296
\ art. VI.?THE PSYCHOLOGY OF GENERAL PARALYSIS
OF THE INSANE. By FREDERICK
TREVES, M.R.C.S.
a disease of so great interest and of so marked a character General Paralysis of the Insane, it would be well to anticipate a more accurate knowledge of its pathology by some attempts to investigate its psychological nature and significance, and by ascertaining to what mental changes its peculiar characSuch an attempt is useful only when ter is to be ascribed. reviewed in connection with the physical evidences of the disease, and is justified as perchance forming bases upon which a more sound and accurate pathology might be raised. Much has of late been successfully written to show that an extensive series of actions hitherto assigned to the direct and present influence of mind are in reality automatic, and performed without even the intervention of consciousness. Such actions, consciously designed at first, are again and again repeated; consciousness is at each repetition less and less involved, until at length their performance becomes purely automatic, or is at least attended by no conscious activity of mind. These actions become, as Dr. Maudsley well expressed it, organically registered; each repetition would appear to make that organisation more complete, and the degree to which an action, or series of actions, is performed without the direct agency of mind would seem to depend upon the soundness of its physical basis in the nervous centres. For example, to sign one's name is, in the educated, perhaps as automatic, and at the In the same time as elaborate, an action as could be selected. nerve-axis one might conceive this action, or rather series of concerted actions, as organically registered and represented by a centre which, if suitably stimulated, would cause the said actions to be displayed, yet without the interference of consciousness, just as in primary reflex acts. Still there was a time when this act would have no physical basis in the nerve centres; when each letter and each part of a letter would be formed with direct consciousness and imply evident guidance of mind: but at each repetition of the act the mind takes a less and less apparent part; until at length the elaborate action of signing a name comes to be classed under the secondary reflex acts, or, as they may be also termed, acquired or educated reflex acts. These remarks, which so far refer to physical actions only,
In
as
297
PSYCHOLOGY OF GENERAL PARALYSIS OP THE INSANE.
may be applied with perhaps an equal appropriateness to the actions of the higher centres of the brain, and to a greater Is it possible extent than might at first sight appear tenable. for a collection of ideas to be reproduced automatically, and for individual thoughts and processes of reasoning to produce an effect, without a consciousness on the part of the individual ? How far one might speak of unconscious thought or of automatic reason is certainly very questionable ; but a want of terms may, perhaps, be some apology for a vagueness of wording. An experienced To take an example of these remarks. a case, arrives at once at a in examining physician, diagnosis : place the same case before a well-read student of equal mental calibre, and he puzzles long before coming to an opinion. What is the difference between the mental processes in the two observers ? It will be said to be merely a question of experience ; The younger observer arrange? but what does this imply ? certain ideas and thoughts; he enters into various steps oi reasoning more or less complicated, and all by an active and conscious effort of mind, until at length he attains a conclusion or definite opinion. Each succeeding case of a similar nature presented to his notice calls up the same ideas, thoughts, and reasoning; but each time he is aware of less active mental interference: constant repetition has made the various processes on which his diagnosis depended automatic; and at last, as the experienced physician, he comes to an opinion at once. If now he were to closely analyse the reason of his immediate diagnosis he would find that quite unconsciously he must have gone through all the steps he first undertook, and which, by constant repetition, have become automatic, or at least exercise their influence unconsciously. Or again : a question?say of morals?is presented to a man for judgment: he at once gives an opinion for or against. It cannot be said that that decision is arrived at by instinct, and it would no doubt be ascribed to " preconceived ideas ;" but such a term implies merely this?that by repeated contact with similar questions the processes necessary for a conclusion have become to be unconsciously performed or passed over, the result alone remaining; the active interference of the mind less and less apparent at each repetition, just as repeated physical actions are at length to be classed as automatic. It will be seen, then, that mental processes such as have just been alluded to are under the direction of a power that primarily calls them into being, and is more or less evident on each occasion of their repetition. To assign a name to this power would be difficult: it may be looked upon as mind in an active
becoming
u
2
298
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
form, in distinction to such mental movements as automatic, or performed without the consciousness of the individual; or as a modified volition; but as a special power it cannot be regarded. The conditions may be briefly stated as these: A certain thought, or series of thoughts, or a certain step of reasoning, due perhaps to some recognised stimulus, is at first performed consciously by the individual, and by conscious effort; at each repetition this conscious power or effort becoming or
conscious
are
less and less marked, and, as it would appear, less and less necessary for the proper performance of the mental movement. During the earlier repetitions the act is quite dependent on this originating or directing energy, but ultimately it would become in a way reflex, responding to a given stimulus without consciousness, and independent?so far as the individual is aware ?of any effort. Constant repetition causes the given mental action, as in the case of the physical action, to be organically registered in the brain centres. It would appear that to an injury of this power, whatever it may be named, we must look for an explanation of the mental symptoms of general Paresis. Now, it is evident that disorder of this mind-power will affect in the main two classes of mental actions?those, on the one hand, that are of quite recent origin, or that have not been repeated sufficiently often to render them organised or independent of the originating energy; and those, on the other hand, that from their indefiniteness, or from their intricate and elaborate nature, are still unable to be performed?although perchance often repeated?without conscious interference; just as those physical actions that are the most complex are the least or made reflex, and are the first to suffer in learnt, easily any case where the mental power is impaired. How these remarks bear on the psychological symptoms of General Paralysis of the Insane may now be considered. It is important to recognise the profound importance in the human mind of Self: nothing is of more general or more intense interest to man than Humanity, and Self is the segment of it with which he most certainly is the best acquainted. All human actions and qualities that are external are brought to Self as to a standard?not necessarily of excellence, but of comparison ; and it is by such comparison that one's defects or virtues become pronounced, and one's relation to the rest of humanity defined. From Self as it is man deduces an ideal Self as he would wish it to be. This is natural to all men, and it is an outcome of that eternal impression of one's weakness, real or imagined, that forms the basis for ambition and the desire for growth and improvement: so the cowardly man is, in his ideal, a hero, the weakling a tower of strength, and the man in need
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
299
moneyed idler. Around each man's Self there is a halo of unreality in which he lives and moves, as he would wish and aspire to live and move. All men more or less are dreamers, from the youth who rises from his novel a hero of romance, even
a
practical man who in his still speculations as unreal as his life
hours will have prois real; and there is not a man who has not drawn up and surrounded himself with an ideal Self, as a kind of standard of perfection to which he would be elevated. In the healthy-minded this finds no expression, and one is aware of the existence of such an ideal only, perhaps, from remarks dropped here and there: some wish, .it may be, if only his property were such, or his health perfect, or his condition this or that, from which one learns that he has placed himself under each of the imagined conditions, and has acted his new part, lived his new life, and moved in his new world?a world as unreal as the lotus-eater's, but with a foundation of fact and a structure raised on the ideal of the perfection of Self. But this halo of unreality with which the Ego of every man is surrounded, is not of an entirely indefinite character. A man does not picture himself as abstractly better or abstractly wealthier, nor is his imagined condition purely an abstract one: it has a character more or less precise: he is wealthier by the addition of so many fancied pounds, ennobled by this virtue or by that, and physically improved by such qualities as he most admires or considers himself most deficient in. Now we have seen that if the power to which all mental processes are due be impaired, those actions, amongst others, will be affected which are the most detailed and elaborate, the most varied, the least rigidly defined, and the least organically registered. Of all processes of mind those involved in the consideration of Self are certainly at once the most general and extensive, the most changeable and complicated, the most vague and the most ill-defined; and of all things, Self occupies in the mind the widest attention, the most frequent attention, and the most capricious attention. Assuming, as above suggested, that in General this mind-power, whatever it Insane of the Paralysis may be called, is the seat of the main lesion, the psychical processes concerned in the consideration o? Self will be the first involved, and will present the most prominent symptoms. In General Paralysis the constraining directing energy is impaired, and Self runs riot: not the actual Self, the mental processes connected with which are more automatic and are therefore still properly performed; but the ideal Ego, the man, not as he is, but as he has pictured himself, and as he would have himself to be. The complicated, ill-defined and flimsilv to the hard
jects
and
300
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
registered mind movements go first, the more precise and automatic still remaining intact. Thus the patient feels himself "perfect," or in his ideal state; he is "first-class," he ails nothing, he wants nothing; he is muscular beyond compare, swift of foot, and keen of vision ; everything is rose-colour, and his world one of self-gratification and enjoyment. The vague, intricate thoughts and ideas with which he has built up an ideal of himself have now free play. He is living in his fancied world; his day-dreams are being realised and perfection reached; in money matters he has his thousands?the thousands that have, perchance, formed often enough a part of his thought; his estates are limitless, his interest unbounded, nothing is lacking, and he is, indeed, all he has ever wished himself to be. The patient is a huge expression of Self, exaggerated and ideal, and presents no ideas nor delusions that are not selfish in He does not imagine, as others who are insane character. might do, that the world is upside down, or on fire, or that some' extraordinary event is about to happen: had he such delusions they would assuredly have still some relation to Self, and the world would have been upset by his own terrific power, or burned for his own gratification, or the event would have some on his own perfection and magnificence. bearing Then, again, the markedly obscene ideas which the patient generally presents may be covered by the same explanation. Every man who experiences animal passions, no matter how simple and exemplary his conduct may appear to the rest of the world, cannot fail under the impulse of such passions to imagine method of gratification; thoughts of this character, some which are the more defined the baser the intellect, are often repeated, and may assume a prominent part in the ideal Ego a man deduces from his actual Self. If the mind powers be impaired, these loosely formed and imperfectly organised ideas have free play when called into action by a proper stimulus, and, as the result, we have those expressions of obscenity which are often a marked feature of the disease. Religious ideas are of a somewhat less definite character, and do not afford so encouraging a scope to the selfish ideal, unless the individual be of marked religious tendencies. Expressions of religion are, however, frequent in the earlier stages of the disease, but very soon cease to be heard of, and are, as a rule, of a happy, smooth, and gratifying nature: the patient will, perhaps, spend many hours in prayer or in reading some religious book, or in what is apparently deep thought; or his ideas may assume a less meditative character, and he will imagine himself about to be made a bishop, or affirm that he is going to preach in a cathedral,
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
301
In the next place, it is to be remarked in regard to the patient's delusions that they are progressive?progressive in The first evidence of number, absurdity, and exaggeration. grandiose ideas is often slight, and the earlier notions will generally be found to have some actual and ascertainable basis; for example, a patient will state that he owes the sum of ?400, when it will be found perhaps that his mind has been much exercised of late about a bill of ?4; or again he will praise his muscles and extol his powers of running and his qualities as an athlete, while he presents a body markedly feeble and illconditioned. Now, could the day-dreams and romancings of many sane men be laid bare and exposed exactly as they pass through the mind, it is to be doubted whether they would appear one whit less ridiculous than the earlier mental symptoms of this disease, or even than the symptoms when the insanity is tolerably advanced. The drunkard, too, when in his cups, presents in a temporary form a mental condition akin to that of the general paralytic; the mental power becoming impaired by the poison, the least automatic mind actions have free play: the nature of those actions has been shown, and we see them displayed in the confident bombast, the exalted ideas, the general self-satisfaction and contentment. The tippler, rising from his glass, shares with the general paralytic his happy frame of mind, his ability to do anything and attempt anything, his increased possessions and his many personal excellencies; the flimsy intricate ideas out of which in his sober moments he has woven an ideal self are freed from the constraining power, and act to a given stimulus in the manner seen. So, too, many of the very old, from a gradual impairment of this mind power, present symptoms that may fairly cause them to be classed as general paralytics. We may meet with an example in some feeble old man of fourscore years, propped up in his chair, powerless of limb and vacant of mind, but with still one great idea of Self: Self is the one great topic that he harps upon from morning till night: there were no times like his times; no companions like his companions; in in other words, that is quite that is modem?or, everything out of the sphere of Self?there is only rottenness. No one knows more than he, or can boast a vaster experience. No one even now can manage his business as he can, and he would wish to see the man who could do this thing Or that better than
himself.
The symptom that illustrates, perhaps as well as any, the statement above made, that the disease consists in an unmasking of an imagined Self, is the occurrence of frequent fits of
302
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
melancholy and capricious sadness. These have their basis of reality in those sudden moments of doubt and despondency to which all men are at times subject, but those more especially whose ideas are lofty and aspirations high. In the youth full of ambition and romance it is perhaps most marked, and is recognised by a name ; in the great speculator or great dreamer it will come to mar his thoughts or mock his soarings, and is perhaps most present when a flash shows him the hopeless disparity between his dream and the reality. One other point of importance remains to be noted. As when there is any impairment of the originating mind energy, those mental processes which
are the least automatic or the mind are the first to show eviconstantly dependent dences of the injury, so those processes that are the most automatic are the last to be affected. This affords explanation in the present disease. For although the flimsy strange ideas connected with his ideal state are luxuriating, he will still present perfectly reasonable notions connected with his actual self. Thus a patient possessed of several thousands of ideal pounds, large estates, and magnificent connections, will yet, in answer to a direct question, state correctly in most instances the amount of his wages, however insignificant, and will own to a trifling 30s. a week, while in the same breath he will talk of his legacy of some thousands. The idea of his actual income has become from frequent and constant repetition automatic, and he answers accordingly. In like manner, he will state correctly the price of his garments, of any jewellery he might be wearing, while he will talk at the same moment of a suit of gold or a chain of diamonds ; and may consider his health perfect while acknowledging to certain past diseases, accidents, and infirmities. All such matters are familiar and defined, and being constantly passed in review in the mind, acquire a hold that the flimsy exaggerated ideas cannot lay claim to. The condition of the memory also presents characteristic features. Matters of recent occurrence that have had consequently but few opportunities for repetition, and that still involve consciousness when called into view, are of course far more directly dependent upon mind than matters of earlier date which have been so frequently repeated as to assume automaticity. So it will be found that the patient, while he will furnish with wonderful accuracy details of his earlier life, will yet give but a vague account of recent events, and will confuse dates and occurrences strangely. This defect in memory is often one of the most marked of the earlier symptoms of the disease, and is especially to be noticed in persons of business propensities and formal habits.
most
on
\ art. VI.?THE PSYCHOLOGY OF GENERAL PARALYSIS
OF THE INSANE. By FREDERICK
TREVES, M.R.C.S.
a disease of so great interest and of so marked a character General Paralysis of the Insane, it would be well to anticipate a more accurate knowledge of its pathology by some attempts to investigate its psychological nature and significance, and by ascertaining to what mental changes its peculiar characSuch an attempt is useful only when ter is to be ascribed. reviewed in connection with the physical evidences of the disease, and is justified as perchance forming bases upon which a more sound and accurate pathology might be raised. Much has of late been successfully written to show that an extensive series of actions hitherto assigned to the direct and present influence of mind are in reality automatic, and performed without even the intervention of consciousness. Such actions, consciously designed at first, are again and again repeated; consciousness is at each repetition less and less involved, until at length their performance becomes purely automatic, or is at least attended by no conscious activity of mind. These actions become, as Dr. Maudsley well expressed it, organically registered; each repetition would appear to make that organisation more complete, and the degree to which an action, or series of actions, is performed without the direct agency of mind would seem to depend upon the soundness of its physical basis in the nervous centres. For example, to sign one's name is, in the educated, perhaps as automatic, and at the In the same time as elaborate, an action as could be selected. nerve-axis one might conceive this action, or rather series of concerted actions, as organically registered and represented by a centre which, if suitably stimulated, would cause the said actions to be displayed, yet without the interference of consciousness, just as in primary reflex acts. Still there was a time when this act would have no physical basis in the nerve centres; when each letter and each part of a letter would be formed with direct consciousness and imply evident guidance of mind: but at each repetition of the act the mind takes a less and less apparent part; until at length the elaborate action of signing a name comes to be classed under the secondary reflex acts, or, as they may be also termed, acquired or educated reflex acts. These remarks, which so far refer to physical actions only,
In
as
297
PSYCHOLOGY OF GENERAL PARALYSIS OP THE INSANE.
may be applied with perhaps an equal appropriateness to the actions of the higher centres of the brain, and to a greater Is it possible extent than might at first sight appear tenable. for a collection of ideas to be reproduced automatically, and for individual thoughts and processes of reasoning to produce an effect, without a consciousness on the part of the individual ? How far one might speak of unconscious thought or of automatic reason is certainly very questionable ; but a want of terms may, perhaps, be some apology for a vagueness of wording. An experienced To take an example of these remarks. a case, arrives at once at a in examining physician, diagnosis : place the same case before a well-read student of equal mental calibre, and he puzzles long before coming to an opinion. What is the difference between the mental processes in the two observers ? It will be said to be merely a question of experience ; The younger observer arrange? but what does this imply ? certain ideas and thoughts; he enters into various steps oi reasoning more or less complicated, and all by an active and conscious effort of mind, until at length he attains a conclusion or definite opinion. Each succeeding case of a similar nature presented to his notice calls up the same ideas, thoughts, and reasoning; but each time he is aware of less active mental interference: constant repetition has made the various processes on which his diagnosis depended automatic; and at last, as the experienced physician, he comes to an opinion at once. If now he were to closely analyse the reason of his immediate diagnosis he would find that quite unconsciously he must have gone through all the steps he first undertook, and which, by constant repetition, have become automatic, or at least exercise their influence unconsciously. Or again : a question?say of morals?is presented to a man for judgment: he at once gives an opinion for or against. It cannot be said that that decision is arrived at by instinct, and it would no doubt be ascribed to " preconceived ideas ;" but such a term implies merely this?that by repeated contact with similar questions the processes necessary for a conclusion have become to be unconsciously performed or passed over, the result alone remaining; the active interference of the mind less and less apparent at each repetition, just as repeated physical actions are at length to be classed as automatic. It will be seen, then, that mental processes such as have just been alluded to are under the direction of a power that primarily calls them into being, and is more or less evident on each occasion of their repetition. To assign a name to this power would be difficult: it may be looked upon as mind in an active
becoming
u
2
298
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
form, in distinction to such mental movements as automatic, or performed without the consciousness of the individual; or as a modified volition; but as a special power it cannot be regarded. The conditions may be briefly stated as these: A certain thought, or series of thoughts, or a certain step of reasoning, due perhaps to some recognised stimulus, is at first performed consciously by the individual, and by conscious effort; at each repetition this conscious power or effort becoming or
conscious
are
less and less marked, and, as it would appear, less and less necessary for the proper performance of the mental movement. During the earlier repetitions the act is quite dependent on this originating or directing energy, but ultimately it would become in a way reflex, responding to a given stimulus without consciousness, and independent?so far as the individual is aware ?of any effort. Constant repetition causes the given mental action, as in the case of the physical action, to be organically registered in the brain centres. It would appear that to an injury of this power, whatever it may be named, we must look for an explanation of the mental symptoms of general Paresis. Now, it is evident that disorder of this mind-power will affect in the main two classes of mental actions?those, on the one hand, that are of quite recent origin, or that have not been repeated sufficiently often to render them organised or independent of the originating energy; and those, on the other hand, that from their indefiniteness, or from their intricate and elaborate nature, are still unable to be performed?although perchance often repeated?without conscious interference; just as those physical actions that are the most complex are the least or made reflex, and are the first to suffer in learnt, easily any case where the mental power is impaired. How these remarks bear on the psychological symptoms of General Paralysis of the Insane may now be considered. It is important to recognise the profound importance in the human mind of Self: nothing is of more general or more intense interest to man than Humanity, and Self is the segment of it with which he most certainly is the best acquainted. All human actions and qualities that are external are brought to Self as to a standard?not necessarily of excellence, but of comparison ; and it is by such comparison that one's defects or virtues become pronounced, and one's relation to the rest of humanity defined. From Self as it is man deduces an ideal Self as he would wish it to be. This is natural to all men, and it is an outcome of that eternal impression of one's weakness, real or imagined, that forms the basis for ambition and the desire for growth and improvement: so the cowardly man is, in his ideal, a hero, the weakling a tower of strength, and the man in need
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
299
moneyed idler. Around each man's Self there is a halo of unreality in which he lives and moves, as he would wish and aspire to live and move. All men more or less are dreamers, from the youth who rises from his novel a hero of romance, even
a
practical man who in his still speculations as unreal as his life
hours will have prois real; and there is not a man who has not drawn up and surrounded himself with an ideal Self, as a kind of standard of perfection to which he would be elevated. In the healthy-minded this finds no expression, and one is aware of the existence of such an ideal only, perhaps, from remarks dropped here and there: some wish, .it may be, if only his property were such, or his health perfect, or his condition this or that, from which one learns that he has placed himself under each of the imagined conditions, and has acted his new part, lived his new life, and moved in his new world?a world as unreal as the lotus-eater's, but with a foundation of fact and a structure raised on the ideal of the perfection of Self. But this halo of unreality with which the Ego of every man is surrounded, is not of an entirely indefinite character. A man does not picture himself as abstractly better or abstractly wealthier, nor is his imagined condition purely an abstract one: it has a character more or less precise: he is wealthier by the addition of so many fancied pounds, ennobled by this virtue or by that, and physically improved by such qualities as he most admires or considers himself most deficient in. Now we have seen that if the power to which all mental processes are due be impaired, those actions, amongst others, will be affected which are the most detailed and elaborate, the most varied, the least rigidly defined, and the least organically registered. Of all processes of mind those involved in the consideration of Self are certainly at once the most general and extensive, the most changeable and complicated, the most vague and the most ill-defined; and of all things, Self occupies in the mind the widest attention, the most frequent attention, and the most capricious attention. Assuming, as above suggested, that in General this mind-power, whatever it Insane of the Paralysis may be called, is the seat of the main lesion, the psychical processes concerned in the consideration o? Self will be the first involved, and will present the most prominent symptoms. In General Paralysis the constraining directing energy is impaired, and Self runs riot: not the actual Self, the mental processes connected with which are more automatic and are therefore still properly performed; but the ideal Ego, the man, not as he is, but as he has pictured himself, and as he would have himself to be. The complicated, ill-defined and flimsilv to the hard
jects
and
300
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
registered mind movements go first, the more precise and automatic still remaining intact. Thus the patient feels himself "perfect," or in his ideal state; he is "first-class," he ails nothing, he wants nothing; he is muscular beyond compare, swift of foot, and keen of vision ; everything is rose-colour, and his world one of self-gratification and enjoyment. The vague, intricate thoughts and ideas with which he has built up an ideal of himself have now free play. He is living in his fancied world; his day-dreams are being realised and perfection reached; in money matters he has his thousands?the thousands that have, perchance, formed often enough a part of his thought; his estates are limitless, his interest unbounded, nothing is lacking, and he is, indeed, all he has ever wished himself to be. The patient is a huge expression of Self, exaggerated and ideal, and presents no ideas nor delusions that are not selfish in He does not imagine, as others who are insane character. might do, that the world is upside down, or on fire, or that some' extraordinary event is about to happen: had he such delusions they would assuredly have still some relation to Self, and the world would have been upset by his own terrific power, or burned for his own gratification, or the event would have some on his own perfection and magnificence. bearing Then, again, the markedly obscene ideas which the patient generally presents may be covered by the same explanation. Every man who experiences animal passions, no matter how simple and exemplary his conduct may appear to the rest of the world, cannot fail under the impulse of such passions to imagine method of gratification; thoughts of this character, some which are the more defined the baser the intellect, are often repeated, and may assume a prominent part in the ideal Ego a man deduces from his actual Self. If the mind powers be impaired, these loosely formed and imperfectly organised ideas have free play when called into action by a proper stimulus, and, as the result, we have those expressions of obscenity which are often a marked feature of the disease. Religious ideas are of a somewhat less definite character, and do not afford so encouraging a scope to the selfish ideal, unless the individual be of marked religious tendencies. Expressions of religion are, however, frequent in the earlier stages of the disease, but very soon cease to be heard of, and are, as a rule, of a happy, smooth, and gratifying nature: the patient will, perhaps, spend many hours in prayer or in reading some religious book, or in what is apparently deep thought; or his ideas may assume a less meditative character, and he will imagine himself about to be made a bishop, or affirm that he is going to preach in a cathedral,
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
301
In the next place, it is to be remarked in regard to the patient's delusions that they are progressive?progressive in The first evidence of number, absurdity, and exaggeration. grandiose ideas is often slight, and the earlier notions will generally be found to have some actual and ascertainable basis; for example, a patient will state that he owes the sum of ?400, when it will be found perhaps that his mind has been much exercised of late about a bill of ?4; or again he will praise his muscles and extol his powers of running and his qualities as an athlete, while he presents a body markedly feeble and illconditioned. Now, could the day-dreams and romancings of many sane men be laid bare and exposed exactly as they pass through the mind, it is to be doubted whether they would appear one whit less ridiculous than the earlier mental symptoms of this disease, or even than the symptoms when the insanity is tolerably advanced. The drunkard, too, when in his cups, presents in a temporary form a mental condition akin to that of the general paralytic; the mental power becoming impaired by the poison, the least automatic mind actions have free play: the nature of those actions has been shown, and we see them displayed in the confident bombast, the exalted ideas, the general self-satisfaction and contentment. The tippler, rising from his glass, shares with the general paralytic his happy frame of mind, his ability to do anything and attempt anything, his increased possessions and his many personal excellencies; the flimsy intricate ideas out of which in his sober moments he has woven an ideal self are freed from the constraining power, and act to a given stimulus in the manner seen. So, too, many of the very old, from a gradual impairment of this mind power, present symptoms that may fairly cause them to be classed as general paralytics. We may meet with an example in some feeble old man of fourscore years, propped up in his chair, powerless of limb and vacant of mind, but with still one great idea of Self: Self is the one great topic that he harps upon from morning till night: there were no times like his times; no companions like his companions; in in other words, that is quite that is modem?or, everything out of the sphere of Self?there is only rottenness. No one knows more than he, or can boast a vaster experience. No one even now can manage his business as he can, and he would wish to see the man who could do this thing Or that better than
himself.
The symptom that illustrates, perhaps as well as any, the statement above made, that the disease consists in an unmasking of an imagined Self, is the occurrence of frequent fits of
302
PSYCHOLOGY OF GENERAL PARALYSIS OF THE INSANE.
melancholy and capricious sadness. These have their basis of reality in those sudden moments of doubt and despondency to which all men are at times subject, but those more especially whose ideas are lofty and aspirations high. In the youth full of ambition and romance it is perhaps most marked, and is recognised by a name ; in the great speculator or great dreamer it will come to mar his thoughts or mock his soarings, and is perhaps most present when a flash shows him the hopeless disparity between his dream and the reality. One other point of importance remains to be noted. As when there is any impairment of the originating mind energy, those mental processes which
are the least automatic or the mind are the first to show eviconstantly dependent dences of the injury, so those processes that are the most automatic are the last to be affected. This affords explanation in the present disease. For although the flimsy strange ideas connected with his ideal state are luxuriating, he will still present perfectly reasonable notions connected with his actual self. Thus a patient possessed of several thousands of ideal pounds, large estates, and magnificent connections, will yet, in answer to a direct question, state correctly in most instances the amount of his wages, however insignificant, and will own to a trifling 30s. a week, while in the same breath he will talk of his legacy of some thousands. The idea of his actual income has become from frequent and constant repetition automatic, and he answers accordingly. In like manner, he will state correctly the price of his garments, of any jewellery he might be wearing, while he will talk at the same moment of a suit of gold or a chain of diamonds ; and may consider his health perfect while acknowledging to certain past diseases, accidents, and infirmities. All such matters are familiar and defined, and being constantly passed in review in the mind, acquire a hold that the flimsy exaggerated ideas cannot lay claim to. The condition of the memory also presents characteristic features. Matters of recent occurrence that have had consequently but few opportunities for repetition, and that still involve consciousness when called into view, are of course far more directly dependent upon mind than matters of earlier date which have been so frequently repeated as to assume automaticity. So it will be found that the patient, while he will furnish with wonderful accuracy details of his earlier life, will yet give but a vague account of recent events, and will confuse dates and occurrences strangely. This defect in memory is often one of the most marked of the earlier symptoms of the disease, and is especially to be noticed in persons of business propensities and formal habits.
most
on
