The symptoms of psychical disorders resemble those of the body in this:
that they are not phenomena absolutely unlike those of the normal
state, but are mere modifications of the latter. In the vast majority
of instances they consist in a relative augmentation or diminution of
healthy conditions, so that for every symptom of insanity we are able
to point out an analogous normal process of the mind.
Considering that even in somatic medicine, with the aid of all the
appliances there at our command, we can not always draw the line
between health and disease, we certainly ought not to expect to do so
in every case presented to psychiatry, concerned as this branch is with
a far more complicated organism than any other department of medicine.
Nor should we draw the limits of health too narrowly; we have to allow
sufficient room for all varieties of minds.
Let a sane man undergo a mental shock, say the death of a near
relative. He will experience an intense depression of feeling, and will
very likely be overwhelmed with grief. The events of the world around
him will pass unnoticed, and things that had excited his interest in
the highest degree will fail to make upon him the slightest impression.
The intensity of this condition will vary with different men. One will
be more susceptible to psychical pains than another. One will be able
to fight down his feelings with his reason, while another will give
himself over to unbridled grief. But whether in greater degree or
less, in some measure, in the circumstances supposed, the sane man
will always experience such grief. Complete psychical anæsthesia, or
insensibility, is a symptom of psychical disease. We observe it in the
most diverse forms of insanity.
On the other hand, it is not unusual to find persons in whom such a
depression of spirits as we have described is brought on by quite
trifling causes. The refusal of a new dress or seal-skin sack, rainy
weather which interferes with a projected picnic, and things of that
description, may suffice to bring on a shower of tears and to conjure
up a state of despair, or at least of deep mental perturbation. In
fact, this is the regular result with children. But in adults we
call it excessive sensitiveness, or psychical hyperæsthesia. It is
especially met with in hysterical and degenerate individuals.
Finally, the same state of deep depression and complete apathy is also
found without the slightest outward reason, being brought on by inward
conditions. In that case we diagnose a grave psychical malady--to wit,
melancholia.
It is the same with the cheerful emotions. Any sound man may, upon
a particularly joyful occasion, as upon the successful passage of
an examination, or the winning of a lottery prize, give way to an
exuberance of behaviour which a hysterical or degenerate subject will
exhibit upon the most trifling occasion. But if such a state is brought
on without any external reason whatever, it betokens a form of disease
which may pass into foaming rage; and this we term mania.
It is just the same with anger, vexation, fear, anxiety, and other
emotions. From the normal psychical action we pass through successive
exaggerations of emotion to a rage quite without reason but determined
by inward conditions.
Even irrational emotion is not without its analogue within the latitude
of the normal state of our spirits. Almost every man has his ups and
downs of spirits, his greater or less mental tone. One day, he knows
not why, he is in good condition for work; another day he has to force
himself to his duty. An artist says, “It is of no use; I am in no trim
for work to-day; I am not in the mood for it.” If we imagined curves to
be drawn of these moods in different men, we should find waves of small
amplitude even in the most solid and stolid men of business; while
passing to the artists, and from them to the Skimpoles, and from them,
again, to persons usually called hysterical, the oscillations would be
greater and greater. The slight spontaneous irregularities of temper
of the perfectly sane man will be manifest only to his most intimate
companions; for he will contrive to give his moods a factitious backing
of reason, though this may perhaps deceive no close observer. But the
hysterical, and those who abandon self-government, will in the wildest
fashion give rein to every freak, quite forgetful of the company in
which they may be. We can, however, assign no accurate limits to
healthy variations. We can not say, At this point precisely sanity ends
and madness begins. There is no such boundary in Nature. The difference
between a particular disposition and insanity is but a question of more
or less.
All our impressions, whether of the external world or of ourselves, are
conveyed to us by the sensory-nerves. The excitation of a sensory-nerve
terminal results in a sensation at the central end of the peripheral
nerve, in the brain. Hence the excitation is propagated to the cortex,
or outer part of the brain, where is the terminus of the sensory tract;
and here the sensation, brayed, as it were, with the residua of former
impressions, is converted into a perception. Every sensation that has
once been worked up into a perception is capable of being spontaneously
or voluntarily excited anew. The re-excitation or reminiscence of an
image which has so arisen, whether by a peripheral excitation, or
spontaneously, or voluntarily, brings along with it the recollection
of other images. Those connecting nerve fibres, by means of which
associated sensations are produced, are termed associational tracts.
The aggregate of a great multitude of reminiscential images belonging
to different organs of sense makes what we call a perceptual idea, or
percept (_Vorstellung_). For example, let the word _bell_ be mentioned.
What does it mean? It brings up the optical image of a certain cubic
curve, the form of the outline of the bell; it brings up the four
letters b e l l; it brings up the sound the instrument produces; and,
finally, it brings up the sonorous syllable which we are accustomed
to fancy resembles that sound. All these images (and mind, that in
psychology we speak of auditory, olfactory, and other reminiscences as
_images_) are recalled, and with them traces of other things associated
with bells--some merry sleighing-party of the hearer’s youth; his
wedding-day, perhaps; the dreadful summons of the people on some
occasion of a fire or of anticipated invasion; and, possibly, some
well-remembered funeral. All these things come welling up to us, like
the swelling of the sound produced by interferences. Language has no
word more vividly significant than _bell_, because the more memorial
images cluster about an idea, the clearer will it be, and the easier
reproduced, or, in other words, the more it clings to the memory. If
you have to remember a name you ask to have it written down, because
the auditory image will be more readily reproduced if once associated
with the visual image.
The more intense and extraordinary an original impression of sense, the
more distinctly will it be reproduced. But after a while the reproduced
image loses its distinctive characters. It becomes vague, and in
that sense weaker. The remembered sound of the cannon of a distant
battlefield, though not perhaps less loud, is less distinguished from
other remembered sounds, unless, indeed, more recent experiences
refresh our memory.
The period of time within which a memorial stimulus of given power can
excite a recollection of given definiteness varies through a wide range
with different individuals. Within the latitude of health there are
good and bad memories, and memories of different kinds. In pathological
cases, this action of the cortex may sink almost or quite to zero, or
be exaggerated surprisingly.
As a multitude of impressions are worked together into an image,
and a multitude of images into a perceptual idea, so a complexus of
perceptual ideas has for its resultant a _thought_, wherein there
is a representation of the way events happen, in general, and of
the relation of our ego to the macrocosm. Such general conception
of the relation between the inner and outer world makes what the
psychologist means by self-consciousness--or, as it has been called,
the consciousness of consciousness, or superintending-consciousness
(_Oberbewusstsein_).
The procedure of thought is perfected in an arrangement of ideas
in sequence. In the waking state there is a ceaseless flow of
percepts--that is, a continual thinking-process takes place in the
brain. Those percepts are occasionally excited by the peripheral
organs, or they are supplied by inward excitations following the tracts
of association.
The sequence of percepts may be determined either involuntarily by
spontaneous associations and outward impressions, or by the active
exercise of attention.
Stimuli from the peripheral organs of sense may be called _centripetal_
actions, the operations of association _intra-central_, and the idea
due to the will _centrifugal_. The function of this centrifugal action
is to bring the ideas into a regular sequence by excluding unsuitable
centripetal percepts, and by strengthening some associations and
weakening others. In common speech we call this centrifugal action
_attention_. It fulfils one of the most important offices of the mind,
since without it thought could not be made purposive.
The power of attention of a sane man has to be considerable, so that he
may hold his ideas in the right order for a long time without fatigue.
In idiots, on the other hand, it is occasionally so completely wanting
that they can not swerve the slow current of their ideas. Between these
two extremes every possible grade of this power is met with. Every
teacher of children knows that some of them concentrate their thoughts
with comparatively little difficulty, while others are at the mercy of
every little presentation in the room or out at the window, as well as
of their own recollections.
The process of association may follow different principles. An idea
may melt into another inwardly allied to it. I hear a musical air,
for example. This sets all sorts of subconscious ideas relating
to music into motion toward the surface of consciousness. Some
circumstance or other, perhaps its recent prominence, gives a clear
outline, let us suppose, to the idea of the Magic Flute before the
others. Now, it is particularly ideas of operatic music whose gradual
movement toward emergence is accelerated. I find myself reviewing
several operas; or, if a number of such ideas emerge at once, a
general conception of operatic music is formed in my mind. Among
these pictures, perhaps one of a grand performance at La Scala may,
by its splendour, obliterate others. By this time my reminiscences
of oratorios, symphonies, chamber music, etc., are sinking back into
slumber, while pictures of various opera houses are crowding up to
the surface. Their multitude prevents my distinctly dwelling upon any
one. The resultant is a general idea of theatrical architecture. Now
memories of other magnificent pieces of architecture begin to take
places in the composite photograph of my imagination, and as, by the
operation of fatigue, the intense assertiveness of the ideas which have
been longer before my mind wanes, perhaps the resultant of those that
remain leaves me thinking of triumphal arches. This is an imaginary
example of a train of association governed chiefly by the principle
called _resemblance_--that is, by the intrinsic affinities of ideas.
Another principle is that called _contiguity_, where an idea, A, calls
up another, B, having no inward affinity for it, because the sequence
of B upon A has an analogy, or inward affinity, with the sequence
of _b_ upon _a_, where _b_ and _a_ are ideas which occurred at some
previous time, _b_ following after _a_. For example, I see a porringer,
let us say, which I remember to have used in my childhood. The whole
scene straightway completes itself in my imagination--the chamber, the
furniture, the nurse, appear before me. Thence my fancy is carried
forward to the day when that nurse was married from the house, and the
image of the man she married is called up. Then follows the picture
of a visit I subsequently made to see how the couple were prospering,
etc. These ideas follow one another because similar ideas did follow
one another upon a former presentation of them. The principles of
resemblance and contiguity may act in conjunction, as they do in the
minds of those who are continually chasing puns and rhymes. Here ideas
the most incongruous may be associated, because the former recalls by
contiguity a word or phrase which by resemblance calls forth another
word, which in its turn reproduces by contiguity the second idea.
We make use of this sort of association in mnemonic verses, such as
“Thirty days hath September,” etc. Countless systems of artificial
memory repose on the same principle; and so does the very natural
method of attending to a general rule observable among certain objects
for the sake of remembering the objects themselves.
The rapidity with which the process of associative reproduction takes
place can be little varied by any effort of the will. It depends upon
the freshness or fatigue of the nervous system at the time. It differs,
too, with different individuals. Under pathological conditions it may
either sink to such a minimum that patients will themselves complain
of their vacuity of mind and mental retardation, or it may become an
abnormal rush of ideas. When the rapidity of the associative process
is slightly increased, the patient feels extremely well. He is in the
mood for brilliant performances, thoughts fly to him, his conversation
sparkles, he improvises, he impresses those about him as being a witty
and clever man. With a still greater rapidity of associative action
there is such a rush of ideas that they tumble over one another, lose
their logical relations, and end in a delirious whirl.
We have thus far considered only cases in which every idea is excited
by a stimulus external or associational. We now come to a different
phenomenon. Almost every man knows what it is, while endeavouring
to think consecutively, suddenly to have an unwelcome image obtrude
itself; perhaps a musical air which he has of late heard too often
repeats itself in his brain without being led up to at all. We often
hear it said, “I can not get that accursed tune out of my head.”
Phenomena of this kind are to be explained by the tendency of some
part of the cortex which has been excessively excited to pass into
the active condition spontaneously. In quite an analogous way the
most complicated percepts may spring up spontaneously, breaking into
the normal current of thought. When an idea thus becomes a continual
hindrance to rational thought, we call it an imperative idea. It forms
a disease inflicting, as a rule, great torment and anguish upon the
patient, and leads to further complications.
We have said that every sense-perception once experienced may be
reproduced without any new stimulus. Now, if, independently of any
associational process, a reminiscential image is excited spontaneously
with extraordinary strength, the vividness, or subjective intensity of
the idea, may be so heightened as to take on every characteristic of
actual perception. Let an excitation run over the path which leads
from the subcortical centre which is the seat of the primary sensation
to the cortical centre of perception, and whether it have a centrifugal
origin, or whether it be centripetally propagated, the result will
ordinarily be the same--namely, that we shall project the percept into
our idea of the outward world. We shall unhesitatingly accept the thing
we see or the language we hear as real external experiences, although
the whole may be nothing but hallucination.
The relative intensity with which a given perception can be reproduced
by a given person depends on the intensity of the original excitation
and the degree of attention that had been originally bestowed upon
it. In different persons the intensity of reproductive power varies
exceedingly. It is low in some minds; while others, especially artists,
possess a very high degree of imagination. Some painters can at will
call up visual images which they proceed to copy upon their canvas
just as if they were painting from Nature; and a successful writer for
the orchestra will seem to hear the effect of a given combination of
instruments, so as to achieve with unerring certainty results that the
greatest theoretician could not rival.
Muscular motions are of three kinds--the automatic, the reflex, and
the voluntary. Automatic motions, such as the beating of the heart and
ordinary respiration, are caused by the action of special centres;
and though they may be influenced by reflex, or even in some measure
by voluntary action, they act, nevertheless, independently. Reflex
motions originate in centres which do not, like the automatic centres,
produce any excitations, but only receive them from sensory nerves.
Examples are the contraction of the pupil of the eye under increased
illumination, and winking upon any touch of the eyelid.
To bring about a voluntary motion, a centripetal impulse is ordinarily
requisite, to stimulate the psychomotor centre. Yet it is possible for
the excitation to arise within that centre. Every man has his peculiar
tricks, unless he has taken pains to conquer them. He pulls his beard,
or sniffs, or bites his mustache, or rubs his hands, or gives some
peculiar twitch, more or less annoying to his neighbours, unconsciously
to himself and without any outward stimulus, simply in consequence
of a chronically excited state of some centre. These excitations are
sometimes sufficient to produce large and co-ordinated motions for
which, in ordinary circumstances, the co-operation of the will would be
requisite. Many people can not sit long still without an uncontrollable
impulse to move about. They jump up from their work, take a turn or two
up and down the room, and then sit down to their work again.
Such excitations as these may likewise be exaggerated to the point of
disease. In mania they are seen in their most extreme form. Patients
yell, rage, strike, and smash, without knowing what they are about.
Among the most important symptoms of psychical maladies, often most
difficult to recognize, are delusions. The general public imagines that
delusions consist essentially in believing something that is utterly
absurd. Nothing could be more erroneous. A delusion may be in substance
quite true, while the sheerest nonsense may be produced in the mind
without any delusion. A person may fancy he has a living creature in
his body, and, though it may in fact be true that he has a tapeworm,
yet, if the opinion is not founded on any sound process of thought, it
certainly is none the less to be classed along with genuine delusions
because it accidentally happens to come true.
Of three so-called “spiritualists,” let one be a simpleton who,
without any logical conviction, has been led--by sheer credulity,
or weak assent to energetic assertion--to admit the phenomena of
mediumship. Let the second be a learned man who has been imposed
upon by legerdemain, and who endeavours to explain what he thinks he
has seen in a scientific way; and let the third be one with whom the
belief is of the nature of an insane delusion. They all believe the
same thing; so that it can not be said that it is the nature of what
is believed that constitutes the insanity. It is rather the mode in
which the belief has come about, its relation to the other operations
of the mind, its mode of expression, its relation to the interests of
the believer, that must be relied upon to determine the alienist to
diagnose a true delusion.
Anomalies of the propensities play a great part in the pathology of
the mind. Like the other symptoms of insanity, abnormal impulses are
but quantitative or qualitative modifications of healthy conditions.
Psychiatry has never discovered any new passion. The appetites vary
greatly in different individuals; and here again we must take care to
allow sufficient latitude to healthy variations. The feeling of hunger,
or the propensity to eat, may in the most diverse psychical disorders
be enormously exalted. This is called hyperorexia. It sometimes goes
so far that the patient tries to devour whatever he can lay hands
on. This is called sitomania. On the other hand, the propensity may
be distinctly lowered in intensity or even lost. This is called
anorexia. Of course, none of these states includes cases in which the
modification of the appetite is caused by derangements of the organs
of digestion. Finally, the desire for food may be directed to strange
substances, as often happens to pregnant women. In the insane this
perversion of appetite will sometimes be so great as to induce them to
eat straw, earth, worms, and even their own filth.
We sometimes find the other propensities equally deranged. The sexual
impulse may be exalted to the highest degree--a state called satyriasis
in men, nymphomania in women. The sexual appetite may be depressed or
lost in total impotence. It may be perverted to one’s own sex or to
other things.
I must apologize for this general description of the symptoms of
insanity, which does not directly concern the subject of this book.
I have entered upon it for the purpose of showing that, in order to
determine the state of mental sanity or insanity, it does not suffice
to produce certain extraordinary or absurd modes of behaviour or
temper; that we can hardly pronounce a man to be insane from any
conduct until we know what his motives are; and, finally, that we are
not to judge from a part of his mental actions, but must get a clear
notion of his whole mental condition. I have further endeavoured to
show that, as far as single symptoms go, no sharp line of demarcation
can be drawn between mental sanity and insanity. Just as there are
physically strong men and physically weak men, men of large bodies and
men of puny bodies, so within the limits of health there are mental
athletes and mental weaklings. Moreover, just as no two men are in
person counterparts the one of the other, so there are no two whose
characters are precisely alike. There are perfectly healthy men with
extraordinary physiognomies or peculiarities of bodily structure; and
in like manner unusual traits of character are to be met with. The
study of such men may be interesting to the psychologist, but it does
not directly concern the pathology of the mind.