecessary the use of
sedatives. If the patients collapse, hot coffee by mouth or

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rectum^ stiychnia^ dignitalis, or hypodermic injections of
camphorated oil are indicated.

It is best that the patients be isolated in a quiet place, with
sufficient attendance to control them at all times. Constant
attendance must be enforced in order to prevent injuries,
and this must be observed imtil convalescence is well es-
tablished. Mechanical restraint should not be employed; a
padded bed or room is preferable. During convalescence
the same indications obtain here as in convalescence from
any acute disease : careful feeding, graduated exercise, and
freedom from all forms of excitement. Finally, one must
be assured of complete recovery before the patients are per-
mitted to resume their usual occupation or responsibilities.
A good index of this is found in the weight, which should
always retimi to normal.

B. Acute CJonfusional iNSANrrr (Amentia)

This form of exhaustion psychosis is characterized by the
rapid appearance of numerous illusions and halliicinations,
clouding of consciousness, and motor excitemerU, with a
duration of two to three months.

Etiology. — The conditions of exhaustion giving rise to
amentia are chiefly childbirth, also acute illnesses, excessive
loss of blood, excessive mental strain, and night watching.
An emotional shock may be the final exciting factor. Women
are more frequently affected than men. Cases of amentia
represent about one-half to one per cent, of the admissions to

Symptomatology. — At first the patients are anxious, rest-
less, and forgetful, sometimes complaining of numbness and
confusion in the head, and inabiUty to gather their thoughts
or concentrate their attention. In the course of a few days
disorientation appears; the surroundings seem changed, and

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they do not recognize relatives. Hallucinations of the dif-
ferent senses appear. They see strange faces and hear
strange voices, birds are flying about, lions are roaring,
poisonous powder is thrown at them, and they are threatened
and cursed by strangers. The numerous hallucinations
form the basis for many depressive delvMons, which are
dreamy, incoherent, contradictory, and often repeated.
Their children are dead, the home is lost, they are to be
hung, are under the influence of some magnetic power which
draws them about, and in the end will consume them. In
a few cases the delusions are expansive; they then beUeve
themselves exalted to some high position, possessed of great
wealth, or they have journeyed around the world. They
will convene Congress, and send an army to Cuba. They
sometimes fabricate extensively.

The attention is attracted by the surroundings and the
patients endeavor to grasp what transpires. It is usually
possible, also, to direct the train of thought by objects held
before them, by movements and gestures; but they under-
stand readily only the simplest occurrences. Some patients
claim that everything is changed, things are not genuine,
the chairs and windows are not the same to-day as yester-
day, the thermometer is not correct, the clock is not right,
and the papers are incorrectly dated. Often the patients
appreciate this inabiUty to understand things, and complain
that they cannot "think right " or that some one "has made
them crazy.*'

There is marked disturbance of the train of thought. The
patients are imable to complete one idea before others in-
terrupt, producing a flight of ideas. Words and sounds
caught up from the surroundings find a place in their ex-
pression, though not necessarily influencing or directing the
train of thought. The speech is sometimes made up of

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single, incoherent, and disjointed words and phrases. Occa-
sionally sound associations and rhymes are heard. In spite
of distractibiUty and flight of ideas, one occasionally finds
the patients holding to single indefinite ideas, usually of
persecution. The amscumsness is much clouded. The per-
sistence of clouded consciousness, with difficulty in arrang-
ing the impressions and ideas, is a characteristic and striking
feature during the intervals when the patients are quiet and
present a normal emotional attitude.

The emotional attitude varies considerably, sometimes with
prevailing happiness, but more often with depression. Alter-
nations of the attitude are characteristic; for short periods
the patients may be elated, and hilarious, with perhaps
/ some sexual excitement, when they suddenly become excited
I and irritable, or they may even be dull and stupid.

In the psychomotor field there is a marked pressure of
. activity. They move about restlessly, crawl in and out of
( bed, destroy clothing, pound and beat, but the movements
I are not very quick, are performed without display of much
\energy, and are planless. The motor excitement is dis-
tinctly intermittent, there being intervals of complete quiet.
Physically. — The sleep is much disturbed, the appetite is
poor, and sometimes there is complete refusal of food. The
body weight falls, but the condition of nutrition is better
than in collapse delirium. The deep reflexes are increased,
the pulse slow, and the temperature subnormal.

Course. — The height of the disease is usually reached
within two weeks, during which time there may have been
remissions of a few hours or even a day with clear conscious-
ness, insight, and disappearance of hallucinations. From
this time the symptoms present characteristic fluctuations.
The more active symptoms may disappear, and the patients
become more coherent in speech, when again they develop

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excitement. Genuine improvement develops gradually.
Even after they have become clear, long conversations or
letter-writing tend to create confusion. In the Ughter cases,
which are the more numerous, even after the patients have
become quite clear, the emotional attitude may show a
slightly elated or depressed condition, as seen in hyper-
activity and garrulity, or distrust, anxiety, g-nd irritability.
The entire course is from three to four months. In the
severer cases, lasting some months, even when the patients
have become clear, a few hallucinations may persist for a
short time, and occasionally indefinite and transitory ex-
pansive or depressive delusions are expressed. The patients
may appear unnatural and irritable and show outbursts of
passion. Even after all the s3rmptoms of the disease have
disappeared, the patients are very apt to show increased
susceptibility to fatigue, while for many months emotional
shocks or injuries are prone to create relapses. The weight
rises rapidly during convalescence.

Diagnosis. — The manic form of manic-depressive insan-
ity is distinguished from amentia by the fact that there
is less disturbance of apprehension than of the psychomotor
sphere; in the manic state, in spite of great motor excite-
ment, the patients usually give evidence of at least a partial
comprehension of the environment. Again in amentia the
movements are slower, more planless, and less precipitous,
and, in quiet intervals, when there is no activity, the patients
are still hazy and confused. The condition of caMonic
excitement is distinguished by the fact that the catatonic
patients in the midst of the greatest excitement are usually
able to comprehend their surroundings, to reckon time
correctly, to recognize persons, and to record some passing
events. The amentia patients even during quiet are some-
what disoriented and fail to recall passing events. Further-

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more, the characteristic catatonic features are absent. To
be silre, catalepsy and automatism may be present, but
genuine negativism, verbigeration, stereotypy, mutism, and
mannerism are absent.

Prognosis. — Death rarely occurs except as the result of
suicide, of collapse during the intense excitement at the
onset, or precarious physical conditions; as, heart failure,
sepsis, and phthisis. The patients almost always fully
recover their mental health.

Treatment. — The indications for treatment are identical
with those in collapse delirium; namely, maintenance of
nutrition and the alleviation of the excitement (see p. 140).
On account of the great tendency to relapse, one should be
extremely careful about allowing the patients to enter an
environment in which they might be subjected to an emo-
tional shock. For this same reason, one cannot resist too
long the entreaties of the patients and their relatives that
they be allowed to enter their accustomed Ufe, before they
have regained their normal weight, the menses have re-
appeared, and the emotional attitude has become wholly

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Chronic Nervous Exhaustion

Acquired neurasthenia is characterized by a diminished
power of attention^ distractibility, defective mental application,
difficulty of thinking, an increased susceptibility to fatigue,
increased emotional irritability, and a great variety of physical
symptoms, mostly subjective, including hypochondriasis.

Acquired neurasthenia must be clearly distinguished from
the psychopathic states or congenital neurasthenia (see
p. 155) . No doubt there are many transitional states between
the two diseases, and especially where both defective hered-
ity and exhaustion are prominent factors. The difference
in the s3rmptoins, their course and outcome, in individuals
free from hereditary taints, it seems, is sufficiently distinctive
to justify the restricted use of the term acquired neurasthenia.

Etiology. — The real nature of the disease has been most
logically pointed out by Mobius, who claims that there is a
kind of chronic intoxication resulting from the effects of
exhaustion upon nervous tissue, corresponding in a measure
to the intoxication resulting from the prolonged excessive
use of alcohol. This view, certainly, is helpful because it
offers a clearer conception of the disease and aids in
distinguishing between those cases which simply involve an
accumulation of the effects of fatigue and those in which the
morbid hereditary and inherently impaired powers of re-
sistance play the essential r61e (congenital neurasthenia).

The rapid, irregular, and extravagant manner of living,
with little relaxation and lack of sufficient and wholesome


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Bleep in individuals actively engaged in business or taxed
with the responsibiUties of the household, is distinctively
characteristic of the American people in the temperate
regions, and accounts for the great prevalence of this disease
in our nation. Besides excessive mental appUcation, the
worry attendant upon responsibiUty is an important factor.
On the other hand, prolonged and excessive physical exer-
tion is at times undoubtedly an important factor in produc-
ing neurasthenia, particularly excessive bodily exercise, as is
occasionally seen in sports, such as golf, rowing, basket
ball, etc. But of especial importance are our faulty meth-
ods of living, with insujBBcient relaxation and improper
nourishment. Moreover, considerable depends upon the
individual powers of resistance. This is particularly appU-
cable to that considerable group of individuals, who always
feel unequal to the demands made upon them and find
themselves quickly and completely exhausted upon any
strenuous effort.

Of the men, naturally those who are more talented,
better educated, and more active, are the individuals who
most often suffer from this disease. Indeed, it is a fact
worthy of note that great capacity for work is frequently
accompanied by greater susceptibility to fatigue. Women,
because of their weaker powers of resistance and their greater
emotional irritability, are more susceptible than men, par-
ticularly the overburdened mothers, teachers, and nurses.
The disease may appear at all ages, but is most often met
between the ages of twenty-five and forty-five, the period of
life during which the greatest mental strain occurs. At an
earUer age it is seen in ambitious students who apply them-
selves too closely to studies without relaxation. Occasionally
sjrmptoms, which differ in no respect from those described
here, develop after emotional shocks and acute illnesses,

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especially influenza^ childbirth; loss of bloody and operations.
The " nervous weakness" which appears during convales-
cence from severe illness is only in part due to simple ex-
haustion. It is doubtful if the disease ever develops after a

Symptomatology. — Prolonged work produces fatigue
and with it difficulty of fmther application. Up to a certain
degree, this fatigue, which may be considered as a safeguard
against overwork, may be overcome by an increased exertion
of will power, which in long and fatiguing work gives rise to
a feeling of " increased effort." Associated with this there
soon develops a characteristic feeling of disinclination and
then a fagging of the will, and when this appears the danger
of overexertion is relieved. While the increased exertion of
the will can for a time balance the effects of fatigue through
an increased expenditure of power, the effects of fatigue
ultimately gain the upper hand and force one to cease work.

The first indications of exhaustion are when, imder cer-
tain conditions, the increased exertion of will continues for
some time in spite of the uncomfortable feeling of fatigue.
This is what happens when work is performed under intense
emotional excitement. The signs of fatigue, which call for
relaxation, either do not appear or are overwhelmed, and
work is prolonged beyond a permissible degree. This in
time leads, on the one hand, to an exhaustion of the available
supply of strength, which recuperates only very slowly, and
is manifested by a sort of prolonged weariness, which persists
after relaxation and is still present to some extent when
work is again undertaken. It also involves an increased
susceptibility to fatigue and a more rapid diminution of the
capacity for work. On the other hand, imder such circum-
stances, the increased exertion of the will also persists and
brings with it an increased emotional irritability.


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Unfortunately, there are as yet no experiments on the
effect of prolonged overexertion on the mind. But we know
from long experience, that, first of all, the ability to con-
tinuously exert the attention fails. The patient is easily
distracted by little things and is inattentive. He is no
longer able to think clearly and sharply, and requires much
more time for his accustomed work. He is also apt to be
f orgetfiil of names and figures, so that the same work has to
be done over several times before he is sure of his results.
His susceptibiUty to fatigue is greatly increased, and his
work is carried out only with constantly increasing difficulty,
requiring greater exertion and more frequent rests. As the
result of this difficulty of work, the patient also loses the
wonted pleasure in his occupation. He finds that he is
compelled to force himself to the work which he previously
performed with ease and pleasure. He, fmthermore,
shrinks from new imdertakings because of obstacles which
appear imsurmountable.

Under the influence of these conditions, the emotional
' attitude also becomes changed. The patients become easily
^ flustered, are ill-humored, unreasonable, peevish, faultfinding,
\ irritable, and impetuous. Customary amusements fail to
/ please, and they become discontented with their occupation.
.' Triffing affairs, Uke the misconduct of a child, inconven-
! iences at work, which normally would pass unnoticed, disturb ,
I them for hoiUB and even days, and may lead to impulsive
outbiuBts, which they later regret.

The patients have not only a keen insight into these
defects, but also a tendency to exaggerate their symptoms.
They assert that the memory is becoming profoundly af-
fected, and that the judgment is failing. The physical
symptoms are even more strongly exaggerated, which aids in
increasing their misery. The excessive anxiety about their

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condition of health leads to a characteristic S3rmptom,
hypochondriasis^ in which there is a tendency to pay undue
attention to any trifling s3rmptoms that may be present.
They believe that they are suffering from some incurable
disease, and especially the one most dreaded. There may
be some genuine disorder, but the real sjonptoms are greatly
enhanced by the attention habitually paid to them. Canker
in the mouth is considered infalUble evidence of ss^philis,
a cloudy urine indicates Bright's disease, and a cough means
consumption. In the beginning these fears may not be con-
sidered in a very serious light, but when they interfere with
the liyeUhood of the patients they may lead to such feelings
of despair that the patients no longer hope for recovery,
make their wills, ^nd not infrequently attempt suicide.

The appreciation of their incapacity creates a feeling
of reserve, timidity, and a lack of self-confidence. They
cannot trust themselves in public and fear fainting upon
the sUghtest exertion. Associated with the loss of will-
power, there should also be mentioned the tendency to
compulsive thoughts and impulsive acts, which sometimes
explain the suicidal attempts. Here are included the vari-
ous phobias, which are fully described in the constitutional
psychopathic states. In the strife to overcome impulsive
ideas, the patients often reach an emotional crisis of short
duration, with restlessness, wringing of the hands, crying
and moaning, and even attempts at suicide. These states
are more apt to follow continued excitations, such as pro-
longed visits or unusual noisiness.

Physical symptoms. — These form a very characteristic
feature of the psychosis. Among the most important S3rmp-
toms are headache, insomnia, general muscular weakness,
parsesthesias, cardiac and gastro-intestinal disturbances.
Cephalalgia, which appears early, may be expressed as a

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headache, a feeling of numbness or a pressure in the head,
which interferes with work. This is usually situated over
the eyes or in the occiput, and increases with exertion until
it becomes unendurable. It is more prominent in the morn-
ing and passes off during the day. Sometimes there is a
feeling of pressure, as if the head were held in a vice or by
a constricting band. It may be associated with vertigo,
dimness of vision, roaring in the ears, or painful pressure

Online LibraryEmil KraepelinClinical psychiatry: → online text (page 12 of 45)