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.
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.
Kraepelin states that many cases of tuberculosis show traits of alcoholic
disease and says that the occurrence of polyneuritic forms of alcoholic
mental disorder is favored by the association of tuberculosis with
alcoholism.
Wernicke does not systematically consider the topic.
Binswanger states that tuberculosis, aside from miliary tuberculosis or
meningitis, produces no mental disorder except phenomena of the amentia of
exhaustion.
Ballet states that there exists a peculiar mental state in the tuberculous.
It is compounded as rule of sadness, of looking on the dark side and of
profound egoism. This readily leads to mistrust and suspicion which may be
pronounced enough to constitute a sort of persecutory delusional state or a
state of melancholic depression (Clouston, Ball). More rarely there are
phenomena of excitation explained in part by fever. In its slightest degree
this phenomenon of excitation is characterized by a feeling of well-being,
of euphoria, which even at the point of death may give the patient the
illusion of a return to health, or there may be a more pronounced excitation
with impulsive sexual and alcoholic tendencies. Autointoxication may lead to
the usual train of confusional symptoms.
If we compare the accounts in the literature of the two conditions here in
question, namely, nephritis and phthisis, we must be convinced, that aside
from so-called autotoxic phenomena, renal disorder seems to be marked by a
tendency to depressive emotions but that phthisis shows not only depressive
emotion but also euphoric and hyperkinetic phenomena.
So far as these results thus hastily reviewed are concerned, they are
consistent with the appearances in the present group of cases. Both the
nephritic and phthisical groups need further intensive study.
As to the question of the spreading inwards or outwards of delusions from
the standpoint of the patient, no analysis is here attempted. It is plain,
however, that the theopaths, as James calls them, or victims of theomania,
to use the French phrase, will be of importance in this analysis because of
the equivocal character of the emotions felt in cases of religious delusion.