Three per cent. of our patients suffer from epileptic mental troubles. In the course of epilepsy there arises gradually a typical degeneration of the brain. The degeneration is, however, only discoverable in severe cases and when the disease has existed for some time. If the attacks have only existed for a relatively short time, not more than a few years, the brain as a rule shows nothing. Seventeen per cent. of our patients suffer from progressive paralysis and senile dementia. Both diseases present characteristic changes in the brain. In paralysis there is most extensive shrinkage of the brain, so that the cortex is often reduced by one half. The frontal portions of the brain more especially, may be reduced to a third of the normal weight. There is a similar destruction of substance in senile decay.
Fourteen per cent. of the patients annually received are cases of poisoning, at least 13 per cent. of these being due to alcohol. As a rule in slight cases nothing is to be found in the brain; in only a relatively few severe cases is there shrinkage of the cortex, generally of slight degree. The number of these severe cases amounts to less than 1 per cent. of the yearly cases of alcoholism.
Six per cent. of the patients suffer from so-called maniacal depressive insanity which includes the maniacs and the melancholics. The essence of this disease is readily intelligible to the public. Melancholia is a condition of abnormal sadness without disorder of intelligence or memory. Mania is the opposite, the rule being an abnormally excited state with great restlessness; likewise without deep disturbance of intelligence and memory. In this disease there are no demonstrable morphological changes in the brain.
Forty-five per cent. of the patients suffer from the real and common mental disease called dementia præcox. The name is a very unhappy one, for the dementia is not always precocious, nor in all cases is there dementia. Unfortunately the disease is too often incurable; even in the best cases, in those that recover, where the outside public would not observe any abnormality, there is always present some defect in the emotional life. The picture presented by the disease is extraordinarily diverse; generally there is some disorder of feeling, frequently delusions and hallucinations. As a rule there is nothing to be found in the brain. Even in cases of a most severe type, lasting for years, an intact brain is not infrequently found post mortem. In a few cases only certain slight changes are present which, however, cannot as yet be reduced to any law.
To sum up: in round figures a quarter of our insane patients show more or less clearly extensive changes and destruction of the brain, while three-fourths have a brain which seems to be generally unimpaired or at most exhibit such changes as give no explanation of the psychological disturbance.
These figures offer the best possible proof that the purely morphological view-point of modern psychiatry leads only very indirectly, if at all, to the understanding of the mental disorder, which is our aim. We must take into account the fact that those mental diseases which show the most marked disturbances of the brain end in death; for this reason the chronic inmates of the asylum form its real population, consisting of some 70 to 80 per cent. of cases of dementia præcox, that is, of patients in whom anatomical changes are practically non-existent. The psychiatry of the future must come to grips with the core of the thing; the path is thus made clear—it can only be by way of psychology. Hence in our Zürich clinic we have entirely discarded the anatomical view and turned to the psychological investigation of insanity. As most of our patients suffer from dementia præcox we were naturally concerned with this as our chief problem.
The older asylum physicians paid great attention to the psychological precursors of mental disorder, just as the public still does, following a true instinct. We accepted this hint and carefully investigated the previous psychological history wherever possible. Our trouble was richly rewarded, for we often found, to our surprise, that the disease broke out at a moment of some great emotion which, in its turn, had arisen in a so-called normal way. We found, moreover, that in the mental disease which ensued a number of symptoms occurred which it was quite labour in vain to study from the morphological standpoint. These same symptoms, however, were comprehensible when considered from the standpoint of the individual's previous history. Freud's fundamental investigations into the psychology of hysteria and dreams afforded us the greatest stimulus and help in our work.
A few instances of the latest method in psychiatry will make the subject clearer than mere dry theory. In order to bring home to you the difference in our conception I will first describe the medical history in the older fashion, and subsequently give the solution characteristic of the new departure.
The case to be considered is that of a cook aged 32; she had no hereditary taint, was always industrious and conscientious, and had never been noticeable for eccentric behaviour or the like. Quite recently she became acquainted with a young man whom she wished to marry. From that time on she began to show certain peculiarities. She often spoke of his not liking her much, was frequently out of sorts, ill-tempered, and sat alone brooding; once she ornamented her Sunday hat very strikingly with red and green feathers, another day she bought a pair of pince-nez in order to wear them when she went out walking with her fiancé. One day the sudden idea that her teeth were rather ugly would not let her rest, and she resolved to get a plate, although there was no absolute need. She had all her teeth out under an anæsthetic. The night after the operation she suddenly had a severe anxiety-attack. She cried and moaned that she was damned for ever, for she had committed a great sin; she should not have allowed her teeth to be extracted. People must pray for her, that God might pardon her sin. In vain her friends attempted to talk her out of her fears, to assure her that the extraction of teeth was really no sin; it availed nothing. At day-break she became somewhat quieter; she worked throughout the day. On following nights the attacks were repeated. When consulted by the patient I found her quiet, but she wore a rather vacant expression. I talked to her about the operation, and she assured me it was not so dreadful to have teeth extracted, but still it was a great sin, from which position, despite every persuasion, she could not be moved. She continually repeated in plaintive, pathetic tones, "I should not have allowed my teeth to be extracted; oh yes, that was a great sin which God will never forgive me." She gave the impression of real insanity. A few days later her condition grew worse, and she had to be brought into the asylum. The anxiety-attack had extended and was persistent, and the mental disorder lasted for months.