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The Time of Some Mental Processes

in the Retardation and Excitement

of Insanity



BY



SHEPHERD IVORY FRANZ



(From the Laboratory of Pathological Physiology of the McLean
Hospital, Waverley, Mass.)




Reprinted from the AMERICAN JOURNAL OF PSYCHOLOGY
January, 1906, Vol. XVII, pp. 38-68.






The Time of Some Mental Processes
in the Retardation and Excitement
of Insanity.




THE TIME OF SOME MENTAL PROCESSES IN THE
RETARDATION AND EXCITEMENT OF INSANITY.



By SHEPHERD IVORY FRANZ.

(From the Laboratory of Pathological Physiology of the McLean
Hospital, Waverley, Mass.)



TABLE OF CONTENTS.

Introductory,

Clinical histories of subjects,
Description of experiments,

Experimental results,

Conclusions



2

3

12

17

31

Introduction. The present work was undertaken in order to
gather material for the solution of the problem : to what part
or parts of the nervous system may we refer the increased and
the decreased psychomotor activity usually found in depressed-
maniacal insanity.

The earlier psychiatrists considered as separate disease enti-
ties abnormal emotional depressions and exaltations, under the
names of melancholia and mania, and the condition in which
there is a more or less regular alternation of the exaltation and
the depression, called circular insanity. The last state was
deemed very peculiar, but until the time of Kraepelin it seemed
not to have been closely associated with either of the two other
conditions. To Kraepelin is due the credit for having shown



that circular insanity, m
form) are interrelated
Manisch-depressive Irresei
main points of the present
pelinian school) of the o




simple
termed
up the
Krae-
eWncholia and



Mnatio

the older circular insanity; 2 a tendency to recurrence, the ab-
sence of mental deterioration, psychomotor excitability or re-

1 This name has been variously translated, the most common being
"manic-depressive insanity." See Hoch's article in Wood's Hand-
book of the Medical Sciences, Vol. V, "Manic Depressive Insanity,"
Paton's recent book: Psychiatry, and. de Fursac, Manual of Psychi-
atry, Trans, by Rosanoff. This designation is a transliteration of the
German, regardless of English meaning and spelling; the word manic
is not given in the Century Dictionary and the word depressive means
"able or tending to depress." It is not the insanity which is depres-
sive but the depression is the "insanity."

*0 cit.



MENTAL PROCESSES. 3

tardation, emotional exhilaration or depression, and difficulty
or (apparent) ease in thinking. These alternative symptoms
may be variously combined in individual cases, the most usual,
however, being the combinations of (a) exhilaration-|-excita-
bility-j-flight of ideas and (b) depression-}-retardation-|-diffi-
culty in thinking. In the excited phase of this condition the
emotional tone is exalted. There is a feeling of bien aise, of ex-
pansiveness, of great ability, and of self-satisfaction. There is
more or less motor excitement and a seeming rapidity of asso-
ciations, with flight of ideas. The associations are usually
superficial and sound associations. The attention is very un-
stable. In the depressed phase there is a lowering of emotional
tone, and a feeling of malaise, of hopelessness, perhaps of fear,
and there may be suicidal tendencies and attempts. There is
often a profound motor disturbance in which the reactions
using that word in its widest sense are slowed, and an ap-
pearance of decrease in associative ability; in other words a
retardation. Any of these symptoms, but of course not oppo-
sites, may be present to a mild or to a most marked degree.

The differences in motor activity of this class of the insane
have been studied to some extent * but so far as I am aware
there is no published account of work such as is here attempted.
At the present writing there is available only an incomplete
skeleton of the work necessary for a full understanding of these
motor conditions. The present article is, however, complete
in itself and is to be considered as part of the general plan.

Clinical Histories of the Subjects. Six subjects were chiefly
used in the research, two normal, two depressed (retarded),
and two exhilarated (excited), as follows:

Normal subjects. F., the writer, upon whom the whole
series could not be made, was used as one normal subject. The
other normal subject was B., a business man, age 49 at the
time the experiments were being made, had been a patient at
the hospital for about seven years. During the course of the
experiments B. was consfileSred 'recovered,' and had been prac-
tically so for about a year. He w'as admitted 2 to the hospital
Oct. 22, 1897. He had previously indulged quite freely in
alcoholic liquors, but for over a year had very little alcohol.
For ten months before admission the patient had appeared not

^Especially reaction times : W. Bevan Lewis, Textbook of Mental
Diseases, 2d edit., London, 1899, pp. 164, 364 and 365. Richet: Dic-
tionnaire de Physiologie, Article Cerveau, Vol. Ill, p. 29. v. Tschisch:
Neurol. Centralblatt, 1885, IV, p. 217. G. Leftnann : Psychol. Arbeiten,
1904, IV, 603-668. On fatigue: Hoch,Journ. of Nervous and Mental
Diseases, 1904, XXVIII, 620-628.

2 The clinical accounts have been copied from the hospital records.
The notes were made chiefly by Drs. A. Hoch, Steele, Roberts and
Hamilton.



4 FRANZ :

so well, had become absent-minded, depressed, and later more
inactive. On entrance he spoke slowly in a monotonous tone,
expression immobile, rather blank, yet said he worried about
everything. He was not clear as to where he was, and in the
afternoon did not remember the physician whom he had seen
for a short time on entrance (morning). Later he was oriented
as to time, place and persons, did not occupy himself, did not
speak spontaneously, but answered calculation questions, even
difficult ones, very promptly, but questions regarding his con-
dition were answered by "I don't know." There was no
memory difficulty. In four months he became a little more
spontaneous, and his sentences were a little longer when he
talked. In the gymnastic class he was reported to make his
movements promptly and well. For four years he remained
practically stationary, answering slowly, doing little, but when
made to do things, as in the gymnasium class, doing them
promptly and well. "It is the fact that with a sufficient ex-
ternal stimulus the patient can act promptly while it seems
that if he has to supply the stimulus himself there is so little
activity that it makes his general condition appear rather the
outcome of an apathy than of a retardation." In June, 1903,
it was noted that "there has been a slow, gradual gain which
from day to day or week to week, or even month to month has
been imperceptible, but which on looking back has amounted
to a very great transformation. The man shows now in regard
to conversation and in regard to occupying himself with every-
thing that is possible in the hospital a very decided sponta-
neity. He shows, moreover, good judgment in his conversation.
He is one of the best billiard, tennis and whist players and is
occupied all the time." He did not ask to be allowed to go
home, did not think he could attend to his business, but when
questioned in regard to his condition the old reply "I don't
know" was sometimes given. During the following summer
the patient was occupied most of the time playing golf, tennis,
etc. There was a gradual improvement, although when any-
thing out of the ordinary arose he was inclined to hesitate a
little. During the succeeding year there was a gradual recov-
ery and at the time of the laboratory experiments he was prac-
tically well, although disinclined to take up business. The
patient was discharged May 29, 1905.

Retarded subjects. Ed., a hotel clerk, age 21, was admitted
to the hospital May 8, 1904, greatly depressed and retarded.
For some years previous to his attack of melancholia he had
been troubled greatly with dyspepsia, and he had always been
inclined to worry about his business and other affairs. In
March, 1904, the patient could not attend to his work, gave up
his position, and was greatly worried about himself. He would



MENTAL PROCESSES. 5

say, as an example of his depressive ideas, "I am no good."
When taken to drive he feared lest the horse was not strong
enough to pull him, etc. At this time the patient was taken
to his father's office and performed what little things were
asked of him, e.g., writing down orders and answering the
telephone, but there was no spontaneity. Gradually he be-
came slower in his movements, but in the beginning of May
was restless and once made an attempt at suicide by drowning.
After this he was even less active, refused food, and was untidy
if not closely watched. He expressed the ideas that he was
turning to stone, that his throat had been cut, that his feet had
been taken off, that he had no tongue, and that his neck was
broken. After his entrance to the hospital he remained in bed,
lying perfectly quiet, seldom moving any part of his body.
Upon repeated requests he did not show his tongue, although
it was seen to move slightly in his mouth, which was partly
open. There was no reaction to pin pricks. He was tube-fed.
When requested he could be made to walk slowly to a chair
and to sit down, but all movements made at command were
done very slowly and often incompletely. It was impossible to
get the patient to answer any questions. On most occasions
he had to be moved by the nurses from place to place. On one
or two occasions he was heard to say "What have I done?"
"Where am I?" About three weeks later the patient obeyed
simple commands such as 'Get out of bed,' 'Sit in the chair,'
but all his movements were made slowly, and with a consid-
erable interval between the command and the beginning of the
movement. Common answers to questions, sometimes given
quite promptly, were "No," "I don't know." He knew his
name and age, and related part of his previous history slowly
but well, but he did not know where he was, how he came to
the hospital, or how long he had been here. He did not re-
member the physician although he had been tube-fed by him
for twenty-three days, three times a day. A few days later he
could not be made to give the date, place, etc., and answered
to all questions "I don't know." At this time he was heard
to remark, "I have no eyes, no arms, no legs." Three weeks
later he knew the names of the nurses and of many of the
patients on the ward, and not infrequently made remarks about
the latter. His time was entirely unoccupied, and was spent
walking slowly about the hall or in the yard, or sitting or lying
about the hall or in his room. On June 2, he ate well three
meals and from that time did not have to be tube-fed. Simple
questions were now answered readily, but questions the answers
to which required the least thought either received no response
or "I don't know." July 30, there was considerable improve-
ment over his previous condition. Occasionally, especially



6 FRANZ :

towards evening, he walked about better, and talked more
freely to the nurses and physicians. At times, however, all
one could get from him was "I am suffering more than any
one else in the world," or "I am all twisted," etc. On general
subjects he often answered well but slowly, but so soon as his
condition was touched upon, he would not answer. He was at
this time perfectly clear regarding his surroundings, oriented
as to time and place, and knew the people about him. On
August 24th, when the series of experiments were begun, the
patient was in the condition just described. He answered
slowly and in whispers and it took considerable persuasion and
often commanding to get him to start upon the work. A
month later, September 26, it was noted that there had been a
steady improvement in the patient's condition. He took part
in games, and made a fairly natural general impression. He
played pool and billiards well. For about three weeks he had
not talked so much of being "abused" and of being "the sick-
est man in the world," and these ideas had been gradually
disappearing. The period of his convalescence seemed to be
very short; he seemed to get well by leaps and bounds. The
experiments were continued from August 24 until his discharge
"recovered" Nov. 9, 1904.

Ev. , the other retarded subject, was at the time of the ex-
periments 65 years old. He was a business man, admitted to
the hospital Oct. 15, 1903. In temperament he was inclined
to be optimistic. He was social and entertaining, but rather
easily irritated. Previous to his present illness he had had six
attacks of depression. All of these had been rather typical,
showing depression, a feeling of inadequacy, and some retarda-
tion. These attacks came respectively at the following ages:
22, 30, 37, 44, 51, and 58. The later ones lasted about six
months, and the course was very similar in all. Each started
with a depression, and a gradual quieting and inactivity.
Then he took little interest in things about him, was depressed
about everything, thinking that his business was 'going to the
bad' and that his family would be ruined. At these times there
was considerable self-reproach, etc. He always spoke i a low
tone and answered slowly. The attacks usually wore off quite
gradually, with an improvement in his physical condition and
a relief from his insomnia, and he returned to his 'natural opti-
mistic self.' During the past five years the patient had been
under a mental strain because of business difficulties. The
present illness began in December, 1902. He began to be de-
pressed and to sleep poorly, but kept at his business until
February, 1903, when the firm failed. He was 'completely
exhausted' by the failure and remained in bed for a week dur-
ing which time his condition was as follows: quiet, felt unable



MENTAL PROCESSES. 7

to do things, had considerable self-reproach, took little interest
in things about him, complained of feeling exhausted and
weak. Then he became restless and agitated and would not
eat. He was sent to an insane hospital in a neighboring city,
his restlessness disappeared and gave place to a retardation.
He remained quiet for the most of the time, sat in one place,
and had to be urged to do things. He was mentally clear,
and well oriented. On entrance to McLean Hospital, October,
1903, the patient answered questions very slowly five to eight
seconds looked quite depressed, obeyed commands slowly,
walked quite hesitatingly, protruded the tongue barely beyond
the lips. He sat about unoccupied, without any spontaneous
talk, almost with no movement. He showed, in fact, a very
typical psychomotor retardation. He is senile physically, but
not mentally. The condition of the patient remained stable.
He was always quiet, saying and doing nothing except an oc-
casional mumbled answer in a tone so low as to be scarcely
audible. His time was occupied in standing quietly or sitting
in one place, occasionally looking around him. He occasion-
ally answered questions briefly, slowly, and in a very low tone.
When told to go to the dining room he went very slowly, but
was able to find his own seat. He ate in a normal manner,
using knife, fork and spoon properly, and at the proper times.
At night he would not undress himself, and in the morning
would not get up until taken out of bed by the nurse. He ate
and slept well. During the next few months the patient grad-
ually improved in that he took more notice of things about
him, moved a little more quickly, and more often. He looked
after his wants better, and was a little more independent, e. g.,
he would go to the dining room when the bell was rung.
From that time the condition remained almost stable. He sat
about the ward, always unoccupied, very depressed, never
talked to any one except to answer questions. He was dis-
tinctly retarded except in the matter of eating, which he did
as rapidly as any one. He dressed and undressed himself
slowly. He was perfectly oriented as to time and place, and
knew the people about him. There seemed to be no memory
defect and no thinking disorder. The following is a note made
August 29, 1905: "Very little change has been noted in the
patient's condition. He is always seen sitting dejected and
inactive in the sitting room, and if asked to shake hands he
extends his right hand very slowly forward. In answering a
question he hesitates for some time, and finally whispers out
a reply. This observation applies to his conduct on the ward,
where his retardation is marked. About two weeks ago he
was taken to the laboratary for four days to be put through a
number of tests. One of these tests required him to read



8 FRANZ :

aloud, which he did quite audibly on the third day. . . .
Other tests were responded to in such a manner as to indicate
that he not only understood all that was said to him, but that
he could do various things calling for a considerable exercise
of his power of attention, recognition and discrimination.
Once an experiment was explained to him, he co-operated in-
telligently, and although with considerable retardation, quite
accurately. . . . His memory is good, as is also his ori-
entation as to time and place. Depressive ideas remain, as for
example, his usual answer to questions concerning his health:
"No better I shall never be any better. " (Hamilton.) This
patient took part in the experiments reported in this paper
from August to December, 1904, and again in August, 1905.
He was discharged to go to another hospital Oct. 8, 1905, in
the condition that had been characteristic of him for the past
year.

Excited Subjects. C., age 48, a mechanic, of fair education,
with a fourth attack of insanity, was admitted as a patient to
the hospital August 2, 1904. The first attack (March 8 to
May 21, 1901) was a depression. The patient had been a
heavy drinker and six years before entrance, in 1901, he had
taken the Keeley cure. After that he did not drink until a
short time before his admission. In the previous summer C.
was very irritable and inclined to worry over small matters.
Then he lost interest in his work. Four months before admis-
sion he stopped work, and thought his friends were against
him, avoided them, became morose and remained at home.
His memory at that time was not good, he slept poorly, but
there was no marked depression. When admitted (March,
1901) the patient said that he stopped work because he could
not attend to it and "got balled up." He had difficulty in
thinking. Multiplications that required much thinking were
difficult and almost impossible. He said spontaneously that
his memory was poor and objectively it was shown to be so.
Things which he knew well, e. g. t when he came to the hos-
pital, when he last saw the physican, etc., took him a long
time to think out. He worried because he could not do his
work. During the succeeding two and one-half months he im-
proved rapidly, felt able to take up his work again, and said
that his memory was good again. His second attack was an ex-
citement (December 4, 1901, to March 18, 1902). After leav-
ing the hospital in May he began to work, bought another
business, worked hard, and showed good judgment in his
affairs. In November he became exhilarated, and talkative,
but not unduly expansive in his ideas. He also showed a cer-
tain forgetfulness. During his stay at the hospital he was
decidedly euphoric and exhilarated. He showed a great deal



MENTAL PROCESSES. 9

of over-activity. He talked much, decorated his room, and
showed a distinct flight of ideas. Everything was said to be
"fine;" the hospital "the finest place in the world," etc. He
showed no memory defect at that time, but on the contrary
had a good grasp on details of both present and past events.
He gradually quieted down and became more normal and was
discharged "much improved." For four months the patient
worked well, but was a trifle irritable from time to time, and
in the summer became quite tired. About three months before
his third admission he began to have difficulty in applying him-
self to his work, and drank heavily. Afterwards he could not
do his work, became seclusive and slept poorly. Readmitted
in December, 1902, he was depressed until May, 1903 (third
attack). In this attack he was more depressed than he had
been in 1901. He said he was 'done for,' would never amount
to anything, others did not want him around, etc. In church
he felt that the clergyman was talking at him because he talked
of vices, and he asked if he should not get up and confess. He
was unoccupied, complained of feeling dull in his head, heavy,
and s~aid his mind was weak and that he could not remember
things. He said very little. Objectively his memory was not
found to be particularly poor, he was oriented in regard to the
place and time, and he knew the names of those with whom
he came in contact. His calculation ability was poor, and he
said it was difficult for him. He improved during the five
months of his stay and was discharged in May, 1903.
Later he became abnormally irritable and excited and returned
to the hospital August 2, 1904. During the interval of over
a year he drank frequently and- at these times neglected his
business. At such times he talked alternately, religiously and
profanely. During the six weeks previous to his re-entrance
to the hospital he was more talkative, sometimes abusive, and
he took no rest and went to meals irregularly. During this
period he was arrested twice for acting peculiarly. His man-
ner at the hospital was a jolly one, and his talk showed a
"flight." He remained exhilarated as evidenced by his gen-
eral activity in sports and in his movements and talk. He was
apt to become irritable at the slightest provocation. This was
his condition during the experiments. In May, 1905, it was
noted that he had become a little quieter, but that he made the
impression of still being mildly exhilarated. July 29. 1905, the
patient was discharged. He had become less exhilarated, but
remained active. His conversation was clear and not particu-
larly expansive. Throughout the last attack the patient did
not seem to realize that his condition was abnormal. The diag-
nosis that was made was "Manic-depressive insanity, circular
form." For a time, and particularly during the first two at-



IO FRANZ :

tacks, there was considerable doubt about the diagnosis. At
first he was considered a case of "General paralysis." This
was due largely to the presence of certain physical signs, e.g.,
no pupillary reaction to light, but good reaction to accommo-
dation. Later the tendo Achillis reflex was noted to be absent,
but there were no speech defects, no tremors, no gait disturb-
ances, and the other reflexes were found to be normal. In
view of the facts that there is no noticeable dementia, and that
there is a regular alternation of the depressions and excite-
ments, it seems most probable that the man is not a case of
paresis. If, however, it happens that he is found to be paretic,
the results of the experiments would not be affected, because
at the time the tests were made he was undoubtedly in an ex-
cited, maniacal condition without dementia. The pupillary
disturbance, I think is the result of the man's occupation. He
has to look alternately at bright lights and to dark objects, and
this would tend to reduce, perhaps abolish, the light reflex.
P., was a bright business man, age 48 at the time of his ad-
mission to the hospital, May 29, 1904. At this time he was
greatly excited and exhilarated, and remained under hospital
care until December 5, 1904, when he was discharged on a visit
home. A month later he was brought back to the hospital
very depressed, after a suicidal attempt. He is now in the hos-
pital (November, 1905). The course of his disease is a typical
mania-melancholia, the manisch depressive Irresein of Kraepelin.
Three years previous to the present attack P. had bought a
business on a friend's advice and when he found later that it
was much worse than any one could have expected, he became
melancholy. This abnormal depression was, however, only ot
a short ciuration, a couple of weeks. Four weeks before en-
trance to the hospital P again became 'worked up' over his
business, but this time the insanity took on the excited form.
Much extra work had been thrown upon him in the business
in which he was engaged, and, in addition, he was occupied
with the affairs of another concern that he was purchasing.
He took a trip to New York in connection with the new busi-


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