Textbook of Disturbances of Mental Life
(or the Disturbances of the Soul and Their Treatment)
Johann Christian August Heinroth
1818 AD
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Introduction:

In 1818 AD, Johann Christian August Heinroth, Doctor and Christian, invented the term "psychosomatic". He clearly stated that insanity was not a bodily illness, but a spiritual choice that violates the conscience that is caused by sin and selfishness: "They [mental illnesses] all have a common starting point, a main principle to which they are subordinated: selfishness". "This presents a difficult problem indeed for the world-man and the Self-man, who, till now, has been accustomed to live and seek his consciousness in these two elements alone. Nevertheless, if the voice of his conscience has indeed come awake, he will have no other choice. He must either live in permanent dissatisfaction, permanently divided against himself and his destiny, or else must obey the demands of his conscience, which is his only means of preserving unity and harmony within himself. His only other course is to deliberately kill his conscience, and thus gain apparent peace of mind bought at the price of self-stupefaction."

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He then goes on to reject all the humoral the causes that most other doctors believed caused insanity. This is remarkably way ahead of his time for a doctor: "The views held on this subject, from antiquity to our own days, are almost ridiculous: black and yellow bile; the melancholic juices in general; the darkened spirits of life; malignant demons; the moon; excessive elasticity of brain moisture; diseased congestion of the cerebral vessels; sthenia or asthenia (excitement and collapse) of the brain (even though these two ideas are not without importance); each of these has at one or the other time been held to constitute the immediate cause, and the immediate cause was usually confused with the disease itself." Heinroth adopts the Christian view that man has a distinct body and soul: "Our inner being, or our inner I, is our soul, while our external Self is our body." Heinroth openly discusses the fact that many doctors believe that insanity is a bodily illness. He rejects this entirely: "A great controversy centers on the question whether the various forms of morbid conditions of the psyche originate and have their seat in the life of the soul, or in the body, namely, in an overexcited, deranged, decayed, disorganized brain ... there is still a tendency to attribute the cause of mental disturbances to the bodily rather than to the spiritual side. To this we have already answered: the body alone is nothing, it has no significance in itself, but only as related to the soul or to the spirit in the wider meaning of the word, since in this life it is the body which is the carrier, supporter, and tool of the soul and of the spirit. This is most clearly indicated by human consciousness, without which there is no human life; and who would contradict his own consciousness?" Heinroth understood that often, there was nothing physically wrong with the insane. "The complete concept of mental disturbances includes permanent loss of freedom or loss of reason, independent and for itself, even when bodily health is apparently unimpaired, which manifests itself as a disease or a diseased condition, and which comprises the domains of temperament, diseases of spirit and will." Heinroth believes that the insane have brought it on themselves by their own choices: "A man is not an animal ... his consciousness, his reason, lead him towards the Deity. That this so rarely happens is his own fault; and this guilt gives rise to all evils that beset him, including the disturbances of the soul." He places the blame for those who are insane squarely upon themselves, their personal choices and self deception: "Anyone imprisoned by passion is unfree and unhappy. The man who is fettered by passion deceives himself about external objects and about himself. This illusion, and the consequent error, is called madness. Madness is a disease of the reason and not of the soul, but it originates from the passion within the soul." Heinroth understood that the mind can make the body sick and the body can affect the way one feels, he believed that in the majority of cases, insanity was caused by the soul alone. "no longer inquire if the soul disturbances are bodily affections (we fully agree that they cannot take place without a bodily affection, but just as firmly deny that their source is in the body) ... For the same reason, the totality of mental disturbances must not be denoted as diseases of the soul organ, because even though the entire body, which is certainly a soul organ, is able to give rise to mental diseases, in the great majority of cases it is not the body but the soul itself from which mental disturbances directly and primarily originate, and it is these disturbances which then affect the bodily organs indirectly." ... "For if we tentatively assume that the body is the materialized soul which has entered the darkness of corporeality, we firstly facilitate the explanation of the mutual interaction between body and soul: for since the body was born of the soul and thus is a part of it, the soul can act on the body, and the body, which is of the same origin, can react on the soul." He states that sin is the etiology of madness and that being insane is actually a sinful state itself like "living common law". Thus he sees all insane as lost souls to the Devil. It important to remember that he also rejected demon possession as a cause of insanity: "A man who stumbles about, with much pain and vanity, in passion and in madness, leads a foolish life, and folly is the sum total of the activity of passion and madness. However, all action originates from the will, and if this will follows and panders only to the compulsion of passion and to the illusions of madness, while ignoring the voice of the as yet undeveloped reason, that is, the conscience, for the sake of freedom and independence, or the voice of matured reason with its clear consciousness of a life of duty, we have a state of recognized sin, and if it is continued and becomes a constant habit, it is vice. ... All three are states of slavery; but while the birth of passion and madness is not voluntary, vice originates from a free will which has made a free choice against good and which has passed to the opposite side in defiance of the call of conscience. Those living in passion and madness merely fail to conduct their lives according to the rule of good (are godless), but those living actively in vice worship evil (are sons of Satan)." Heinroth realizes that his view (evil causes of insanity and the state of insanity itself is evil) is rejected by his fellow "mad doctors" of his day: "Thus, both the inclination and the stimulus, and their product, must be definitely recognized as evil. This consideration is completely ignored by conventional views on the morbid conditions of the psyche." Heirnroth, as a Christian, sees a loving God calling a rebellious man to himself. When man on the basis of his own free will rejects God, sometimes the result is insanity. This is the foundation of his etiology of madness. It is not the fault of the Creator, Who communicated His nature to us and then left us free, but the fault of the man who voluntarily abandons this nature. ... The man who scorns this repeated summons and is content with and stays only in the non-Divine existence and life will become enslaved by the non-Divine and lose his free will; ... A prey to passions, madness, and vice, the creative processes will be impeded, halted, and forced back in many different ways. Thus, ... we arrive at the concept of a disturbed mental life, or, in short, disturbance of the soul. Heinroth recognizes that not all sinners destined for hell are insane. He describes a group of "lost sinners" who are on their way to insanity, though they still retain free will: "All passions, follies, and vices, all prejudice, all meanness, all malice, all wickedness, all dishonesty of individuals and the masses, and all effects, results, and products of perverted activities, and perverted life in general, are just so many spurs to evil, so many weights imposed on the soul to pull it down into the kingdom of gravity, darkness, and slavery. ... But unless a powerful stimulus gains sway over this sick soul and pulls it into the sphere of an actual disturbance of the soul, only the inclination to evil will persist, and the life of this individual, though joyless, dreary, and oppressed, will not be devoid of consciousness and free will." Heinroth does not believe church preachers should be involved in curing insanity. His logic is this. Since insanity is a states of "unfreedom" the "talking cures" preachers provide are of no use. This is why all his treatments are physical moral treatments and punishments. "The clerics, as the recognized shepherds of the soul, are just as unfit for the tasks". But he also defrocked all the atheistic chemical psychiatrists of today who are absolutely ignorant, or violently opposed to God, Christianity, the Bible and the spiritual outlook of man. "It is the purpose of the doctor of the soul to bring the mentally disturbed, whose inner life is totally darkened, back to light. But how can he do this if he himself does not live in light? It is necessary to sharply emphasize this point of view of the doctor of the soul. Whoever cannot make this point of view his own must give up the name and the power and the business of a doctor of the soul." Heinroth takes the unusual position that although man becomes mad on his own free will choices, once full insanity has set in, the man becomes "unfree" and is no longer to be held responsible for his crimes. This is the earliest concept of the insanity plea in Germany. About 50 years later, the insanity plea was first used in England. "But we must not forget that in a true mental disturbance each of these disorders must occur to an extent equivalent to complete, permanent loss of freedom ... For the moment at which unfreedom makes its appearance and clearly manifests itself by unnatural, i.e., unreasonable, actions, behavior, words, glances, or gestures, that is the moment of this procreation. From this moment on, the man has lost claim to the kingdom of freedom, to the kingdom of the spirits, at least for as long as he remains in this cycle. He is an automaton: his thinking, his sensation, his activity, proceed in a mechanical manner, no matter whether it appears as if they were determined by himself. They are in fact determined by urgent impulses only, if they are controlled at all." He argues that the murderer who is insane cannot be held responsible for reason of insanity: "A murderous or a predatory attack, or a public insult and abuse can set a man entirely beside himself; and this is confusion in the highest degree. ... This condition is unfree, and a man cannot be held responsible for the consequences thereof, except if it can be proved that the condition was self-inflicted, or else that he could have prevented it from arising. ... The state of a compulsive urge occurs if somebody, without being confused, is still unable to resist the urge to commit an illegal action. The urge itself is called compulsive, since it is not voluntary but is guided by a compulsive stimulus. Heinroth states that the mad doctor alone determines if a person is "unfree" and can invoke the insanity plea. "This will be easy for the physician to determine once he has observed the type and the degree of the unfree state." Heinroth has 9 type of insanity, all of which are unfree: "Insanity, Dementia, Rage, Melancholia, Idiocy, Apathy, Insane melancholia, Confusion, Timidity" Finally, Heinroth employs all the forms of "moral treatment" that all the other mad houses were using. He gives great details on how to run an asylum and specifies a building that could be viewed in hind sight as a torture chamber: "A special building must be set aside for the physical treatment of the mentally disturbed. This building should have a special bathing section, with all kinds of baths, showers, douches, and immersion vessels. It must also have a special correction and punishment room with all the necessary equipment, including the Cox swing (or, better, rotating machine), Reil's fly-wheel, pulleys, punishment chair, Langermann's cell, etc." (Textbook of Disturbances of Mental Life and Soul, Johann Heinroth, 1818 AD)

"In short, for Heinroth it is not loss of reason, which psychiatrists would now call loss of the ability to test reality, that characterizes madness or "true insanity"; it is instead loss of freedom. What Heinroth meant by loss of freedom is exactly the same as what psychiatrists, and others, now mean by lack of rationality, competence, or responsibility—namely, that the "sick" person is not behaving properly, that he is not acting of his own free will, and that his conduct should, accordingly, be constrained and controlled by those who know better and can therefore safeguard his "best interests." Still firmly planted in a religious conception of life, Heinroth understood more clearly than most contemporary psychiatrists that we call persons mad or mentally ill who behave badly—that is, whose conduct does not conform to social expectations but is, instead, "selfish" or under the sway of his "passions." The cause of all mental disease, according to Heinroth, is selfishness or sin, two terms he often uses synonymously." (The Myth Of Psychotherapy, Thomas Szasz, 1979 AD, p70)

"Heinroth's assertion that the insane lack freedom—"individuals in this condition exist no longer in the human domain, which is the domain of freedom"—is a strategic claim. Because the patient is unfree, the psychiatrist is justified in coercing him: medical control is treatment, psychiatric oppression is liberation." Referring to patients for whom Heinroth believed recovery was possible, he wrote: —What is needed in such cases is constraint, which is in no way cruelty or inhumanity, but necessary for the reeducation of such patients to the norm of reason.... For as long as such and similar patients have their will, nothing can be done with them." Heinroth's aim was to justify not only torture as treatment but also the medical profession's monopolistic control over the study of "mental disturbance" and the treatment of the mental patient: "Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment!"50 Under the revealing heading "Medicina Psychica Politica" [Psycho-Political Medicine], Heinroth declares: "It is the duty of the state to care for mentally disturbed persons whenever they are a burden to the community or present a public danger."5' Ipso facto, the psychiatrist is an agent of the state. According to Heinroth, "They [mental disturbances] all have a common starting point, a main principle to which they are subordinated: selfishness." In contrast, "The doctor of the soul (or psyche)...has overcome selfish interests and treats for purely humanitarian reasons."" (Coercion as Cure, Thomas Szasz, 2007 AD, p 75)

 

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Textbook of Disturbances of Mental Life or the Disturbances of the Soul and Their Treatment, Johann Christian August Heinroth, 1818 AD

Johann Christian August Heinroth

1818 AD

I. BASIC CONCEPTS

Chapter One

THE CONCEPT OF MENTAL LIFE

§ 1. The common features of human life and the life of all known living things are sensation and movement. On the other hand, a feature characteristic of human life only is consciousness. Life develops towards this, and is then accompanied by it up to its final extinction. Though man is able to live without consciousness, he can do so only at the level of plants or animals.

§2. Breathing and digestion, as well as propagation through copulation, are common to man, animal, and plant; the phenomena of sensation and motion, necessary for self-preservation, are common to man and beast. However, human life is meant to be lived consciously, at the various levels of consciousness; it is indeed the objective of human life to attain the highest level of consciousness.

§ 3. Consciousness itself is the awareness of existence. But the type of this existence, like the kind of knowledge, is very different at the inception of human life, its middle period, and its termination; it also varies in a general manner and can be more limited or freer, weaker or stronger, lower or higher. Hence the various degrees of consciousness.

§ 4. The lowest level of consciousness, and thus also the lowest level of human life, is represented by the child, the primitive man, and primitive peoples. It is merely the consciousness of the external, of the surrounding world. At this level even man himself is only the world, the external, the object. He is all senses; he is a sensual being; his perceptions, feelings, and desires belong to the external world which fills him with joy or with sorrow depending on whether it is friendly or hostile to him. Pleasure is his aim, and the casual happening is his deity.

§5. Man will rise to the second level of consciousness as soon as the various activities of his developed senses have awakened his reason and his perceptions crystallize into ideas. At this stage, the knowing in man becomes its own object; the Self in man, hitherto bound to man's surroundings, now comprehends the idea of the I. In contradistinction to world consciousness, man becomes conscious of his own Self which represents the essence of his entire corporeal and mental existence. It is this integral, indivisible whole which represents the Self. This is the individual man. The concepts humanity and the Self are fully identical.

§6. It is in vain that we attempt to separate the soul from the body or the body from the soul. The concepts of I, man, individual, invariably imply the oneness of body and soul. We are aware of having a body only if we oppose something internal, that is, the Self, against something external in ourselves. Our inner being, or our inner I, is our soul, while our external Self is our body. Thus, there is only one Self or I (individuum) of man which consists of body and soul, of the internal and the external, and the one cannot be thought of without the other. It is not a union of two different things, but a single life which has developed in two directions: externally (in space) as body, internally (in time) as soul. In the same way as a tree forms a root system under the ground, while forming a trunk and a crown above the ground. The part of the tree which lives in the dark bowels of the earth is like the body of the tree, while the part of the tree which is visible in daylight above the ground is like the spirit of the tree. And who would deny that the roots and the crown are parts of the same tree and that they are both included in the idea of the tree? The visible and the invisible form one whole and are not merely indivisible but are not even different in kind.

§ 7. It is this soul which dwells in the consciousness; first as something with feelings, sensitive to joy and pain, and striving to satisfy its innate needs, and in which the satisfaction or nonsatisfaction of these desires appears as disposition or heart. Later the soul appears as a spiritual creative power, or spirit, combining sensual perception with intelligent creation. Finally, the soul is will, that is, the energy which drives the soul itself to action. The soul is thus disposition, spirit, and will which are fused together in a single consciousness but act in a separate manner while remaining in an organic harmony.

§ 8. Self-consciousness represents a substantial transformation of consciousness. The self-conscious man perceives the difference between his own Self ( §5) and a world which acts upon him and to which he reacts by his own action, so as to ensure his independent preservation and to use it for his own aims. These aims are invariably directed towards his own Self, just as they originate from his own Self. Whatever man does is for the sake of his Self, his own person. To him the laws of his own understanding are the supreme and the most compelling rules governing the world. His aim is independence, and necessity is his deity.

§9. The majority of educated human beings are found at this second level of consciousness; however, most of them remain in the lower sphere of consciousness without holding any definite concepts on their own identity or the purpose of their own lives. Their existence is fulfilled by the mutual relationship between their own Self and the surrounding world. It is their sole purpose to ensure, each one in his own manner, their existence and meanwhile to enjoy the world. Consequently, for them there exists nothing but themselves and the world, that is, nothing except something inside themselves and something outside themselves. Any other ideas they may hold do not originate from their self-consciousness, since this self-consciousness has the Self as the only focus and the only reference point. The law governing this stage of consciousness is: everything for the sake of the Self and for the sake of one's own existence.

§ 10. The highest, last stage of consciousness develops only in few people, even though the seed of the highest consciousness is found in all of us and is striving to grow, just as the self-consciousness has grown out of world- consciousness. Just as self-consciousness originates from the opposition of the internal to the external, so too does the highest consciousness originate from an internal opposition in the self-consciousness itself. We all begin to experience this opposition early in life, even in our childhood. Opposed to the Self and to the strivings of the Self, there arises a contradiction within the self- conscious man. This contradiction, though experienced in the Self, does not originate from the Self itself but from a higher activity in the Self which we call conscience. This conscience, which appears as a mere internal feeling in the self-consciousness, is the seed of the highest consciousness. In its initial appearance as feeling it is not yet aware of itself but is merely contained by and included in our self-consciousness.

§ 11. Conscience is a necessary natural phenomenon which appears inside ourselves just as inevitably as the senses or the limbs appear in the external man. However, it is only a seed which, like any other seed, must be nurtured and cared for if it is to assume the definite, living form which it was intended to assume, namely, the highest, the perfect consciousness. Many of us do not even suspect that this seed could grow, and such people therefore never promote its growth. In most men conscience lives only as a seed; in some of them (we do not like to say in many of them) it is smothered and robbed of its vital force by the overwhelming weight of world-consciousness and self- consciousness (the struggle for possessions and for existence). In a few individuals, who are the most pitiable of all, it has dried out and died, leaving the undisputed victory to selfish, animal desires.

§ 12. Let us now turn away from these men to those who carry within themselves this germ of highest consciousness and life, though not recognizing it for what it is. The conscience, this stranger in our Self, who has come to us we know not how, not from outside but from inside, appears in our Self as a monitor, as a warner who demands something which should be there but is not. In short, this is an antagonist of our world life and our self-life. This unwelcome appearance interferes with our day-to-day activities and with the quiet course of our accustomed daily life. As to a man wandering in a labyrinth, our conscience, like a compass needle, shows us the clear, straight path which we must follow if we wish to be at peace with our soul and attain the haven of happiness towards which we wish to sail with all our might.

§ 13. And wonder of wonders! Our conscience does not deceive us. At every step of the way on which we follow it we feel a wonderful harmony of our soul with the world and with itself, such as could not be attained by any of our former worldly and selfish efforts. This unity, peace, clarity, inner joy, would be unthinkable at lower levels of consciousness. But this state is not yet that of the highest consciousness; it is only our own self-consciousness, filled with a wonderful, strange purity and clarity, which persists for only as long as we do not think about the world and about Self. But since such thoughts always come back all too soon, this condition of inner joy immediately disappears, and we are once more left exposed to the darkness and confusion of our everyday existence.

§ 14. Only as long as we do not think about the world or about ourselves will that happy state persist. It is not as if we could or should forget the world or the Self, it is only that we ought not to live in them, for them, or through them, for our conscience requires that we should live on the higher plane on which we have experienced this state of joy. We should not forget the world and the Self or expunge them from our memories, should not erase them from our feelings and thoughts or exclude them from our activities; but we must no longer belong to the world and to the Self and must deny them in so far as we no longer acknowledge them as our masters, guides, or sources of happiness.

§15. This presents a difficult problem indeed for the world-man and the Self-man, who, till now, has been accustomed to live and seek his consciousness in these two elements alone. Nevertheless, if the voice of his conscience has indeed come awake, he will have no other choice. He must either live in permanent dissatisfaction, permanently divided against himself and his destiny, or else must obey the demands of his conscience, which is his only means of preserving unity and harmony within himself. His only other course ( §11) is to deliberately kill his conscience, and thus gain apparent peace of mind bought at the price of self-stupefaction.

§ 16. Briefly, just as the demands of a sensual consciousness or of a world consciousness concentrate on mere being or on mere enjoyment of life, while those of self-consciousness concentrate on the self-existence or on Self, so the demands of conscience concentrate on a non-self-existence. However, this negative demand is meaningful only as long as the demand originates from the conscience, that is, from something foreign to self-consciousness. As we continue to satisfy, more or less willingly, the demands of this stranger, a change takes place not only in the motives of our actions, but also in our point of view, and the negative demand for unselfish action appears to us as something loftier, as a positive demand for self-devotion, that is, for love.

§ 17. This exalted point of view and its consequences will become ours if we abandon ourselves honestly and truly to the compass needle of our conscience, if we become interested in our conscience, surround it with loving care, and if we accustom ourselves to live in the initially foreign element of our conscience, its views and interests. As we do this, our point of view changes: we step out of our own Self, just as we formerly stepped out of the world into the Self, and the new country which we have entered now becomes our home and the stage of our life. Our own Self and the world have retreated into the background; we now live for things other than the world-interest or the Self-interest, and the life which is now opening before us is another, higher life, which can only be lived through sacrifice and abandonment of the previous life for the sake of the world and of the Self.

§ 18. However, a man always cares most for his dearest treasure. Our sacrifice of the world and of our Self is merely a stake erected to bring the highest prize; once we have reached the peak, anything less will be as nothing. But this higher thing, which we cannot find either outside us, in this world, nor inside ourselves, in our selfish ego, must necessarily be found above us and manifests itself in the conscience and through the conscience, so that this conscience, with unimpaired activity and effectiveness, continues to spread through our innermost being to fill our entire consciousness. It then displaces all lower consciousness and itself becomes a new kind of consciousness and is no longer felt as something foreign, as conscience, since it is no longer opposed in its own domain. Its strength and effect are now displayed differently than before: as something perceiving, that is, as reason.* Reason is thus the highest consciousness.

§19. We perceive by our reason the higher things, that which is above us, which means that reason is our sense of things which are higher than our Self and the world; for the action and the effect of each sense is to perceive, to feel, to learn. Thus, if consciousness is indeed an inner sense, as it must be since it is the center of all perception, it follows that reason, as the highest consciousness, is the inner sense intensified to the highest degree. Since world-consciousness and self-consciousness are capable of perceiving only the finite things which are limited in time and in space, and since reasoning consciousness is opposed to these two kinds of consciousness, it follows that reasoning consciousness, or reason itself, is the sense of the infinite, the unlimited, the eternal. This is the Higher Thing above us which initially manifests itself, namely as conscience, in the feeling, that is, in the dark consciousness, and later in the reason, being the purest, clearest kind of consciousness. For reason is the source of light of our entire being, at the same time our inner light and our inner eye.

§20. Only he who has seen this reason, this inner light, can grasp and understand it; but darkness, that is, mere world consciousness and Self- consciousness, cannot do so. For this man there exists nothing higher than the world and the Self, the outer and the inner things, space and time. External things are a fable for him, yet it is in the Eternal that reason dwells. The Eternal is a free, holy being; if He is received into the highest consciousness, He fills the soul, then cleansed from all low feelings, with inexpressible joy, and manifests Himself as the true, eternal existence and life.

* [The German word for "reason," "Vernunft," is derived from the German expression for "perceiving," "vernehmen" — a connection clearly emphasized in the German text.]

§21. From the point of view of reason, the life of the world and the life of the Self, though not an illusion (as many would like them to be), are not true existence either; they are merely growth and development, but life on the highest plane is the summit and consummation of living existence. For just as there is no such thing as a dead existence, the name existence can only rightfully be given to the perfect, unchangeable life. This life means solely living in reason, in light, in love, in holiness, and in God.

§ 22. God, holiness, eternity, a fulfilled life, manifest themselves to reason and to reason alone. God will come into being and He is for us only inasmuch as we are aware of Him and experience Him in reason and through reason. It is only through reason that we can reach God. (No man can come to the Father save through Me.) Whoever fails to use this highest sense cannot develop; he is like the blind and the deaf: for him the object is not there, because the sense for it is absent. It is useless to seek proof of Divine existence, life, and activity for those who do not themselves see or hear God and do not perceive Him. Who could explain the beauty of a picture to the blind or the beauty of music to the deaf? The development of reason, that is, the growth of conscience to a consciousness filling our entire being, is the condition of a truly human, that is, a free and blessed, life.

§23. For it is the purpose and the destiny of man to be free and happy, even in this life and not only after death, to develop the immortal in himself, and thus to render himself receptive in this life for this eternity, for the everlasting and boundless happy life which will be his lot after the spacetime-bound form has perished. Only the man of reason, in whom reason dwells and whom it wholly possesses, is aware of this destiny; he is aware of it with a certitude equal to that of life and consciousness, which is identical with consciousness and life itself. But the man of reason also knows just as surely that a selfish man of the world can know nothing and believe nothing of this destiny. Such a man must stake the true life and true existence on the earthly, time-space existence and material possessions; and, whether he knows it or not, he remains a slave to the world and to his own Self. As long as he maintains this viewpoint, he can never attain lasting peace, security, and joy.

§ 24. The essence of human life is contained in the conception of these levels of consciousness. It follows that human life is different in each man, since consciousness is different in each man. This in no way signifies that human life remains at the mercy of accident, but rather that the laws of nature which fill the world and ensure its perpetual development also fill and stimulate the internal being and life of individual men and of the human race towards a gradual organic growth from the lower to the higher stage. The forces of nature, however, do not do this, as they do in the external world, by exerting the violence of necessity, but rather by gentle guidance and direction in the only one on Earth who was created free. Though it is due to necessity that world-consciousness develops in a child, that self-consciousness grows out of world-consciousness to become an independent entity, that conscience, which is opposed to self-consciousness, rises above it; but while these three stages of consciousness are indeed like the roots, the trunk, and the crown of a tree, in which the crown bears an abundance of flowers and fruits, it is nevertheless not with the same measure of necessity that the roots and the trunk of human consciousness yield the flowers and fruit of human life, namely, the developed reason and its subject matter — being the world of truth and beauty and peace and light and love. And it depends on man himself whether he loses himself in earthly existence and accumulation of possessions or avoids this course and denies the world and Self to follow the Guiding Spirit Who opens up to him, already in this space-time world, a dwelling place which offers him eternal existence and an eternal world. Of these, the space-time world represents only a fragmentary image, a preparatory stage, a school for growing.

Chapter Two

THE CONCEPT OF A HEALTHY MENTAL LIFE

§25. We feel healthy if we feel perfectly well, if no feeling of helplessness overwhelms us, if we are not suffering from any pain which impairs our activities, and, generally, if our willing, joyful activity is not impeded by any obstacle offered by body or soul. Men whose entire life is devoted to the body and who use their souls and their consciousness to fill their bodies only will consider themselves healthy if their bodily welfare is unimpaired and if the organic processes which maintain the existence and activity of the body are not disturbed. But the man who considers himself to be not only a bodily but also a spiritual being, with a spiritual life which is his proper element; a man who refuses to separate body from soul and is present with his soul at each bodily function, while giving the body its share of the soul; to whom body and soul are equally holy, since the former is only the external embodiment of the soul, while the latter is to him the inner rendering of the body (§6) — such a man will not experience half-health or a health of one-half of his being. For just as his outer and inner Self, his body and his soul, are the same Self and the same life, with a complete harmonious mutual interaction between the two (except that the action of the external, bodily Self is unconscious, while that of the internal, spiritual Self is conscious), so too his feeling of well-being comprises both body and soul, and he will feel healthy and well only if he is outwardly and inwardly comfortable and free. He will then be in a state of human health.

§26. This state of human health inevitably and inseparably comprises bodily health, since a man cannot exist without a body. But it just as inevitably and inseparably comprises spiritual health, which penetrates bodily health and is penetrated by it. Mental (spiritual) health is so rarely experienced, and is experienced by so few people as the true condition of life, because few people can perceive as vividly with their inward sense as with their outward senses, and also because mental health cannot be experienced if it is in fact absent. We are so accustomed to compensate for our mental discomfort by catering to bodily comfort that we are ready to assume that inward peace and satisfaction are not of this world. We patiently bear sickness and upsets in the spiritual Self and gradually learn to consider them as being almost natural; but we compensate by being doubly concerned with the welfare of our bodily Self and with our material life.

§ 27. Whoever adopts such an attitude has no sense for human health and no idea of it. An inward sense must be completely awakened ( §19), and with it an interest in life on a higher plane and in a feeling for life, if the need and the desire to retain this feeling as a part of our well-being is to arise in us. Once this awakening has taken place, the needs of the inner sense are stimulated and we find neither peace nor quiet nor a feeling of comfort until this sense achieves its object, which is holiness ( §20), and becomes forever impregnated with it. The vital feeling which results is imparted to the whole man and uplifts body and soul into a joyful, pure, refreshing, strengthening element of free existence. It is as though the man be lifted from a domain of darkness into a kingdom of light, his real element, in which for the first time he can breathe freely and move freely.

All bonds which pressed on him fall away, all painful desires and wishes which disturbed his feeling of complete well-being are silenced. His view of the world and of his own soul is clear and serene. The all too frequent feeling of physical impotence emanating from mental incapacity disappears, to be replaced by a joyful feeling of strength pervading his whole being. All feelings, thoughts, and desires are purified and uplifted, and harmonize with one another. The whole man is filled with and pervaded by a joyful, active vitality. The feeling of this harmonious, serene vitality, the delight of which cannot be compared with any feeling of pleasure on a lower plane, is the true state of human health.

§ 28. A man in this state of mind, into whom heaven itself seems to have entered, has not thereby escaped the earth in any way. He enjoys, acts, and thinks as other people do, but not in the same manner, that is, not on the same level. While others lose themselves in pleasure and become slaves to it, or else languish from painful privations, he enjoys the pleasures of external life soberly and moderately and becomes their master, since he is also his own master. Privations only intensify his inner strength and compensate him for the lack of external pleasures by giving him the feeling of inner freedom and independence. While others are driven to and fro by their fears, cares, and doubts born of an unstable disposition and an uncertain spirit, he is of good cheer, secure in his faith, and certain of the future. In his feeling of the higher life, he carries the assurance of all the gladness which will be his in time or beyond time. And when others give up in despair, he goes about his work with enthusiasm, without worrying about the future, and completes another joyful day of labor.

§29. To him earth is neither heaven nor hell, but an exercise ground for developing his strength, and for increasing it to a maximum. He participates in everything created by art, discovered by science, that strives for a common goal, and spreads goodwill and generous friendliness. He takes part in all these activities insofar as his aptitudes (talents) enable him to. He lives in others and for others no less than in and for himself; one may indeed say that he lives mostly for the sake of others. He is tolerant of everybody, bears with everybody, and takes everybody as he is, according to his station in life, in nature, his failings, and imperfections. For he knows that he, too, has serious failings, and does his very utmost to eradicate them, gently in others, ruthlessly in himself, since they represent obstacles to a true and fulfilled life.

§ 30. He is enchanted and excited by everything beautiful, good, and magnificent which he finds in humanity; he receives it with love and appreciation and uses a successful development in others as a model for his own development. The past and the present worlds are thus holy to him. He takes his place joyfully and eagerly in the ranks of the elite marching towards the aims of humanity. In this mood we find him every morning after awakening and every evening when his day's work is done. His life is filled to an ever- growing extent with purity, joy, and full strength, and the anticipation of this fulfillment makes him happy and gives the highest stimulus and greatest zest to his feeling of human health.

§ 31. Such a state of human health does not depend on the outer world alone and on bodily health but has its roots in the innermost soul of man, and can be achieved and maintained only if the fully developed inner sense, which includes the outer senses and the man himself, is carefully nurtured and tended. The healthy man feels himself lifted into a freer atmosphere and carried through it by a higher power. The free vital feeling in him rushes through all his nerves and veins; his feeling is that of a man who was tired and now emerges from a refreshing bath. His blood flows easily, all his senses are awake, and all his movements are easy and forceful. But these feelings, impressions and motions are received into a consciousness and emerge into the external bodily being from a consciousness. This is not supported by and does not exist within itself, in isolation, and is even less determined and bound by the influence of the outer world but clings to the inexpressible, holy, eternal Being, Who fills it and enchants it. This ever-flowing spring is its only source of nourishment and provides it with strength and light and love: strength for the will, light for the spirit, and love for the soul.

§32. Thus the healthy state of man is achieved. Is it an illusion? , a dream? , or only an ideal which cannot be attained on this earth? This question can be decided only by those who have already experienced this state, even if only for a few, most beautiful moments of their lives. Its reality is proved by its possibility, and additional proof is afforded by our natural tendencies and capacities, the entire organization and entire course of development of our consciousness within which our human life must move (§1). If all this is clearly and faithfully considered by an unprejudiced man and observer of his own soul, such a man must come to the inescapable conclusion that a loving creative force and wisdom has lifted his inner being from the plant and animal world that bears and nourishes his body and has carried him by his inner being into the radiant kingdom of conscience, and has at once destined this man to emerge from the night of blind existence into the light of a full, pure life, namely by realizing the opportunity he is given to live a life blessed in reason and in freedom, in strength and light and love, and thus also in God, his Creator Himself.

Chapter Three

THE CONCEPT OF DISEASED MENTAL LIFE

§ 33. Just as health in general (§ 25) means internal comfort and well-being and is externally evident by undisturbed, free vital activities of all kinds, so too can disease in general and a diseased mental state in particular be recognized as internal discomfort and is externally evident in many ways by limited or completely suppressed vital activities. We may therefore unhesitatingly say that the essence of health is the freedom of life, while the essence of sickness is restriction of life. Just as complete freedom ( §32) is the highest form of life, so complete, multilateral, unrepealable restriction of all vital activity is death.*

§34. In every sickness, in every diseased state, the vital activities are more or less restricted and the resulting kind and degree of discomfort are in proportion to these restrictions. However, man is a human being only inasmuch as he is a conscious living being. A state of human disease is therefore a state in which man is more or less restricted in his consciousness. Consequently — since there is only one state of human health, namely that in which man lives or strives to live as a reasonable being ( §§27 and 31), from the first moment in which he follows his conscience up to the highest stage in which his being becomes one with reasoning consciousness — any consciousness not open to conscience or reason is a diseased consciousness; and this is clearly evident, since the feeling of freedom, the feeling of blessedness, is absent here.

§35. It follows that the state of human disease is only possible in the domains of world-consciousness and self-consciousness, which also means that it is impossible outside of this domain, in a purely corporeal life (if such life, separated from consciousness, could at all be thought possible). Conversely, however, the bodily life, which is received into the consciousness and which cannot be experienced without it, is susceptible to attack by every human sickness (if, indeed, it is not actually being attacked) and, depending on the extent and nature of the diseased state, may indeed become diseased, since the entire man is only one life ( §6), and — though this life is externally and internally differently created and separated into independent, closed circles — each such circle is vulnerable to attack and may succumb to the disease of other organic circles in the event of disease owing to the free activity and harmonious interrelationship of the different circles.

* See the author's Beytrage zur Krankheitslehre (Contributions to Medical Science), Gotha, Perthes. 1810.

§36. Originally, consciousness is not in a diseased state, either as world- consciousness or as self-consciousness: for both are necessary stages in the development of general consciousness to highest consciousness ( §24). But when conscience has come awake, life is lived not in the world but for the world, while life not in the Self but for the Self turns to sin, that is, to a state where nature and destiny are opposed, and therefore free growth of the highest human being is hampered and a diseased life results. Thus, in this state there is never a feeling of internal peace or satisfaction but only an ever-fruitless striving thereafter.

[he correctly denies Calvinism, which says that man is created impure. Instead he says that the conscious is originally created perfect and clean.]

§37. The sinful man lives for the world, or for the Self, and really for both. For whether he be bound by his possessions or by his existence, his desire for possessions is forever aimed at his existence and his being, and one cannot be imagined without the other. But striving for material property and for existence, insofar as it is not a means to a higher end but an end in itself, is a state of sin and human disease, being a decline from the freedom for which man was born to the bondage of plants and beasts. Conscience, which is not only a stammering voice of reason but has the power of deeply moving the feelings and consciousness of the wide-awake man, is intended to lead him into the domain of freedom and holiness for which he was created. If he still clings, against his better knowledge or at least against his better instinct — be it due to his deliberate sluggishness or because he freely follows his inclination, freedom of choice being man's privilege by birthright — to that which a holy voice in his consciousness distinctly tells him is not good and not right for him, then he disturbs his own development, the revelation of life which is intended to become reality through him, in short, the law and order of existence and life itself. His offense against the highest life will work havoc, inhibition, and restriction with his life, that is, he will be in a state of human disease.

§ 38. Possessions and existence are the love of the world-consciousness and the self-consciousness, and the heart lives in this love. It is the heart which is the source of every human disease, and in the heart dwells hell as well as heaven. The heart is the shrine and the sanctuary of life, and its focus is love and loving bliss. But as love for earthly existence and earthly possessions, even if satisfied, cannot fill the purely human consciousness, it cannot satisfy it but always leaves the thorn of vain longing in the soul. Since such a soul lacks a proper understanding of itself, it is more eager for external satisfaction when it is less inwardly satisfied. It is therefore truly in a state of suffering which we call passion.

§39. All passion is truly a state of human disease which also attacks bodily life and casts it down to an extent depending on the strength or weakness of the passion. It is aimed either at possessions or at existence (§ 37) and, by its mentality, it is either lust or fear, depending on whether gain or loss is imminent. Desire and fear are the chastisement suffered by the world-man and the Self-man throughout his life.

§40. In accordance with the directions they take and with the states of mind they produce, passions form a very complex tissue in the human soul. For they are as varied as the objects of desire and fear and the forms of existence and possession can be. But all have in common that they rob the soul which panders to them of peace and freedom, and thus take the soul out of the sphere of higher consciousness. Anyone imprisoned by passion is unfree and unhappy.*

§41. The man who is fettered by passion deceives himself about external objects and about himself. This illusion, and the consequent error, is called madness. Madness is a disease of the reason and not of the soul, but it originates from the passion within the soul. When free of passion, we may err and be deceived, but the free spirit soon turns away from error and deception; but madness is a truly diseased state of the spirit since it originates from a diseased state of the soul. Man cannot be freed from madness until he is freed from passion. In madness the spirit is fettered and man, just as in passion (both being indissolubly linked), is unfree and unhappy.**

§42. A man who stumbles about, with much pain and vanity, in passion and in madness, leads a foolish life, and folly is the sum total of the activity of passion and madness. However, all action originates from the will, and if this will follows and panders only to the compulsion of passion and to the illusions of madness, while ignoring the voice of the as yet undeveloped reason, that is, the conscience, for the sake of freedom and independence, or the voice of matured reason with its clear consciousness of a life of duty, we have a state of recognized sin, and if it is continued and becomes a constant habit, it is vice.*

§43. Since it has its seat in the will, vice is the most morbid of all states of disease; for it is opposed to reason, whereas passion and madness are merely outside of reason. All three are states of slavery; but while the birth of passion and madness is not voluntary, vice originates from a free will which has made a free choice against good and which has passed to the opposite side in defiance of the call of conscience. Those living in passion and madness merely fail to conduct their lives according to the rule of good (are godless), but those living actively in vice worship evil (are sons of Satan). The two are by no means identical; for whereas in the former state a return to a healthy human condition is often easy, at least always possible, in the latter it is always difficult and often impossible. It is a weakening of the moral strength, through which alone the fallen can rise again, that renders the abandonment of any vice so difficult. One whose disease is vice is near spiritual death.

§44. These are the states of human disease which render impossible the feeling of human health: the peace of mind, inner purity and joy, pure sympathy, and forceful and vigorous activity and creation. These states of disease obtain their hold on man stepwise, since vice is preceded by madness and madness by passion. No one starts by suffering from vice; it is only after the spirit and soul have become diseased that the will becomes so too. Whether or not the diseased state is immediately intensified in the measure in which the innermost depth of life and the force of free decision (the will) have become affected, there is no difference between all these diseased states insofar as they all ( §40) are unfree. Even so, in none of them is it impossible to return to the state of human health, since no such diseased man is unable to lift himself out of the state of slavery which he has adopted into the domain of freedom. He still strongly feels the heavy weight of his chains and he clearly perceives the voice of the warning savior from within himself.

* See the author's Beytrage zur Krankheitslehre (Contributions to 'Medical Science), pp. 239-260. ** "Theorie des Wahnes" (Theory of Madness), in: author's Beytrage zur Krankheitslehre, pp. 260268.

* "fiber die Natur and die Arten, so wie die pathologischen Wirkungen des Tasters" (The Nature, Types, and Pathological Effects of Vice). Ibid., pp. 268-280.

§45. In these diseased-health states of passion, madness, and vice, man, often without knowing it, denies his own nature in which all strives to attain the highest development of consciousness. Man cannot be at peace if he is not free. The satisfaction of all his earthly desires brings him no happiness. He keeps struggling towards further goals; and as long as his efforts keep moving in the narrow circle of world-consciousness and self-consciousness, he remains a plaything and a slave to his inclinations which often remain unknown even to himself. All his inclinations should uplift man, for this is what his nature wishes. Freedom and independence become his goal without his being aware of it, but both inhabit the sphere of the highest consciousness which rarely anyone develops in himself and which is disregarded by most people. To these people conscience will forever remain something foreign; nay, many of them will consider it as their foe, since it should become their innermost state, their main quality, their true Self. And thus most people stagger blindly and foolishly through life, only to ask at the end what its true meaning was. Many find no meaning and no merit in life and destroy it, since it has no value for them, or else complain bitterly of an existence in which they see no sense and no purpose, which is full of misery and sorrow and yet, at the end, passes away like a breath of wind or a shadow. They still manage to be happy enough in their fruitless attempts and activities if they spin the thread of their life with some moderation; these are considered by most to be the wise men among fools and an example to be followed. But even for these apparently wise persons there is no inner happiness, and they keep yearning in vain for something better. They ignore the sense of the saying "the Kingdom of Heaven is in yourselves." Others, however, who fail to exercise even this extent of moderation and are unable to restrain themselves in any way, encounter several situations to which they do not necessarily succumb but against which they are not armed and which to meet they have not the necessary inner strength and security. These are states of a total loss of freedom which are related to those just described as death is related to sleep. Just as sleep is merely a passing state in which the free forces are fettered, and from which they may break forth, nay, strive to break forth, to the activity of daylight, so death means a complete and irreversible standstill of these forces. The states of human disease so far discussed, in which freedom, though temporarily given up, can be regained and reborn at any time. are but a sleep of this freedom. But the diseased states discussed below, which are the proper subject matter of this book, are the very decline and death of true freedom and of all truly human life.

Chapter Four

THE CONCEPT OF DISTURBED MENTAL LIFE OR DISTURBANCES OF THE SOUL

§46. The development of human life through all its ages may be considered as a journey made at a measured pace and aimed at the highest consciousness or life of reason; nay, one is forced to this conclusion or else to consider that man, with all the tendencies and forces which determine his life, is a creature which spends its existence in perpetual self-contradiction. The free creative force in man, his imagination, at first resembles the still amorphous sap of plants which rises by way of roots, stem, branches, and leaves, is purified and transformed into flowers and fruit. The mental life of a child is sensual, and the imagination of the child exercises itself in the sensual world in play. The play urge is the child's expression of love. The mental life of the age of youth is also wholly dedicated to the imagination and concentrates the entire activity of the creative force on one point, on one object, viz., beauty; the beauty urge is the expression of love in youth. Not necessity but love is also the mother of the arts which originate from the individual man and from the human race, inasmuch as the individual and the society live and love in the way of the young. The mental life of mature age extends all the accumulated and complete activities of the creative force into the broad spheres of life with the aid of reason, and it is the business of this age to understand and to bring order, to enlighten and to control, and to stand free and independent through reason or at least to strive for freedom and independence. The urge for freedom is the expression of love of mental life at its zenith. Science is the daughter of this age. The mental life of advanced age, the age of maturity, intensified and purified by the exercise of the creative force at the previous stages, now operates in the sphere of reason and turns the creative force away from the world and from the love of the senses, of free imagination and reason, grasps them back, and lifts them up into the invisible, unconfined world of the highest freedom and highest love. Wisdom is the expression of love of old age. This is the straightforward, natural course of development of man and of humanity through all stages of life; thus the growth urge of man, like the sap of flowers, is guided towards the Eternal. This growth develops from one form to another, through the domains of sensuality, free phantasy, and ratio in the form of play urge, beauty urge, and freedom urge, like so many turning points in life and in its consummation. As the mature man gradually begins to withdraw from the fetters of the external world and from worldly love, so too should he become reborn to eternal love in the inner world of freedom and in the perfect life.

§47. This is the way man ought to grow. We learn this through faithful observation of his developing urge for growth in a regular determined form. But a man is not a plant, and natural necessity is not his all-powerful master. Even though his conscience, his supreme law, affects him with all the severity of a natural necessity, he is nevertheless free not to obey it. Thus he is the first and the only creature on this earth who is a free agent. But this freedom of choice which is left to him between the outward, earthly and the inward, other-worldly life, this free will, is his only opportunity to pass from his earthly existence to an eternal life in strength and in light, and to attain love and bliss (for only through a godly life can he become part of Divine nature, and freedom is an element of Divine nature), but it may also be the reef against which the attempt of the Creator to lift him from the temporal to the eternal may shatter. It is not the fault of the Creator, Who communicated His nature to us and then left us free, but the fault of the man who voluntarily abandons this nature. Man may be brought up to the highest life if he lets himself to be brought up thereto; but as this is usually not the case, confusion reigns over most of his life and often kills it, spiritually and bodily.

§ 48. The Divine intentions in man are frustrated by man himself in many different ways. The way to the highest development in world-consciousness and in self-consciousness leads through senses, imagination, and reason, but human life must not become arrested at the lower stages of development and refuse the Divine summons to proceed to higher things. The man who scorns this repeated summons and is content with and stays only in the non-Divine existence and life will become enslaved by the non-Divine and lose his free will; this loss will not be direct or immediate, but the only possible truly free condition of life, and with it the feeling of pure satisfaction and joy, will be lost to him (§34). A prey to passions, madness, and vice, the creative processes will be impeded, halted, and forced back in many different ways. Thus, by observing such a disturbed process of the inner organization that should have served to attain the complete life, that is, the free life, we arrive at the concept of a disturbed mental life, or, in short, disturbance of the soul.

§49. This concept is as yet very general, and no definite meaning has so far been assigned to it. It means nothing more than a mental life impeded in some way in its normal growth. Thus, any diseased condition could be denoted as mental disturbance. However, it must be borne in mind that passion, madness, and even vice often assist the soul of a man who, admonished by the voice of his conscience heard through the dim fog of his condition, may gather his forces, break his chains, and rise to a freer, higher plane and pursue good with a greater will. Furthermore, in any soul which still retains its free will, that is, is at least potentially free, and which is enslaved by some but not all relationships of life (for good seed often bears fruit in the midst of weeds), the condition of the disturbance, the whole interference with the inner life, is neither complete nor exhaustive. Therefore the concept of disturbance of the soul must be understood more precisely as a total halt, a total standstill, or else as an innate desire of the creative force, which was originally intended to produce the highest development, for the opposite, that is, for self-destruction, and must be restricted to cases in which such signs are distinctly evident.

§50. In this condition the free will exists no more and is replaced by complete and permanent loss of freedom. This condition prevails in diseases commonly known as mental breakdown, aberrations of reason, madness, diseases of temperament, mental diseases in general, etc. All these diseases, however, much as their external manifestations may differ, have this one feature in common, namely, that not only is there no freedom but not even the capacity to regain freedom. The world-consciousness and the self- consciousness are to a greater or lesser extent disturbed, confused, or wholly extinct, while there is no room for the reasoned consciousness, since free will, which is the receptacle of this consciousness, has died. Thus, individuals in this condition exist no longer in the human domain, which is the domain of freedom, but follow the coercion of internal and external natural necessity. Rather than resembling animals, which are led by a wholesome instinct, they resemble machines and are maintained by vital laws in bodily life alone.

§51. The designation disturbances of mental life or disturbances of the soul, used to describe this condition, is justified by the meaning underlying it (§50). Even in colloquial usuage, not of literary men but of the common people whose voice so often expresses an obscurely felt premonition, disturbed people are those who carry the stigma of unreason and loss of freedom in their way of thinking, acting, and perceiving. It is clear that the concept of being disturbed is here applied to mental life alone, and the disturbance of these individuals, or their condition, is something which determines their attitude to mental life, namely, the suppressive or destructive effect on their entire inner development process, on the genesis and maturing of reason. It is thus not an unrelated, but, on the contrary, an affecting and effective condition. To denote this by the word disturbance is perfectly suitable, since the word has a double meaning, a passive and an active one. It describes, firstly, the condition itself, and secondly the processes taking place in this condition (similarly to the word fermentation).

§52. The reason that we insist on the name "mental disturbances," i.e., disturbances of the soul, in preference to all other names which are in current use (and are thus exposing ourselves to the charge of eccentricity) is that none of the other terms includes the entire group of diseases with which we are dealing here but merely describes some particular disorder. For mental life can he disturbed in a great variety of ways. In so far as soul is like temperament, it can fall sick as temperament does, in so far as it is like spirit, it can fall sick as spirit does, and in so far as it is like will, it can fall sick as the will does. The soul is an inner vital activity which, like any activity known to us from experience, can be unnaturally intense, or depressed, or else, instead of being outgoing, can convulsively withdraw into itself. But we must not forget that in a true mental disturbance each of these disorders must occur to an extent equivalent to complete, permanent loss of freedom (§§49 and 50). Thus when the mind in a condition of the most passionate tension is also withdrawn into itself and lives only in the world of its dreams, we have a condition of madness. When the temperament that has withdrawn into itself as it were erodes itself, then there appear the signs of melancholia. When the over-tense spirit moves out of its proper sphere we observe the manifold signs of insanity, such as senselessness, frenzy, and craziness*, when the spirit has sunk to complete nothingness it loses itself in idiocy. Finally, when the will has burst its bounds, there appears rage, the very opposite of which is apathy. Thus the various domains of the soul suffer from various disorders. Although these are marked by the common stigma of the loss of freedom, they distinctly differ from one another in their external manifestations and in their typical features. It follows that we must not confuse these conditions with one another and select one particular appellation to be used as a general name; it is accordingly a very grave error to denote all the manifold mental disturbances as madness, insanity, craziness, or manias, or diseased temperament, or disintegration of the spirit. Not even the name mental disease, no matter how general it may appear, is an appropriate appellation for the entire range of mental disturbances. Firstly because not every mental disturbance is a disease though every such disturbance represents a diseased condition, since every disease is a process which ends in return to health or in destruction, and in many of these diseased states, such as in permanent insanity, all traces of a vital reaction, without which no disease is thinkable, have become extinct. This is also clearly true of idiocy, which is often the ultimate stage of all mental disturbances. Even in affections of the body a disease must be distinguished from a diseased condition. Thus, a fever is a disease, while limping, double vision, a malformed spine, etc., are diseased conditions. So much for the first reason.

Secondly not every mental disturbance is a mental disease. The process of mental activity needs the bodily organism and, in particular, integrity of the brain and nervous system. If these organs are injured, that is, if the brain is injured by a skull fracture, the mental life becomes just as disturbed as if it were unbalanced by fright or by a powerful passion. Mania, insanity, or idiocy which have arisen as a result of external effects of this kind are still mental disturbances, that is, interruptions of the mental life, without being in the least diseases of the soul. For the same reason, the totality of mental disturbances must not be denoted as diseases of the soul organ, because even though the entire body, which is certainly a soul organ, is able to give rise to mental diseases, in the great majority of cases it is not the body but the soul itself from which mental disturbances directly and primarily originate, and it is these disturbances which then affect the bodily organs indirectly.

[The idea that all varieties of insanity are a loss of freedom is an interesting parallel to what Jesus said, "the truth will set you free" and Paul "in sin we are held captive as slaves"]

* [The German: "Wahnwitz, Aberwitz, Narrheit" as well as "Wahnsinn" is translated as "madness," while "Verrucktheit" is translated as "insanity," simply in order to render into English the distinctions made by the author. Obviously, these terms are not used here in their modern meanings, whether medical or colloquial.)

§53. It follows that to us Germans, who are so rich in exact, fully fitting appellations, no better expression is available than "mental disturbances" for those disorders in which reason and free will are permanently disturbed (§54). In fact, this is the only expression which does not define too exactly any particular form of disturbed mental life but comprises all forms thereof, in accordance with their principal characteristic. Thus, be it the soul or the body which is the main origin of the diseased condition, be it the spirit, the temperament, or the will which shows signs of illness in the unfree state of exaltation or depression, be it a true disease or a diseased condition, in every case the name "mental disturbance" will suffice as a class appellation, describing all the different types and kinds of permanent diseased affections of the soul, and naming each of them according to its principal characteristic ( §49).

§54. But the idea of mental disturbances is not exhausted by the above (§§49-52) explanations. The disorders described by this concept must firstly be of a permanent nature, for temporary attacks of a disturbed mental activity, as for example under influence of drugs, cannot be so denoted because they are not permanent. Second the disturbance of mental activities or of mental life must, indeed, constitute the essential, the evident, the typical feature of the disorder, in accordance with the old principle a parte potiori fit denorninatio. Thus, for example, fever accompanied by delirium, even if persisting for hours, days, or longer, cannot be denoted as a mental disturbance since the essential sickness is the fever itself. Thirdly, since the common feature of all mental disturbances is permanent loss of freedom, or, which amounts to the same thing, loss of reason, any diseased condition which does not have this essential feature must be rigorously separated and excluded from this definition, however much we may be accustomed to use it inclusively for a large number of peculiar conditions and manifestations. The latter include sleepwalking, which, though indeed a diseased condition, represents a mental life which is not contrary to nature, but merely unusual, for it does not include loss of reason. The same may be said of all feverish diseases and of all brain and nerve diseases as such, including phrenitis, paraphrenitis, rabies, feverish delirium, catalepsis, apoplexy, and all soporose conditions, diseases of the senses including the so-called hallucinations, epilepsy, St. Vitus' dance, ergotism, incubus, hypochondria, and hysteria. Even the so-called weaknesses of the spirit and psychic aberrations must be carefully separated and distinguished from the concept of mental disturbances proper. Among the former are: a failing memory, weakness of imagination, of reason, and of judgment; the tendency to be absent-minded and to become lost in thought; fickleness, recklessness, etc., since in all these the capacity for reasoned activity is not lost and the condition is not that of a true loss of freedom. It could perhaps be said that among the disorders just enumerated that should be excluded from the concept of "mental disturbances," such as phrenitis, catalepsis, apoplexy, etc., there is indeed loss of reason and loss of freedom, that is, a totally disturbed mental life. However, it must be borne in mind that in all these cases the disturbance of mental life does not constitute the nature and the essence of the diseased condition and is not the diseased condition itself, but only an accompanying manifestation thereof. Furthermore, and most important is, that in these cases there is no disturbance, that is, no unnatural condition of mental life, because mental life has been rendered ineffective by conditions present in the bodily organism, and thus there can be no question of any disorder of mental life.

§ 55. And thus the concept of mental disturbances is now completely defined and separated from all other concepts. The complete concept of mental disturbances includes permanent loss of freedom or loss of reason, independent and for itself, even when bodily health is apparently unimpaired, which manifests itself as a disease or a diseased condition, and which comprises the domains of temperament, diseases of spirit and will. It follows from all that has been so far discussed that the field of mental disturbances is a separate, independent domain of diseased conditions, which exists in its own right. Its scope and richness, its importance and (as will be seen below) its complexity are so great that any inclusion of extraneous subjects would be highly superfluous, even if it were not a contradiction in itself.

Chapter Five

THE CONCEPT OF "DOCTOR OF THE SOUL" [PSYCHE]

§56. If we assume that it is at all possible to cure mental disturbances, or at least to cure some of them under certain conditions, there arises the following question. Since it is the degenerate mental life which must be led back to normal, since it is the humanly healthy condition (§27) which must be restored, would this be the task of a doctor? or perhaps of a cleric? of a philosopher? or of an educator? There are arguments which speak in favor of each of these four viewpoints, and each of these professions is at least apparently entitled to take possession of this curative task. We must inquire to which of these professions (or perhaps to none of them), in their conventional and customary meaning, we are to entrust this branch of medical art and science.

§57. Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment. Indeed, doctors have claimed this right in their compendia and practice. (Meanwhile publications on these diseased conditions have been published by men who are not doctors. It is also common knowledge that treatment of such conditions by nonmedical men in England has given excellent results.) Nevertheless, since we are claiming that mental disturbances are the opposite of human health and since this claim is not arbitrary but stems from a faithful observation of human nature, we must separate this entire sphere of manifestations from the forms of illness which have symptoms the doctors are accustomed to diagnose. We must transfer them to another domain, the domain of mental life, with which doctors (since they are only familiar with bodily nature) are not familiar with regard to both the recognition of the disease and its treatment. The medical studies to be indicated below (Introd. II) testify to this complete ignorance; furthermore, the point of view and the sphere of activity for which doctors are trained and prepared at high schools of learning and at the sickbed are totally different from the legitimate and true ones given in the present textbook. Accordingly, since doctors are pupils and adepts of medicinal art and science in the field of disturbed bodily lives only, they are not directly and immediately suited, at least not in their present condition of both education and experience as practicants, to carry out the business of healing the psyche.

§58. The clerics, as the recognized shepherds of the soul, are just as unfit for the tasks, owing to their point of view and the training and direction they have received. For their field of activity is the moral nature of man for as long as it exists and not after it has died or at least temporarily disappeared. Their business, their profession, is thus concerned with a sphere which is quite different from the one with which the doctor of the soul must be familiar. Philosophers, especially psychologists, have at times ventured into the sphere of disturbed mental life, at least theoretically, but they cannot accomplish anything, even in the theory of mental disturbances alone, unless they apply themselves to a faithful observation of nature. This has not yet happened, as will be demonstrated later (Introd. II). Since their activity is confined to the writing desk, nothing in the nature of practical work can be expected of them, whereas the purpose of medicine of the psyche is precisely to take action in order to teach the art of guiding the disturbed mental life back to normal.

[Heinroth is saying that since preachers only use talking cures, they are not enough, since he believes that the person degrades to a state that only physical moral treatments, punishments, tortures will fix. These physical treatments are outside the realm of Ministers of churches. He also believes that insanity is often accompanied by other physical illnesses that only a doctor can treat. This is good advice. A person suffering from insanity should first have a full physical from his doctor to correct all physical ailments, then is the time to look inward to the heart and will. He also believes that a doctors qualifications include all the skill and knowledge of a minister of a church. In Heinroth's case, this was certainly true, since his mother wanted him to be a preacher. How different it is today, where atheistic psychiatrists are absolutely ignorant, or violently opposed to God, Christianity, the Bible and the spiritual outlook of man.]

§ 59. This science and art has much more in common with the art of an educator, and even doctors agree that curing mentally disturbed individuals is at the same time a reeducation. But all will consent, at least, that this science and art was not invented by educators, even if it already existed; and educators, just like clerics, are at present trained and prepared to deal with free human force, but not to restore a freedom which has been lost. However this may be, the sphere of activity of both educators and clerics is already so large that they are fully occupied therein and should not be irresponsibly made to assume this new burden, even if they consider themselves qualified to do so.

§60. However, these requirements, or at least some of them, are such as can never be met by an educator or by a cleric or by a philosopher. For the doctor of the psyche must first be a physician, in the full ordinary meaning of the word. He must be learned in the medical traditions and versed in medical practice, partly because mental disturbances are often accompanied by bodily disturbances which they excite, maintain, and modify, partly because in very many instances it is possible to influence the mentally disturbed only through their bodies. It must therefore be concluded that the doctor of the psyche must indeed come forth from the class of physicians. We are purposely saying come forth, for he must not remain in this class, firstly because this class is sufficiently occupied in its own field, whereas the field of soul medicine is so large that the forces of an active man are fully engaged therein; secondly because a doctor of the psyche must undergo special training and must go in a direction which is altogether different from that of a doctor of the body.

§61. For whoever takes upon himself to be a doctor of the psyche must be specially schooled by the psychologist, by the cleric, and by the educator; or rather, he must develop in himself the gift for psychological observation, must adopt a religious point of view, and must himself attempt to live the life of a cleric, or such a life as a pious man would live, that is, to lead a life of reason, or, in the words of the Holy Writ, a life in Christ, or must walk in light, all of which is the same thing. Finally, he must become proficient in the methods of the educator, transform them to his own ends, and carry them over into his own sphere. But essentially is the only education in reason which also coincides with the other needs of a doctor of the psyche. For neither true psychology nor the true art of education is conceivable unless it is guided by and viewed through the eye of reason. Only reason is able to recognize the nature of mental disturbances in all its forms, and only reason can heal those which are curable)

§62. This truth will not be understood, and thus will not be admitted, by most men, essential though this may be. It will remain unrecognized by a man who has failed to place himself in the element of the life of reason. If we live in reason and for as long as we so live, there is bright daylight about us: the fog of prejudice is dissipated, the barriers of base opinions fall away, the world of the spirit is open before us, and everything, including our activities in what we know as nature, receives a spiritual aspect. We no longer see dead matter outside ourselves or within ourselves, we only recognize forces or, rather, one single force in its many manifestations and laws. From the point of view of reason everything stems from the eternal force and is itself a force which is predestined to infinite development. But all natural forces are governed by a law which is just as eternal as the primordial force itself, and which is not just the blind rule of necessity but is the highest intelligence to which our own intelligence is related. Living in this intelligence, we also look through its eyes and can penetrate the deepest meaning of things. We do not become endowed with new senses but learn to know and to use those with which we were born. We no longer expect our senses to furnish us with reason and with spirit generally but, on the contrary, it is the spirit which penetrates the senses and these themselves become spirit. The manifestations of the world and of human life now acquire altogether new connections and relationships. In ourselves and outside ourselves we discover forces and an efficiency of which we never dreamt before. We become more receptive to the living influence of external laws; in ourselves, in our own consciousness, too, there arise laws through the application of which we are capable of restraining, at least to some extent, external nature, diseased nature, diseased mental life, to hold it in its path or to recall it. But none of this happens and none of this can be perceived unless we have set ourselves free, have denied ourselves world-life and Self-life, or briefly, unless we have lifted ourselves up into the sphere and into the life of reason, at least during the finest hours of our life; and this is clearly not every man's object.

§ 63. This is what a doctor of the psyche, or rather one who has committed himself to being one, must do. Reason is the organ of any recognition and ought to be developed not only by a physician but by all men. This in fact happens very seldom, which explains why our knowledge and our actions are so often blundering. Whoever does not live in light lives in darkness (and a deceptive light, say, the light of a false philosophy, is also darkness), and it is the purpose of the doctor of the soul to bring the mentally disturbed, whose inner life is totally darkened, back to light. But how can he do this if he himself does not live in light? It is necessary to sharply emphasize this point of view of the doctor of the soul. Whoever cannot make this point of view his own must give up the name and the power and the business of a doctor of the soul.

[Heinroth has just defrocked 99% of all psychiatrists from their job since the vast majority of them are evolutionary and atheistic unbelievers in God. He counts them as unfit, and we agree!]

§64. Thus the doctor of the soul (or psyche) is a true man of reason. He has overcome selfish interests and treats for purely humanitarian reasons. He considers his patients only as sufferers and not in relation to his own personality. Much is gained even by this attitude alone, since in this manner he obtains an unprejudiced, correct view. He does not hold the vulgar and limited view according to which it is the bodily relationships which determine both the disturbance and the cure, but will concentrate on the soul life and will view all diseased manifestations of the psyche in relation to the latter. From the very outset he influences the patient by virtue of his, one may be permitted to say, holy presence, by the sheer strength of his being, his glance and his will. The will exists in man as a force which is not cultivated; it is however the will which gives rise to all creation, and man, too, has his share of this creative force. The will is the principle of miracles, the principle of magnetism. The magnetic manipulation is only an ad hoc device, a kind of mechanical stimulant of the will. But will without spirit is blind, and will without temperament is barren. The man of reason combines all forces of his inner being for a full understanding and for the living deed. Sapere aude!

§65. The concept of doctor of the psyche was outlined here only in terms of an ideal, an example, which all physicians of the body training for the profession of doctor of the psyche must attempt to emulate. None of the conditions here enumerated can be omitted. Reason cannot be bargained with. But wisdom and strength are not cast down from heaven onto the blind or sluggish. They must be won through struggle.

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Reason cannot grow and cannot operate without organs. Senses and reason, observation and experience, both one's own and that of others, must be considered, everything must be exercised and tended, everything must be used. Thus we need above all to have a clear idea of medical recognition and action if we are to establish the right means for correct recognition and advantageous action* by the doctor of the psyche.

* (I.e., diagnosis and successful treatment.]

Chapter Six

THE CONCEPT OF MEDICAL RECOGNITION AND ACTION

§66. In general, we recognize an object if we are able to give an exact account of its nature and its form; for all objects have a nature and a form. But the nature of all things is the force which inhabits them, and their form is the manifestation or the expression of the law which maintains or limits these forces to their natural framework. Force and law constitute not only the world and all that exists therein but also all that which carries and holds the world. We live and work in force and law, and the observation of the manifestations of both furnishes us with all the elements of our recognition.

§ 67. The doctor observes, or is supposed to observe, the manifestations of a diseased life, both the manifestation of the disturbed vital force — in order to learn how deeply the life is affected by the hostile attack and how far it independently reacts to it — and the form, which is a definite outward manifestation of the diseased vital relationships. All force is manifested only in the form, and it is thus the immediate task of the physician to observe the manifold manifestations of the diseased life.

§68. The individual manifestations of the life that has become diseased under certain circumstances (which are known as symptoms) are observed and compiled by the physician. They can be merged into the manifestation as a whole, into a definite form of the disease; and the manifold forms of diseases, repeatedly observed and collected, yield one whole, which, though not yet a clear recognition, not yet the theory, nevertheless is the outward condition thereof. For the nature of theory is the understanding of what has been observed, and the elements of the theory are observation and understanding. There is no understanding without observation, but observation without understanding cannot be evaluated. Observation comes from the external, understanding from the internal, world; thus the sum total of observations, which is known as experience, is the external condition for a theory.

§ 69. Observation (and thus also experience) must, however, include not only the forms of disease as something at rest but also everything which may affect the diseased life favorably or unfavorably. It is a general rule that observation does not rest at any one point, does not limit itself to any particular kind of manifestation, while leaving all others untouched but, just as does light, extends over all objects affecting life, the near as well as the far. The observer thus becomes even more familiar with the great variety of conditions and influences. But while the observation cannot be limited in scope and proceeds at perfect freedom, that is, observation is comprehensive, it must at the same time be incisive if it is not to he superficial. It must dwell for a while on every feature, in order not to miss anything which is noteworthy and should be observed. Only thus is the observation exhaustive, and only thus are we able to obtain the materials which are required required for recognition.

§ 70. A complete understanding can only come from a complete picture. Such a picture is acquired by observation, but understanding, though based on it, is not acquired but is created by one's own internal, free but lawful activity of reason, that is, the force which comprehends the connections and relationships between things. It is through understanding, that is, through the lawful internal limitation of objects, that the objects or the general picture become the property of the mind. What was previously merely seen now becomes thought; the external becomes the internal and the foreign becomes one's own. The picture which has become an idea is now informed by clarity; thought unlocks the nature of things before us, while mere contemplation furnishes us with their external form only. This is why it is only understanding that affords us complete recognition; but not when understanding is separated from contemplation: only when it enters and informs it.*

§ 71. But the phsyician's recognition is not merely something passive, is not a mere absorption; it is rather the effect of his own free activity, the natural transfer of the inner form (namely, the thought form) onto the external materials which correspond to this thought form. It is only faithful contemplation that affords true comprehension, because the outer and the inner laws of nature correspond to each other. But it is only the fully receptive and watchful activity of reason that results in a complete understanding of contemplation. Thus it is necessary for the physician first to train his own organ of recognition, that is, his scientific sense, just as an artist trains his art sense; he must learn to observe faithfully and to think freely (without external disturbance). The lack of this ability in so many physicians and the occurrence of spurious observations and immature thinking have led to the many spurious and immature theories prevailing.

* [The German word "Anschauung" (viewing, contemplation, clarity, picture, etc.) is used in this paragraph indiscriminately in all these meanings.]

§72. Every man acts in accordance with his own judgment, and so does the physician. Medical recognition ought to lead to medical action. It is only after the physician has taken cognizance of the relationships and connections in the diseased life that he is in a position, provided he has the suitable means, to take expedient action in order to affect the disturbed life relationships. Thus, the basis underlying his action is the recognition, the theory; this must accompany him at every step in his action, for once he has ceased to act in accordance with recognition his actions become and remain blind. But activity itself and the series of medical actions are not definable by a theory, that is, cannot be formulated so as to constitute a conception formed by contemplation and comprehension, for theory (the nature, forms, and changes of the diseased life) is something which historically already exists, which has become created, formed, completed, and surveyed. The series of medical actions, however, must yet be developed and formed, not in accordance with an inner necessity as the form of, say, a plant, but in accordance with external, random conditions which can neither be foreseen nor summed up. Thus, for this action we can merely give rules for the cases possible, that is, the rules of the art; and the sum of these rules is known as technique. Thus, to each its own: to contemplation the theory, to action the technique! It is not as if theory were superfluous (for, let it be repeated, no action is possible without the theory, which must introduce the action and accompany it at every step); but the business of action is totally different from that of recognition.

§73. It is definitely not permissible for a physician to make himself a plan for his action, and the idea of a therapy plan is to be rejected; he must at all times coordinate his action or lack of it (for abstention from action is also activity) with the dictates of the nature of the organism and of the disturbed life. For it is the great merit of his theory that these dictates are properly comprehended and understood. His theory is the organ through which he can understand the oracle of the diseased life, the voice of nature which is in need of help and is yet itself helpful at the same time. The physician opens up the resources of his entire activity, the aim of which is not to regulate the diseased life arbitrarily and deliberately but rather to serve and to obey the wisdom of nature and to assist it. The object of the activity of the physician, the diseased life, is not dead matter on which the physician, as an artist, like a sculptor working in marble, can impose any form he pleases, but is a force and a life in its own right which, even when diseased, follows its own laws and must be treated in accordance with these laws. There therefore cannot be a more opprobrious name for a physician than the name healing artist; firstly because it is not he that heals, but the force and order of nature and of life itself, and secondly because he is not an artist in the accepted sense of the word. While his action is art, it is so only as regards the kind of training which he must undergo and not as regards the treatment of the object. For where the object cannot be freely treated and the form of the artist's own spirit imprinted on it, we cannot speak of art, inasmuch as art is an external representation.

§ 74. The action of the physician consists in supplying the diseased life with something it needs, or of removing from it something which is burdensome to it, or of holding off the effects which are disadvantageous to it, or of taking care that the diseased life might resume the abandoned equilibrium without let or hindrance. In all these respects he cannot act arbitrarily in accordance with some preconceived plan thought out in advance but must be guided by the particular moment and by the coincidence and interrelationship of the circumstances. His only accomplishment and his only merit is the correct survey and evaluation, and the result of his knowledge, recognition, insight, theory (whatever we wish to call the sum total of his contemplation and understanding), which originate from his personal observation and experience.

§75. This theory, if it is derived from nature, teaches him to proceed according to nature and to adapt his procedure to the circumstances in every case, in accordance with whether or not these circumstances make a fruitful activity possible.

Non est in medico semper, relet'etur ut aeger: interdum docta plus valet arte malum.

A physician who approaches each patient with the hope, nay, confidence in his ability, of helping him is an ignorant physician, no matter how wise he may deem himself. He has scorned the lessons of observation and experience and must now expiate it by fruitless attempts and frustrated efforts.

§76. Our knowledge is patchwork, and so is our activity. We most moderate our demands and expectations of theory and technique but must set no limit to our efforts to master both. But our ultimate and highest goal we should see not so much in an eventual perfection of medicine as in its eventual abandonment; and it must be the earnest striving of every physician to destroy the potentiality of disease. This paves the way for an altogether different, a highly pleasing, aim for medical activity, namely that of prophylaxis.* Thus, the physician is like the brave and wise monarch who drives the enemy out of the land in time of war, while in time of peace he ensures that no war breaks out.

* [The word prophylaxis ("Prophylaktik") appears in the German original.]

Chapter Seven

THE CONCEPT OF PSYCHOSOMATIC [PSYCHOSOMATIC] THEORY AND TECHNIQUE

§ 77. It follows from the general concept of medical theory and technique that both these must also be the criteria by means of which the student of psychological medicine will be prepared and trained for his work. The theory and technique of psychological medicine is the next subject of this textbook. It is first necessary, however, to give a summary notion of the subjects included in this science with reference to its development, arrangement, and sequence, in brief, in its organic context. This is the more necessary since the science is itself new and does not lean on the artificial architectonics of existing medical systems but follows its own path — that of treatment according to nature.

§78. All true science and art begin from the elements and proceed in a gradual manner from the simple to the complex and from the general to the particular. The technique must be preceded by theory, which itself consists of particular links. These are determined by the point of view which the theory must initially adopt and by the directions in which it must advance. Each natural phenomenon, and thus also each phenomenon displayed by a diseased life (in our case mental life), is intrinsically something conditional, and the conditions of its appearance are its elements. Thus, theory must first adopt a standpoint from which it can survey and present all the conditions of a disturbed mental life. Accordingly, its first link is the science of the elements.

§ 79. Anything created from elements has a certain content and a certain form. The content is simply the definite force by which the elements are joined, and the form is merely the manifestation of the law within which, included and imprisoned, the force is what it is ( §66). The nature of the force is only apparent in its form. Accordingly, the nature of the disturbed mental life is apparent in its form and, inasmuch as it can be disturbed in many different ways, in these different forms. It follows that a theory that is to be used to detect and to expose the nature of mental disturbances must first be applied to the observation and description of these forms. The second link in the theory is therefore the science of forms.

§80. Since observation wakens comprehension, and since it is only through comprehension that we can get a glimpse into the nature of things (§68), the path to the last stage of theory is blazed by the science of forms, which offers nothing but observations. At this stage theory attempts to comprehend the observed, that is, to convert observation relationships into comprehension relationships which not only fully correspond to the observation relationships but also, by explaining the genesis of the forms, reveal their essential nature and the factors giving rise to their existence. This is indispensable if any medical action against the mental life affected by disease is to be contemplated. Thus, the third link of the theory explains the suffering and the activity and, in general, the inner states of the diseased mental life in as far as these are the result of the conflict between its own forces and the destructive powers. And since this third link of the theory discloses to us the substance of diseased mental life, it can rightfully be named the science of substance.

§81. So much for the subject and content of theory. But the theory also yields the elements of the technique, which now need only be singled out and clarified. For the recognition of firstly the elements of sickness which give rise to the disturbed forms of mental life; secondly these forms themselves in their development and mutations under harmful and healing influences; and thirdly the determining forces of which these forms are the outward manifestation, all taken together, makes it possible to counter the elements of disease with the elements of cure. This technique in its first stage, or the first link of the technique, which deals with the search for methods of healing, or better for methods of treatment, is properly known as heuristics.

§ 82. But although heuristics indicates the ways in which help can be offered, if help is at all possible, it does not supply us with the remedy. Heuristics only points to the remedies in general, but a detailed knowledge must be achieved by observation and experience. The ordered arrangement of these, in accordance with the aims of heuristics, is the second link of technique and appears as the science of remedies.

§83. It is now the subject of the third link of the technique to show us how to proceed in accordance with the indications of heuristics in each particular case, how to identify the remedies indicated at every stage of the given case, and in accordance with the kind and severity of the case, how to apply these remedies, singly or together with other aids. This link should also indicate, according to the circumstances, whether the treatment is to remain unchanged or is to be changed. This third link, since it deals directly with the treatment of the disturbed mental life, is rightfully named the science of cure.

§84. The entire system of psychological medicine would be contained in these links of theory and technique, were it not for the fact that helpfulness of the doctor of the psyche either is already utilized by the state in another manner and in another connection or ought to be utilized in future — owing to the specific power and substance of his activity. Utilized already are his skills in connection with legal procedures and in connection with police work; what ought to be utilized should be by the services of upbringing and education, generally. Thus there exists a third part of psychological medicine, namely, the psychosomatic [psychomedical] nomothetic activity, or legislation, for two different fields.

§85. For just as nobody is a better and more thorough judge of mental disturbances, their presence or absence, their kind and degree, the consequences they produce and their probable eventual course, than the doctor of the psyche, so too it is he whose advice is sought by the judge, and by the police investigator of criminal cases in connection with legal cases or orders by the police, when disturbances of the psyche interfere with orderly communal life, and the application of his opinions forms part of legal and police medicine. Thus this subject becomes a subject of police legislation or civil administration that is affiliated with the medicine of the psyche proper, as the first branch of psychosomatic [psychomedical] nomothetics.

§ 86. Secondly, since the doctor also has to provide the means for prevention of possible diseases, and since the doctor of the psyche must have a thorough knowledge of mental disturbances, including their origin from the most remote sources, nobody can have a better knowledge of their prevention than he. It is accordingly his business to collect these means in an appropriate manner and to interrelate them suitably for practical use. This work, which consists in education and training for a life of reason, is the second psychosomatic [psychomedical] nomothetical branch, known as prophylaxis.

§87. We have now completed our description of the concept of mental disturbances (§51 and 52) and thus of the concept of psychosomatic [psychomedical] theory, technique, and nomothetical science. There is as yet no proper system of psychiatry,* certainly none based on the principles stated in this book. The point of view and the direction given by us to this science and art may also serve as a measure of all the efforts so far made to recognize and to treat mental disturbances. In support of our views as presented here it is desirable and even necessary to show that the concepts of the recognition and treatment of disturbed mental life advanced by theoreticians and practitioners of ancient and modern times are narrow, one-sided, superficial, fragmentary, and often erroneous. We should also show that in all these cases it is only the materials, that is, observations, which are suitable for our purpose. It is therefore appropriate at this stage to give a critical history of psychiatry and psychiatric literature from the earliest antiquity to our own days.

* [The word psychiatry ("Psychiatrie") appears in the German original.]

II. CRITICAL HISTORY OF THE THEORY AND TECHNIQUE OF MENTAL DISTURBANCES

FROM EARLIEST ANTIQUITY TO OUR OWN DAYS

Chapter One EARLIEST ANTIQUITY

§88. Before the time of Hippocrates in Greece there is no definite medical theory or art and certainly no medical literature to be found in Greece or any other country. This is even more true as regards the medicine of the psyche. Nevertheless, we have very early records of observations, views, and even treatments of specific kinds of mental disturbances. A brief survey of such records will form a suitable introduction to the historical survey we are about to present. We shall omit the general, indefinite, and unattested traditions of the inhabitants of India and Egypt and shall begin with the Hebrews and the early Greeks.

§89. The oldest Hebrew documents, and the oldest Greek myths and traditions, tell us that mania, madness, and melancholia were known at a very early date, but that such conditions were considered to be brought about by divine or demoniac beings, and the treatment of the sick individuals in their community was guided by these views and varied in accordance with the national character.

§90. The Hebrew records describe a picture of rage (Mania misanthropica. Sauvages) in Saul and of melancholia (Melancholia silvestris, erratica, or else M. metamorphosis, zoanthropica) in Nebuchadnezzar. Suspicion, envy, anger, and hate brought about the rage in Saul. "But the spirit of the Lord departed from Saul and an evil spirit from the Lord troubled him" (I. Sam. 16, 14); "And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him" (ibid., 16, 23), etc. Thus, there was no incense burning, prayers or sacrifices for Saul, but music, and probably also singing. Nebuchadnezzar, King of Babylon (600 B.C.), who had conquered Egypt and destroyed Jerusalem and Tyre, became overbearing, and as a punishment had to roam for seven years among the beasts of the field, himself not unlike a beast with matted hair and a dumb look fixed on the earth. Nothing was done to cure him, for who would want to oppose Divine punishment? He became well again after he had lifted up his head and prayed to the Lord of the Heavens.

§91. According to the account of Josephus [Flavius ] [Book VIII. chap. iii. 5. Antiq., Book VI. chap. viii. 2.], King Solomon already possessed the art of dealing with demons, which he used to help and cure humanity. His seal ring had special powers. It carried the fiery-colored root Baaras, which had been found by the king, and which sent forth a radiant gleam, especially in the evenings. (In the times of Josephus, Solomon's art of driving out the devil was widely practiced, and Josephus tells us how this was done. The patient had to inhale the odor of the root, and thus the demon was extracted from the body with the nasal mucus.) Feigned madness, moreover, was known as early as the time of David. David himself managed to save his life by this expedient (I. Sam., 21, 14-16): "... and feigned himself mad in their hands ... " by salivating and making marks on the doors of the gate. King Achish then reproved his servants: "Lo, see the man is mad: wherefore then have ye brought him to me? Have I need of mad men ... ? " which shows that even in those days many were afflicted by such diseases and could be recognized by certain symptoms.*

§92. According to the oldest Greek myths, Orpheus (1511 B.C.) saved Eurydice from Persephone through the power of his lyre. What else can this myth signify but a cure of melancholy by music? According to Herodotus, 120 years before the expedition of the Argonauts, Melampus cured the madness of the daughters of Proetus, of whom Virgil speaks:

Proetides implerunt falsis mugitibus agros

by the application of Helleborus albus (our Varatrum album; cf. Hahnemann: dins. de Helleborismo Veterum. Lips. 1812). A similar kind of madness (lycanthropia, kynanthropia), in which patients howled like wolves, barked like hounds, and prowled in the fields and around cemetery tombstones at night, was reported by Marcellus Sideta, a contemporary of Galen, to be epidemic, and even hereditary, in Arcadia in the month of February. Polybius (Hist., IV. 20. 21.) praises the law givers of Arcadia for commanding citizens who tended to suffer from melancholia to engage in music. The madness of Scythians (Melancholia Scytharum) who, according to legend, thought themselves changed into women, was also an epidemic disease. Examples of rage in antiquity are given by Hercules and Ajax; examples of madness brought about by the Furies (accompanied by epilepsy) are presented in Orestes, Athamas, and Alkmaeon; examples of depression and melancholia, by Bellerophon, who, according to Homer, was detested by the gods who imposed a curse upon him:

* Carus, Psychologie, Vol. V, p. 420 ff. See ibid., p. 398 ff. for Hebrew nomenclature of morbid states of the psyche.

Qui miser in campis moerens errabat Aleis,

ipse suum cor edens, hominum vestigia vitans.

Cicero, after Homer.

§93. We consider this to be the most suitable place to cast a glance at the course of development of mental disturbances themselves. In the earliest, vigorous antiquity they were manifested as the most violent affections and passions, namely, wrath (Erinna) and vengefulness (the avenging Erinnies), and occasionally as rage and frenzy, which are isolated outbursts of unrestrained passion. These were rough and heroic times. A second period includes the ecstasies of imagination, the raging, erotic, wildly poetic enthusiasm (Maenads, Cassandra, Pythia), the dream-madness accompanied by cramps, contortions, and epileptic convulsions. This could be called the poetic era. The third period is that of a more artificially organized society. The advance of civilization, increased material wealth, luxurious living, make loss of happiness, riches, or honor unbearable, and open the gates to melancholia and madness.* As we enter the era of positive religion, we encounter fanaticism and religious melancholia; a still later period, in which metaphysics were literally believed, brought systematic insanity and craziness.** Foolishness and idiocy are the children of the last weakness and enervation of an age degraded by unnatural acts and enervated by debauchery. t

§ 94. As we can see, the development of mental forces in humanity is accompanied by an ever-advancing, ever-more-degraded degeneration of these forces. This is true of periods in world history in general and in the history of every particular nation, for every nation gradually passes through the same cycle from birth to decay. However, this order and this sequence are not invariably or inevitably displayed, and, as in any other case, this rule is broken by exceptions which arise at all times. Madness and melancholia were known in the earliest times — though they were not typical of those periods — as much as frenzy* in most recent periods. The climatic differences between nations greatly affect the principal and most widely spread forms of mental disturbances. The character of northern and southern peoples, of hot and cold, dry and wet regions is faithfully reflected in the manifestations of the diseased psyche. In the ancient era the differences between India, Egypt, Palestine, and Greece were just as great as the differences we perceive today in Europe, the origin of all modern culture and all modern decay, between Spain, France, England, Holland, Germany, and Switzerland. We shall speak of more anon.

* [In German: "Wahnwitz" (not "Wahnsinn").]

** (In German: "Aberwitz".1

t Cams, Psychologie Vol. II, p. 224 ff. and Vol. V, p. 394 ff.

§ 95. Finally, a study of the kind and degree of recognition and treatment of mental disturbances observed in early antiquity shows that these bear a striking imprint of the childhood of the human spirit. The imagination of a child, who comprehends all natural phenomena poetically and to whom every natural event must have a supernatural cause (which shows, at least, a vivid imagination and a promising potential), was also displayed in the judgments and procedures of the ancients. To these peoples, the manifestations of a diseased soul were not human and had no human origin but were something produced by higher powers, which could only be removed by propitiating these angry powers. Hence, there were priests and witch doctors with their prayers, incantations, recipes, magic formulas, incense burnings, prescribed purification rites, and other cures of this kind. Indeed, even music and the use of music were not separated in those days from their relation to the higher powers. Music, accompanied by religious dances and chants, was a magic device to influence the demons. Even medicinal herbs and roots were gathered and utilized during religious ceremonies; and to regard this as deceit by the priests and superstition of the people is to misjudge the character of those times and customs, whereas one should speak merely of a childish mentality and childish illusions. Deceit and superstition belong to later periods and to more degenerate customs. Moreover, fear of the gods, faith in the priests, and an imagination stimulated by the sensual religious customs, practices, and consecrations may well have produced many a cure; in our times this can neither be denied nor proved.

[In German: "Tollheit."]

Chapter Two

HISTORY OF THE, RECOGNITION AND TREATMENT OF MENTAL DISTURBANCES BY THE GREATEST PHYSICIANS OF ANTIQUITY WHOSE WRITINGS ARE EXTANT

§ 96. When they emerged from their childhood, the great nations of antiquity discarded their primitive views. Owing to the newly awakened spirit of exploration and to the speculations in philosophers' schools, the world of imagination, the rule of the gods, and the world of the spirits had had to yield ground to the material world, and the study of the nature of things was now based on their physical elements. The attitude adopted by the Greeks and others in their study of diseases was affected in the same way. An account of the spirit of Hippocratic medicine is outside the scope of this book, and we shall content ourselves with a survey of Hippocrates' writings insofar as they deal with the rudimentary theory and art of treating mental disturbances.

§ 97. We shall begin by outlining the concepts of mental disturbances and their main symptoms in the sense in which they occur in the writings of Hippocrates; we shall then follow the semiotic, diagnostic, and prognostic observations in these writings and we shall end with the scanty indications of treatment found therein. We point out at the very outset that these writings form the origin of the views and manner of treatment which were followed by all physicians, from the time of Hippocrates down to our own times. Manifestations of diseased mental states are believed to originate from the bodily organism as regards both their nature and form and, except in isolated cases, are so treated. We believe that this attitude has been responsible for numerous theoretical and practical errors and is the reason why medicine of the psyche as a special science was only born in our own days. Nowadays, we have indeed a freer view and a deeper understanding of human nature, which paves the way for medical advances, whereas to an observer living during any period between antiquity and our own days, such a view could only appear for a lightning moment, only to disappear immediately again into the darkness of the night.

§ 98. Hippocratic writings differentiated between passing and permanent, feverish and nonfeverish states of confused speech and of irrational speech and action in general. Temporarily confused speech was named paraphrenitis, while permanently confused speech, which is a symptom of the disease, was known as phrenitis or paraphrobyne megale with complementary names such as meta gelotos, meta spoydes, etc. The expressions parakopsai, exenai, manenai, ekmanenai, are also used to describe mad ravings accompanied by violent gestures; the same phenomena in a milder form are named leresai, paraleresai, paraphronesai, and parenekhtenai.* The general name for all conditions of this kind is paranoia which is the common feature of phrenitis, melancholia and mania. A striking illustration thereof may be found in the Book of Diseases (Ilippocr., Opp. Foes., page. 460. 50.), where hints as to the origin of these conditions are also presented: "But also those suffering from phrenitis greatly resemble melancholics as regards their confusion. For the melancholics, when their blood is destroyed by bile and mucus, sink into a confused state; some of them rave as well. This is also true of phrenitis. But both mania and confusion decrease when there is less bile than mucus in the blood." Bile and mucus recur again and again, and indicate a purely bodily disorder. As a clear proof thereof we may quote: melagkholika** algemata (pains caused by spoilt (body] juices, possibly gout) and met. nosemata (Aphor. 56., libr. 6 and Aph. 40. libr. 7), which mean apoplectic fits and convulsions. Sometimes mania and melancholia are distinguished in these writings from phrenitis and from each other, but not consistently so. Thus, the term melagkholia may be used to denote a certain mood, a morbid tendency of the body (De aere, aquis et locis, p. 288, 6; De victus ratione in morbis acutis, p. 403. 36.; De affectionib., p. 325; De morbis vulgaribus, p. 1090), or to denote craziness} in general (De morb., pag. 460. 48), even when accompanied by fever (ibid., 460. 45). Conversely, the term mania may mean no more than intense feverish ravings (De judicationib., p. 55. 41.; De morbo sacro, p. 460. 59) or a disease accompanied by anxiety and depression, namely, melancholia (De victus ratione, libr. II, p. 351. 50 — Aphor., VI, 21). However, according to Aph. VI, 23., the word "melancholia" has definitely and exclusively the last-named significance: "When fear or depression (dysthymie) persists for a long time, then it belongs to melancholia." On the other hand, mania which is manifested by violent, angry ravings, is differentiated from melagkholia and, owing to the absence of fever, from phrenitis (Aphor., III, 20-22 and VI, 56 — De morb., libr. I, p. 460. 30-44 - De morbo sacro, p. 309. 1-20 - De morb libr. I, p. 461; libr. II, p. 486).

* [Where the German text gives Greek words in Greek script, the letter chi (x) has been rendered into kh.]

** From melagkholikos--Greek for "black bile."]

t [In German: "Tollheit."I

§ 99. The symptoms compiled in Hippocratic writings (after Zwinger, Opusc. Hipp. Aphoristico - Semiotica, Basle. 1748) instruct us best on how far the eye of the observer has penetrated and on which sights it rested longest.

We list the symptoms in the following groups (after E. H. DOring, Hippocratis doctrina de deliriis, Marburg, 1790): A) signs of approaching attack; B) signs of attack in progress; C) signs of abatement. We must however remember that in no case is it stated if the symptoms described are those of independent mania or melancholia or only of a disease accompanied by fever; the last-named case must have been the most frequent. For the sake of brevity, we shall merely cite these symptoms.

A) signs of approaching attack

1) Unbecoming, frequent, useless expectoration (phrenitis). Praediction., 1. 6; Coac., 94.

2) Stubborn silence (confusion of reason). Praedict., 1. 54.

3) Talkativeness, nasty replies (fury). Praed., 1-26 and 44.; Coac., 51.

4) Unusual behavior (delirium). Coac., 47.

5) Trembling tongue (confusion of reason? ). Coac., 253.

6) Dry tongue (phrenitis). Coac., 254.; Praed., 1. 3.

7) Palpitations in precordium and rolling of eyes (delirium and fury). Praenot., 31.;Praed., 1. 36; Coac., 282. 298. 300. 302.

8) Buzzing in the ears (fury). Praed., 1. 18.

9) Pain in the side (delirium). Praed., 1. 22.

10) Tossing about (phrenitis). Praed., 1. 27.

11) Deafness (confusion of reason). Praed., 1. 52.

12) Restlessness, sleeplessness, pale-colored urine, sweating of head (phrenitis). Praed., 1. 4.

13) Bilious vomiting (confusion of reason). Praed., 1. 10.

14) Lockjaw (phrenitis). Praed., 1. 11.

15) Intensification of fever (phrenitis). Praed., 1. 15.

16) Trembling (phrenitis). Praed., 1. 34.

17) Rigidity (confusion of reason). Praed., 1. 35.

18) Lassitude with diarrhea, headache, thirst, sleeplessness, muttering, motionlessness (confusion of reason). Praed., 1. 38.

 

B) signs of attack in progress

1) Insensitivity to pain (disease of reason). Aphor., II. 6.

2) Unnatural position (delirium). Praenot., 13.; Coac., 497.

3) Gritting of teeth (fury). Coac., 235.; Praenot., 15.; Praed., 1.48.

4) Glittering eyes (confusion of reason). Coac., 351.

5) Deep, slow breathing (delirium). Praen., 19.

6) Dirty, dusty eyes (fury). Praed., 1. 17.

7) Trembling voice (fury). Praed., 1. 19.

8) Thirstlessness, sensitivity to noise (phrenitis). Praed., 1. 16.

9) Anxiety and sadness (melancholia). Aphor., VI. 23.

 

C) signs of abatement

1) Increased delirium after suppression of monthly purification. (Result: mania and melancholia). Praed., I. 123.

2) Blood in stool, dropsy, sporadic fever. (Result: recovery from insanity, (mania)). Aphor. VII. 5.

3) Hemorrhoids and knotted veins (dissolves mania). Aphor., VI. 21.

4) Placid sleep (dissolves delirium). Aphor., II. 2.

5) Dreams (good sign with phrenitis patients). Coac., 90.

6) Shivering in fever (dissolves delirium). Aphor., VI. 26.

7) After hemorrhage, vomiting, the swallowing of intestinal juices following upon a stitch in the side, head injury, or sleeplessness, delirium is a bad sign. Aphor., VII. 10. 11. 14. 18.

8) Violent mania that changes into mild madness is a bad sign. Prorrhet., I. 53.

§ 100. One can see that the observations were always concentrated on feverish conditions rather than on chronic, independent mental disturbances. Mania and melancholia are hardly ever mentioned. save in generalities. An example is a note saying that confusions of the reason arc most frequent in spring and in autumn (Aphor., III. 20. 22). Only rarely Hippocratic writings indicate any treatment of mental disturbances. In one single instance (Hippocr., Pero manies, ed. Gruner) - and even this case is based on a quoted document - there is a reference to the causes, variety, and treatment of individual mental disturbances, namely that "a diseased condition of the brain (§ 98) is the result of bile and mucus, the former producing raging melancholia, and the latter quiet melancholia; insanity (mania) can be healed by bloodletting, water with honey, infusions of hellebore (veratri pocula)." In yet another place there is mention of baths (fomentationes) which should precede treatment by hellebore (About the Diet, I. 33.). "The madness of these patients (the description is probably that of melancholia) is of a slow nature; they weep even if no one offends them or beats them; they are afraid of things which are not dangerous, saddened by things not their concern, and their ideas are not those of sensible men. Baths are useful for such patients, followed by purging with hellebore." Again (ibid., 36.): "those in whom madness is milder and those only approaching madness should be suitably purged by hellebore, after they have been prepared by baths." For general remarks on the application of (white) hellebore see Aphor., IV. 4. 13. 15. 16.; V. 1. 4.*

§ 101. It is clearly seen that at the time when Hippocratic writings were compiled there did not exist even a rudimentary theory or art of medicine of the psyche, but these writings nevertheless gave rise to a narrow-minded view of mental disturbances and their treatment, which view grew and flourished in the course of the centuries which followed. Thus (§ 97) the observation of somatic appearances of mental disturbances, being directed more at the passing disorders appearing during fevers than at the chronic, independent kinds, led the observers to look for the nature, the origins, and the remedies of such conditions in the bodily organs, forces, and constitution, so that a false trail was followed from the very first up to the latest times. The observations of the diseased conditions as given in the Hippocratic writings, which, although faithful, are immature in their interpretation, have remained the guiding principle of the most eminent physicians of all the periods which followed. Those who trod a different path, instead of aiding the development of the theory and of the art, lost themselves in their own obscure speculations and they abandoned plain truths for the sake of artificial illusions. The further development and intertwining of both these elements form the subject of the history of medicine. Only the most important landmarks in the history of medicine of the psyche will be outlined below.

* J. H. Schulze (resp. Th Israel) De Elleborismis Veterum, 4, Hal. 1717. Sam. Hahnemann, De Helleborismo Veterum, 8, Lips. 1812.

§ 102. Many schools and sects of medical philosophy flourished in post-Hippocratic times, up to the disappearance of all true and false science in the so-called barbarism of the Middle Ages. It is with full justification that we omit these famous but hollow names and from a period of almost a thousand years mention only the very few men whose writings, next to those of Hippocrates, make the bright starlight of ancient medicine shine even in our own days. We proceed to outline the heritage of the theory and art of medicine of the psyche left to us by Cornel, Celsus, Aretaeus, Galen, Caelius Aurelianus, Aetius, and Alexander of Tralles. In passing, however, we shall first mention an anecdote told about Erasistratus, who performed the famous mental cure on the lovesick prince Antiochus, son of the Syrian king Seleucus Nicator (304 B.C.). Erasistratus, who was the pupil of Chrysippus, diagnosed the disease of the prince by observing his changed color and trembling and palpitations which appeared whenever his stepmother Stratonice entered his room. The cure is well known but must be attributed to the genius of the man rather than to the advanced art of healing of his days. It was inspired by sound common sense.

§ 103. A. Cornelius Celsus was not a Greek, and lived a few centuries after Hippocrates according to S. Sprengel, Geschichte der Medizin [Medical History]; he lived during 3-14 C.E., under Tiberius. After the Father of Medicine, he is the first writer worthy of our consideration. He lived one hundred years before Galen, and in the preface to his treatise, written in the classical Roman spirit, he stated that medicine is an art which is only a few hundred years old and mentions Hippocrates, Herophilus, Erasistratus, and Asclepiades as his only predecessors. By that time medicine had radically changed, owing to the controversy between the empiricists and the rationalists, and Celsus' steady, clear spirit, rising high above the heated partisan disputes of his days, pointed out the golden rule, namely, that neither the general nor the particular must be neglected in medicine. The references to the diversity of mental disturbances found scattered throughout the Hippocratic writings like seeds that have not yet germinated have been recapitulated and developed by Celsus (De Med., libr. III, cap. XVIII.) systematically but briefly and have been characterized by a few, sharp distinctive marks. He is more accomplished than Hippocrates, and his science is more advanced. However, he gives no detailed descriptions of diseased states but merely the diagnostics which are needed in order not to go astray in the treatment. For him treatment is the main thing, and he prescribes treatments without specifying his reasons therefore, for he is an artist of medicine and refused to deal with subtleties. However, his art is still marked by various deficiencies and imperfections, as will be seen when considering the views of this classical writer.

§ 104. The condition which is generally referred to as paranoia in Hippocratic writings, and which we would denote as dementia or loss of reason, Celsus calls insania and divides it into three forms, the first of which he calls phrenitis. Strangely enough, the other two forms received no names, and the fact that Celsus never uses the words mania or melancholia is no less strange. His three forms are based on their different durations. Phrenitis is nothing but acute mania, which is displayed by different patients to various extents. Prolonged delirium is common to all, but some patients are gay, others sad; some are easy to restrain, others are difficult; some are simply wild, others are reticent, dissembling, sly, or enterprising. The former can be left free, the latter must be restrained, and no regard must be paid to their apparently reasonable requests and entreaties: "quoniam is dolus insanientis est." Some of them cannot stand light, others cannot stand darkness, and it is necessary to act according to circumstances. During the first attack there is no other way than to hold the patient fast. During an emergency, however, if their strength is sufficient, the patients are bled, given purgatives, their head is shorn, they are given bitter herb fomentations and sneeze-producing agents, one after the other. Finally, after the fever has abated, frictions are applied, and sad patients need this more than happy ones. The treatment of the psyche must be individual for each patient: the shy ones must be encouraged, while the wild ones must be restrained, if necessary by blows. Undignified laughter should be counteracted by reproof and threats. Morbid thoughts must be dissipated with music or noise. However, the patients must be agreed with rather than contradicted, and their reason must be brought back to normal only gradually and in a roundabout way. Sleep, which is so necessary to them, must be ensured by treatment with soporifics, for example washing the scalp with poppyseed water while applying light friction. A cupping glass placed at the back of the head provides relief and sleep. The diet should be light; honey water should be given as a drink.

§ 105. The second form of insania takes a longer time and fever is almost absent. It is manifested by sadness, which seems to originate from black bile (melancholia). Celsus proceeds to give the treatment without any further description. He recommends bleeding when necessary, vomiting, and purging by white hellebore, twice-daily frictions, and intense exercise as soon as practicable. Anything that inspires fear in a patient should be avoided; the patient should be encouraged and distracted from brooding.

§ 106. The third form lasts the longest, is the least dangerous to life, and the patient feels no bodily discomfort (craziness). This may take two forms: either the imagination calls forth unreal images (insanity), or else the reason is bound by perverted ideas (folly).* First of all one must watch whether the patient is sad or merry. The treatments are black hellebore for purging if he is sad and white hellebore to induce vomiting if he is merry. Both treatments must be periodically repeated, according to circumstances. The craziness of reason** (si consilium insanientem fallit) must be treated with severity. Absurd speech and actions must be punished by deprivation of food, restraint, and blows. The patient must be forced to notice, to retain things in his mind, and to remember. In this way he is taught reflection through fear. In the treatment of this disease it is also useful to startle the patient or to give him a bad fright suddenly. As the patient recovers from his perverted state, the treatment is changed. It should also be watched whether the patient laughs or is sad and depressed without reason. The merriness of the insane patient is best treated by the system of sudden frights, as above. Sadness is treated by lightly applied, prolonged twice-daily frictions, pouring cold water over the patient's head, and oil baths.

As a general rule, all mental patients (insanientes) need much exercise, much friction, and a light diet without wine (wine should only be given if the disorder originated from fear). The patient must not be left alone, with strangers, or with people to whom he is averse. He must change his surroundings and must make a long journey every year following recovery.

§ 107. The system of Celsus deserves to be discussed in detail. We can see in him the doctor of the psyche, and since no earlier writings on the subject are extant, we may greet him as the first writer on the medicine of the psyche, even though his views may be in part based on those of Asclepiades, who should probably be considered to be the father of medicine of the psyche, as we shall see later. The prudence displayed by Celsus in the treatment of the psyche, his scrupulous attention to circumstances, his expedient distribution of remedies by kind and by degree, are exemplary. He has as yet only a dim idea of the nature of the diseases of the psyche, but he already calls it: corporis affectus, qui certis partibus assignari non possunt. That he differentiates between three forms of loss of freedom (insania) in accordance with their duration testifies, too, to his prophetic insight into the nature of these disorders with reference to the acute general tension or the progressively longer-lasting relaxation of the individual organs of the sensory system caused by the different intensities of stimulation of the psyche. In acute mania, the orgasm* is strongest; this disease resembles an inflammatory fever. This is also why he names the disease phrenitis, that is, inflammation of the soul. According to Celsus, melancholia tends to be chronic (spatium longius rccipit) i.e., it is midway between acute and fully chronic and is so partial that it does not even interfere with the vital functions (ut vitam non impediat). His third form is insanity, and this keen diagnostician subdivides this disorder into madness and folly. He gives no detailed description of any of these forms, but his descriptions suffice to identify each disorder and to apply the required treatment. Thus, Celsus cannot claim to have invented anything in somatics but has outstanding merits in the domain of the psyche. We can therefore confidently say that, next after Asclepiades (§ 109), it was he who laid the foundations for the medicine of the psyche or, rather, continued to build on them.

(In German: "Wahnsinn" and "Wahnwitz," respectively.( tin German: "Verstandesverrticktheit."]

§ 108. Aretaeus of Cappadocia is the nearest in time to Celsus (81 C.E., under Domitian) and is famous for his excellent accounts of various diseases. The fifth and sixth chapters of his book On the Causes and Signs of Acute and Chronic Diseases contain a description of melancholia and mania. He refers to melancholia as sadness of the soul brooding over one object (athymie epi mie phantasie) and adds that fever is absent. "It appears when the black bile rises upwards, into the stomach and the diaphragm. Since, however, the word bile (thole) is synonymous with anger, raging patients are also called melagkholikoys, and, in general, melancholia seems to be the first stage of mania and a part thereof (mimics arkhe kai meros)." This important passage attracted the attention of many physicians living at later times, who generally accepted and faithfully followed the description of Aretaeus. More of this later. According to Aretaeus, the only difference between melancholia and mania is that in the latter violence is always a constant feature, whereas the former is manifested in different ways, such as fear of poisoning, fear of men, religious phantasies, or a tendency to suicide. Aretaeus believes that the seat of melancholia is in the precordia. If the head is also affected, we have mania, which occurs more often in men; in women this disorder is rarer but its form is more violent. Melancholia typically affects the middle-aged and appears in summer and in autumn, while spring is decisive for the cure. Aretaeus ends with a detailed description of the symptoms and the course of melancholia. Mania is a permanent confusion of reason, not accompanied by fever or only by sporadic fever. Delirium brought about by drugs is not mania, since it is transient, while mania is a permanent condition. This concept must also exclude amentia senilis which, though permanent, is a state of weakness, while mania is a state of strong excitement. The latter proceeds without interruption and is incurable, while the former is intermittent and can yield to skillful treatment. There follows a detailed description of mania. This gives a sufficient example of Aretaeus' embracing sense of observation, which lighted the way of physicians living in more recent times. Observation is the principal merit of this writer, for his treatment of disorders is in no way outstanding, at least as far as we can judge from extant writings (De curatione morb. diuturn., libr. I, cap. V). No word is said about treatment of the psyche, but much is made of bleeding, cupping, vomiting, and purging; here, too, hellebore is the main remedy.

* [The word is used in the German in the sense of "crisis."]

§ 109. Caelius Aurelianus, who seems to have lived before Galen (see, for example, J. G. Voss, De nat. artium, libr. V, cap. 12) and, like Soranus, to have been the contemporary of Trajan and Hadrian, gives (Morb. Chron., libr. I, cap. V and VI) a description and treatment of mania and melancholia which are more detailed, systematic, definite, and precise than those given by Aretaeus, especially as regards mania. He begins by presenting a whole etymological glossary of the word mania, then speaks of a slower or more rapid origin of a chronic confusion of reason in the absence of fever, namely that mania which is distinguished from phrenitis by this very absence of fever and appears more frequently in young and middle-aged men than in women, boys, or old men. He immediately attributes the origin of the disease to hidden or open reasons such as intemperance, specifically to psychic intemperance. (in which he is in agreement with Aretaeus): frequent waking at night, love, anger, sadness, fear, and spurious religious feelings. He then lists the symptoms of the onset of the disease. It is noteworthy that he explicitly denies that mania is a disease of the soul, firstly because philosophers found no cure for it, secondly, because it is preceded by bodily disorders. In his treatment of the disease he insists most of all on the exclusion of external stimuli (light, visitors), on the proper training of the male attendants, and on other psychological precautions: for example, that means of arousing fear be abandoned if they have lost their efficacy or if they have no effect at all. He was the first to have mentioned leeches as a somatic remedy. He preaches the classical method and gives this name to his treatment, in honor of the school to which he adheres. He attributes just as much importance to sleep as his predecessors. Psychological remedies are recommended for convalescents: reading and speaking exercises, theatrical performances; in any case, entertainment for each patient after his own manner: not for the farmer as for the sailor, etc.; games only for persons without any education at all. He believes that bodily exercise is particularly healthy. Naturally, neither baths nor frictions are omitted. Finally, he disproves the methods of Asclepiades and Themison, and thus we are able to become familiar with them. Especially as regards the former, he objects to his use of singing (music), whipping, compulsion to regular emptying of the bowels, binding, coercion through hunger and thirst, and cures through wine and love. Though not agreeing with his objections, we are thankful to him for stating them, since we learn in this way that Asclepiades was a wise physician and esteem him as the father of the medicine of the psyche, whose teachings were apparently put to better use by Celsus than by Caelius Aurelianus.

§ 110. With melancholia Caelius Aurelianus deals much more briefly than with mania. According to him, sadness is the principal feature of this disease. It is encountered more frequently in men and in middle-aged persons than in women and in persons of other ages. This disease is caused by failure of the digestive tract, sadness, and fear. His description of the symptoms resembles that of Aretaeus. The treatment is the same as for mania. As a consistent methodologist, he objects to bleeding and to the use of hellebore, which means that he throws away the child together with the bathwater, and by recognizing solely strictum and laxum, he exposes himself to the charge of one-sidedness. If he had only read Celsus!

§ 111. Only at this juncture is the stage set to present the great, world-famous Galen (161 C.E., under Marcus Aurelius and others). We find, however, that little or none of his genius was devoted to mental diseases. His book on the recognition and treatment of diseases of temperament is little but a title without any content and in any case does not concern us here as it is merely a condemnation of the customs and morals of his age. Subjects that might be of use to us are found only in scattered fragments, such as: Andr. Lacunae Epitome opp. Galeni, Bas. 1551 ; De loc. affect, libr. III, cap. 3 (in chapter 6 he distinguishes between three kinds of melancholia); De symptom different., pag. 666. 16; De causs. sympt., libr. II, pag. 683. It all has already been stated by older writers but here is forced into Galen's artificial, that is, unnatural system. There is nothing on the treatment of mental disturbances in his genuine writings. Writings ascribed to him but recognized as not genuine contain nothing that has not been said before, and psychological remedies are not mentioned. The brevity with which Galen is mentioned in this hook is a measure of his significance in the domain of the medicine of the soul.

§ 112. After Galen follows — as a servant following his master, yet after a long period of time (300 C.E., under Julian) — Oribasius, nicknamed by ancient physicians "the ape of Galen," though he quotes other authors too. For our purpose, he is only a compiler. Moreover, only a fragment of his essay on melancholia (Synops., I, VIII. c. 7) remains, for it begins with the third kind of melancholia, which is nothing but hypochondria. The main symptoms are fear and sadness, and the cure consists of baths and good nourishment. Persistent cases are treated by aloe, absinthe, colocynth, and black hellebore. He, and many of his successors, differentiate between melancholia and insania, the latter being the mature fruit of the evil of black bile. The title of his short article on the subject is ex Philumeno. The treatment of insania (madness, insanity, folly) is the same as that of melancholia. The tenth chapter deals with lycanthropy (from Marcellus), which is apparently a special kind or a special degree of melancholia: nightly prowling in deserted places, howling like dogs or wolves, etc. The description must have originated from an able writer, for the image of the patient is very vivid. It was reproduced by that old copyist, Aetius, who was clearly very pleased with it.

§ 113. Aetius (543 C.E.) is also only a compiler of our science. He begins by presenting Posidonius' extraordinary interpretation of phrenitis. For the first time this disease is stated to be an inflammation of the brain membranes, accompanied by high fever, etc. If the frontal part of the brain is affected, there appear disturbances of the imagination; if the middle ventricle of the brain is injured, there are disturbances of the reason, while injuries to the brain at the back of the head result in disturbances of memory. Pothen ayte e sophia? As to the description of insania (after Archigenes and Posidonius), we notice a certain development and refinement in the concepts inherited from antiquity. Confusion of reason without fever but accompanied by laughter and singing or by sadness and anger are caused by the penetration of pure blood (in the former case) or blood mixed with yellow bile (in the latter case) into the brain. If this affection is gradually processed by the body itself, the disease disappears of itself but recurs owing to new accumulations; this is often periodical and happens once or twice every year. Middle-aged persons, passionate and intemperate persons, persons with impaired digestions or suffering from suppressed blood evacuations, tend to suffer from this disease. Its precursors are laughter or anger, buzzing in the ears, black spots before the eyes, insomnia, fear, and a heavy head. Thereafter, the disorder increases in intensity until it can no longer be restrained. The cure consists of a light diet and bleeding, after which the patient must be coaxed into sleep, for bloodletting followed by insomnia is harmful. If the attacks persist, local treatment is indicated, namely, bloodletting from the central vein on the forehead and leeches applied to all parts of the head. Towards the end of the disease the treatment consists in baths and hellebore. We shall now give one more quotation from Galen and Rufus on melancholia. The initial stage is that of hypochondria, but this may easily lead to fixed ideas. Philotimus effected a psychological cure of a patient who believed he had no head by placing a leaden hat on his head. Rufus explains the fear which manifests itself in melancholia by inner darkness produced by black bile, since darkness is something to be feared. He explains that sad melancholia is caused by black bile which is already present in the temperament or else is produced by a faulty diet; wild melancholia, on the other hand, is produced by yellow bile. How the poor spirit of man twists and turns to create light from darkness! He prescribes the usual cure, but ends by making a truly wise remark, stating that the patient often recovers only when he needs nothing more on this earth, and that cures must be periodically interrupted. Finally: De insania lupina, ex Marcello (cf. § 112 on Oribas).

§ 114. Alexander of Tralles was a contemporary of Aetius and one of the last writers on medicine before the eclipse of science in the Middle Ages. He is the prince of them all, because of his keen, careful observations, his complete, orderly, clear exposition, and his reasonable, practical recipes for treatment based on his own experience, Antiquity knew of no more perfect doctor of the psyche. We shall omit his masterly presentation of phrenitis, since matters closer to our own subject are more urgent. He includes the entire field of mental disturbances (De arte medica, libr. I, cap. 17.) under the concept of melancholia in the wide meaning of the word. The same disease may manifest itself in many different ways, in accordance with the coincidence of many different causes, and also depending on whether it is acute or chronic. Thus a disease may manifest itself in merriment, anger, apathy, fixed ideas, fear of death, or hope for death; and it may be intermittent or permanent. Middle-aged, gaunt persons of dark complexion who do not eat well, are inclined to worry, and in whom the usual blood evacuations are suppressed are candidates for melancholia. Its first symptoms are a red face, swollen veins, spots before the eyes, etc. The cure begins by bleeding at the arm or at the leg and most be followed by local treatment.

Deeply rooted melancholia becomes almost incurable and develops into a periodic mania, from which it differs only in degree. The correct treatment is drastica and baths but not bleeding, as the ancients believed.

Chronically melancholic, mad patients are described. Several instances of cures effected by psychological means are given. These include the leaden hat of Philodotus.* In another cure, Philodotus gave an emetic to a woman who thought she had a snake in her stomach, secretly introduced a snake into the vessel, and thus effected the cure. Alexander himself noted that a woman who had become melancholic while her husband was away was cured by his unexpected return. Rooted melancholia cannot be cured by psychological but only by somatic means, such as drastica [drastic purgatives] or baths. If even these are without effect, Alexander recommends the use of the Armenian stone (copper vitriol? ), which he prefers to white hellebore. After the patient has regained strength due to good nourishment and baths, he must be distracted and encouraged and must return to his usual occupations. If a residue of the disease has remained after the cure, a second, similar cure should be effected at a suitable season of the year and should be pursued in moderation but with persistence, when the stubborn, apparently incurable, disorder will yield to the treatment.

§ 115. The line of physicians up to the early Middle Ages concludes with the compiler Paul of Aegina (630 C.E.). In his paper De re medica (libr. III, cap. 11) he begins by mentioning idiocy, which manifests itself as loss of reason and memory. In accordance with the teachings of Galen, he attributes the disease to a bad mixture (intemperies), namely, the preponderance of wet, dry, and hot, etc., elements. The cure is chosen accordingly (cap. 14, De melancholia et insania). There are three kinds of melancholia: brain melancholia (mania), general melancholia, and wind melancholia (flatuosa), which is the same as hypochondria. The symptoms, the causes, the treatment, are all copied from other authors. One recognizes the ideas of Camel. Aurelianus and Alexander of Tralles. Likewise are chapter 6 (De lycanthropia) and chapter 17 (De amantibus) (about the libertines) copied from earlier writers.

§ 116. This completes our survey of the heritage of psychological medicine left to us by antiquity. A. Cornel. Celsus, Aretaeus, Cael. Aurelianus and Alexander of Tralles, who were independent thinkers, are the founders of psychological medicine. To the others we are grateful inasmuch as they preserved for our use many a note of the eminent physicians which otherwise would have been lost. A general glance at the views of these old masters tells us that, although they were not familiar with the nature of the disorders against which they fought and to which they then assigned the terms melancholia etc., they already knew the most important measures to be taken in such cases, which is after all what matters most. Precisely those ideas on which all of them prided themselves most, namely, that disturbance of mental activities is caused by a corporeal matter such as yellow or black bile — or else, if this idea is rejected, by general qualities such as strictum and laxum — precisely these ideas prove the investigator's urge to obtain a clear picture of matters and the inadequacy of means at his disposal for this purpose. Far be it from us to smile at the scanty, one-sided, hypothetical explanations of the ancients, much less to despise them, for we ourselves are condemned to similar ignorance. If we have become wise, we have learned from the advanced research that has taken place during the past centuries that it is best to refrain from any attempt at explaining the manifestations and to be content with the search, by diligent observation, for the simplest laws governing them. We may consider ourselves successful if we have succeeded in discarding all erroneous views and interpretations, since these cloud the observing eye of the investigator, make the treatment uncertain, and result in innumerable fruitless efforts.

[Ascribed to Philotimus in §113.]

§ 117. We must now ask if that which we have presented so far is really all antiquity has to offer us in the way of research and treatment of mental disturbances, and nothing more has been transmitted to us up to the beginning of the Dark Ages. Does it not boil down to a few descriptions of imperfectly differentiated forms of diseases and (with a few noteworthy exceptions) of equally imperfect treatments of individual cases, not even confirmed by a faithful presentation of accomplished cures, but only prescriptions amounting to dead letters, to be taken on trust because their underlying reasons are not understood and their success cannot be proved? This is indeed so, we might be tempted to say: alas! indeed so if we had any right to expect infantile experiments of an early world to yield more than they really can. These experiments, in their presentation, interpretation, and treatment, are the highest peaks to which the thinking man of antiquity was able to rise and which were expressed through the words of a few individuals. As to the nonthinking man of that time, all we can say is that he failed to think. This judgment applies not only to uncivilized nations but also to the nation which determined the character of modern times and which had a decisive influence on the entire world of ideas of recent centuries, the Hebrews. The early ideas of the Hebrews on mental disturbances (§§90 and 91) were carried over to later periods with the gradual spread of Christianity. Their world at that time swarmed with demons, and their old, pure belief in miracles degenerated into numerous forms of superstition introduced by the different peoples with whom they came into contact. The Jews had become familiar with the art and practice of Egyptian, Chaldean, and Persian sorcerers and magicians from the earliest times, with the result that already in the first centuries of the Christian Era, the occult sciences of magic — mixed with misunderstood Pythagorean and Platonic ideas, Kabbalah, theosophy and theurgy — gained ground first among Jewish Christians and, through them, among non-Jewish Christians in the Orient and the Occident. The enervating luxury and the moral degeneration of the decaying Roman Empire welcomed and greedily absorbed all aberrations of the spirit and temperament. Thus medicine, too, became a network of trickery and superstitious hoaxes; all true medicine came to be considered superfluous or even despicable and was replaced by magic signs and words, all kinds of magic arts, exorcisms, amulets, and relics. Curt Sprengel in his history of medicine gave a masterly description of this confused and undignified spirit which prevailed among degenerate Jews, Christians, and pagans under the Caesars of the first centuries of the Christian Era, and indeed among these emperors themselves, including Claudius, Vespasian, Hadrian, and others. It is indeed on Sprengel that we rely for the truth of our assertion that during those unhappy centuries and up to and including the total barbarism of the Dark Ages which then descended on the earth, true recognition and treatment of mental disturbances could not even be imagined. For the eminent writers of a later period were, like Alexander of Tralles,

rani nantes in gurgite vasto.

There began the rule of monks; and what can flourish under their rule other than the monks themselves?

§ 118. We are justified in omitting the dark Middle Ages, in which Greek medicine was no more and Arab medicine in no way assisted true art and science but only shared, together with the medicine practiced by monks, the negative merit of saving some of the valuable memorials of antiquity from total oblivion. We shall be silent about the centuries in which monks and saints of all ages, both sexes, and all positions in life tried to cure the sick, including the mentally disturbed, by driving out all kinds of devils through praying, laying-on of hands, holy water, unctions, relics of martyrs, and amulets. These are the centuries when emperors and kings, bishops and holy women, performed miracle cures the efficacy of which, with doctors and patients, stemmed only from the faith in miracles, with which we shall deal in another place. We are also forced to ignore, or to mention only very briefly, the first manifestations of the rebirth of science and art, partly because there were so few of these manifestations during the first few centuries of this age, and partly because space must be saved for the many topics to be discussed on the medicine of the psyche in modern times. We shall now proceed to give an account of the important landmarks on our way from the end of the Middle Ages to the most recent era.

Chapter Three

THE PERIOD OF TRANSITION FROM THE OLDER TO THE NEWEST HISTORY OF PSYCHOSOMATIC [PSYCHOMEDICAL] THEORY AND ART

§ 119. Medicine did not lag behind in the general resurgence of sciences. However, the first manifestations of its recovery were limited to the restoration of the ideas of antiquity through translation and interpretation of the works of the ancients and an almost slavish obedience to their teaching. Galen in particular, even more than Hippocrates, acquired many new admirers and mechanical imitators. This blind devotion to the authority of the ancients could not be broken until a new path was blazed by the revolutionary founders of chemical medicine, until the soon following discovery of the circulation of the blood drew a sharp boundary between old and new medicine, and until the rise of the chemical school was supplemented by that of the mechanical and iatromathematical schools. None of these efforts profited the medicine of the psyche in any way. In fact, this medicine was altogether forgotten, except that in compendia, in accordance with tradition, among the diseases of the head, deliria, and among those caused by spoilt bile, melancholia is included. But these accounts were copied by one writer from another, and all were taken from the ancients, with Galen as their oracle. Thus the book by Dan. Halbach De cognoscendis et curandis anion morbis ex Galeni sentenia appeared in 1515 in Venice. However, this incorrect, one-sided tendency soon gave way to independent, more thorough, and more natural research.

§ 120. Between the end of the 15th century and the beginning of the 18th, all eminent medical writers, principally authors of compendia, gave special sections on mania and melancholia. In most of these the archaic views, admittedly, persist, but in others there are accounts of numerous more or less complete observations of noteworthy cases, and as we come to more recent works, instructive cadaver dissections are recommended. But all these writings are, in the spirit of the centuries which had only just passed away, pervaded by the faith in supernatural influences of demons etc., so that even the most lucid and best-educated men before and after Luther and Melanchthon were not free from these confusing misconceptions. This is particularly true of those who permitted mystical sciences, theosophy, astrology, etc., to gain sway over them, and this is why, despite all their knowledge, they often disdained any treatment of mental disturbances and referred their patients to the offices of the clergyman.

§ 121. This group included the predecessors of Paracelsus' school, its disciples, and those imbued with the spirit of this school. The first to be mentioned here is Agrippa von Nettesheim (b. 1486 in Cologne), the famous author of the book De vanitate scientiarum. If general magnetism may be included in the group of remedies of the psyche, then this author is noteworthy for his conception of actio in distans, outlined in his work De occulta philosophia (libr. I, cap. 6). According to him, idols of all kinds are responsible for remote power which they can exert over distances of up to 100 miles. (Three hundred years later Mesmer extended this idea to the entire universe, and his Universal Fluid bears a striking resemblance to the power-emanating idols.) These views were later shared by J. B. Porta, who deserves to be mentioned as a writer on psychology on account of his book De humana physiognomia (quomodo animi proprietates naturalibus remediis compesci possint), Frankfurt, 1592. In his book De mania he clearly paves the way for the conception of magnetic manifestations by introducing the concepts of sympathy and antipathy. Indeed, van Helmont, who was born in Brussels in 1577, declared in his Tractatus de morbis, Art. 17. 18., the concepts vis magnetica and sympathia to be identical, and demonstrates them in natural phenomena, e.g., the motion of wine in a barrel when the grapevines are in bloom. Van Helmont, by virtue of his rich, all-embracing, penetrating spirit, and being a bold opponent of Paracelsus (b. 1493) (who will not be mentioned here, since he did not engage in the medicine of the psyche), deserves a place of merit in our roll. True, he was not free of the superstitions of his time which allots to witches, sorcerers, and demons some influence on the diseases; nor was he free of the phantasms and illusions of his own imagination which, in spite of its power, we must consider sick, since he way his own soul (Imago mentis. 13.) as a shining crystal; however, his thorough studies on the origin and nature of mental disturbances (cf. Demens idea, 30-39), his advice to cure the insane by plunge baths (cf. Demens idea, 47-50), his remarkable observation of the effect of aconite (which he simply calls Napellus; cf. Demens idea, 12 ff.) on his own person that yielded important information on magnetic clairvoyance in the precordia, all deserve admiration and unreserved praise. Just as praiseworthy, but for another reason, is Wierus (b. 1515), who was driven by his zest for knowledge to visit Africa and, like J. P. Porta and the first systematic writer on legal medicine Paul Zacchias (Quaest. med. legal., Rome, 1621), made an important contribution to the extirpation of sorcery and of unspeakable cruelties committed against those suffering from melancholia and folly. Wierus, in his tractates De praestigiis demonum and De lamiis, preserved for us a large number of unusual cases. The most noteworthy were later selected by the scientist Th. Arnold for inclusion in his well-known and instructive work Observations etc. on insanity, Leichester, 1782, which will be mentioned later. Wierus himself is still the child of his age and while compaigning against superstitions, is himself not free of them. The same is true of P. Zacchias, who considers the so-called possessed as truly sick but still thinks that they are the tool of evil demons attracted by the disease.

§ 122. We must now turn away from these men, who are noteworthy mainly for their descriptions of the forms of diseases of the psyche, in particular demonomania, in order to consider the purely medical observers and numerous writers of the past centuries who made important theoretical and practical contributions to medical science and are the pride of Italy, France, Holland, Germany, and Switzerland. Italy, to begin with, produced many excellent observers who are quoted, even today, by classical authors such as Arnold, Chiarugi (Della Pazzia etc., to be mentioned below). The most excellent among them are Mich. Savonarola (d. 1462), a learned physician who reproduced their best ideas in his book Practica Majorum, and whose psychological, nosologic, and practical contributions are worth noting. Thus, we have his description of insania canina and lupina (Pratt. M., rub. 12), erotomania (Pr. Al., p. 69), a mania produced by retention of the seminal fluid (Pr. M., tract VI, rub. 19), and his proposals for a cure of melancholia (p. 67), in which he agrees with the ancients in recommending tonics, stimulants, and warm baths. Vict. Trincavella (b. 1491 in Venice), professor in Padua, was also a protagonist of the medicine of antiquity, and is particularly famous for his collected expert opinions. He diligently observed the diseases originating from the consens of the nerves (e.g., Conf. medic, libr. I, cons. 23). In his 13th opinion he gives a very clear description of raging melancholia. He agrees with Savonarola on the treatment of this disease.

Joh. Bapt. Montanus (b. 1489) shares the reputation for antique learning with Trincavella; he also shared his interests. He was known as the "second Galen." He wrote numerous commentaries on older physicians, and also Comilla medica, in which he noted among other things (tonsil. 23) that black spots were formed on the bodies of melancholics. Hieronymus Mercurialis (b. 1531) was one of the most eminent of the learned physicians of his time. In his Consultation. et respons. medic., Venice. 1620 (Tom. III, cons. 5) we find the interesting observation that hypochondria was becoming very frequent owing to increasing luxury. Tom. II, cons. 27 contains a detailed account of the origin of melancholy from psychological sources. He noted correctly (Tom. III, p. 7; T. IV, pp. 6, 64; T. II, p. 101) that children frequently become dull and truly melancholic as a result of blows and rough treatment meted out by their tutors. He remarked in T. II, cons. 23 that there is no melancholia without disturbance of the digestive functions. In T. III, p. 101 he recommends blister plaster* as a stimulating and restorative treatment of melancholia. Franz Valleriola (d. 1580) was professor in Turin and was famous as an observer. He described (Observat. med., libr. III, 7) a case in which a man who had become melancholic for love could be cured by having his hemorrhoidal vessels opened. His Obs. med. rar., libr. I, obs. 5 gives a faithful, concrete description of true insanity produced by love. Hieronymus Capivacci (d. 1589), professor in Padua, takes (Practic., libr. I, cap. 11) the old view according to which melancholia is a darkening of the vital spirit. He, too, recommends blister plaster as a remedy. Prosper Alpin, who was born in Vicenza in 1553 and was the father of semiotics, did not adopt any scholastic system. He was a much-traveled man and became professor in Padua. In his book De medicina Aegyptiorum he gives us a number of important psychological facts. Thus, he tells us (p. 58) of Egyptian fanatics who thought that they were saints and roamed the desert, looking like dried-up mummies with their black, dirty, lean bodies, and exposing themselves to all the hardships of the weather and the seasons. His book De medicina methodica (libr. X, cap. X) contains an excellent description of melancholia, documented by several case histories. Lucas Tozzi was born in 1640 in Aversa near Naples and was professor at Naples. He and contemporary Alex. Pascoli, professor in Rome, made their historical contributions to the forms of diseases of the psyche, the former in his Med. theoret. pract., Lyon, 1681, the latter in his work De homine. The former presents insanity caused by jealousy, the latter describes lycanthropy. Bellini, who was born in 1643 in Florence and was professor in that city, gave us an excellent description of melancholia in his work De 7norbis capitis. We shall omit, for the sake of brevity, the contributions of Ant. Pozzi, Baglivi, Malpighi, and Marinelli (De morb. nobil. anim facult.), and shall close this section with the famous Morgagni (b. 1681), who, in his immortal work De sed. et causs. morb., epist. I. Ad capit. dolorem, epist. VIII. De mania, melancholia et hysteria, epist. IX. De morbis a veneno inductis, epist. XI. De deliriis, quae sine febre contingunt, bequeathed us a veritable treasure of observations and results of dissections.

(Application of cantharides cerate and a plaster in order to cause blistering of the skin.)

§ 123. The French, the Dutch, the Swiss, and the Germans are also included in the roll of honor of the sixteenth and seventeenth centuries. The two most prominent Frenchmen are Fernelius (b. 1486 — according to others in 1506 — in Amiens) and Riverius (b. 1589 in Montpellier). They gave us interesting descriptions of case histories and cadaver dissections — the former in his "Pathology" (e.g., libr. V. cap. 7), and his Medic. univers. (e.g., T. II. p. 96), the latter in his Praxis medica and in Observat. med. et curat. insign. Another Frenchman to be mentioned is Theoph. Bonnet, b. 1620. His Sepulchretum anatomicum contains a treasure of case histories and cadaver dissections that has remained useful to this day. Among the Dutch, the following merit special distinction: Peter Forest (b. 1522 at Alkmaar) for his classical Observationes. In libr. I. 10 he describes a pure-bile mania, while libr. X. 25 contains a description of genuine lycanthropy. In libr. X. 30 he relates the case of a cure of melancholia caused by love, which is the same as that reported by Erasistratus. Jac. Heurnius (b. 1543 in Utrecht) was also a classical scholar and had similar interests. In his Prax. med. Henr. Regius (b. 1598 in Utrecht where he was also professor) explains every disease by means of case histories. A commentary on his works was written by Broen, a physician who lived in Rotterdam towards the end of the 17th century. He gave an excellent description of acute mania in his Animadvers. medic. in Regii Prax. med., libr. I, § 15. Among the Swiss, the following surpass most others living at that period, both those already named and those yet to be cited: Joh. Schenk von Graffenberg, born in Freiburg im Breisgau in 1530, freed himself completely from the yoke of the Greek school, as indicated by his observations, which are highly valuable to doctors of the psyche. Felix Platter, born in 1537, professor in Basle. He made it his chief task to observe the effects and consequences of submission to passions. To us his work is especially important because he was the first to attempt a classification of mental disturbances (Praxis med., Basle, 1625); the latter shall not remain unquoted in this place.

Morbi mentis

1. Mentis imbecillitas

Hebetudo, Tarditas, Oblivio, Imprudentia.

2. Mentis consternatio

Somuus inmodicus, Carus, Lethargus, Apoplexia, Epilepsia, Convulsio, Catalepsis, Ecstasis.

3. Mentis alienatio

Stultitia, Temulentia, Amor, Melancholia (this last disease is attributed to possession by the devil, and is left to the legions of the devil), Hypochondriacus morbus, Mania, Hydrophobia, Phrenitis, Saltus vitt*.

4. Mentis defatigatio

Vigiliae, Insomnia.

Naturally, if we are to classify true morbis mentis — i.e., a state in which the spirit or the soul are quite diseased — by definite manifestations (forms), then only Plater's third class is valid, for his first class deals only with weaknesses and symptomatic states, the second merely lists somatic states in which the activity of the soul must be considered as dormant, while the fourth class contains other symptoms, which at most point to psychic disturbances but are not, in themselves, diseased states of the soul. Moreover, to be exact, even the third class should be diminished since temulentia, amor, morbus hypochondriacus, hydrophobia, phrenitis, and saltus viti do not properly belong to the third class (§54), so that we are left with only stultitia, melancholia, and mania. Nevertheless, since he was the first to compile a nosologic table, Platter rightfully deserves his laurels and his errors are forgivable, especially since eminent later nosologists were guilty of errors no less grave. Of the Germans, we shall ignore all but the scholarly Dan. Sennert (b. 1572), professor at Wittenberg. in his large work Practicae medicinae, libr. IV, Wittenberg, 1628-1635, written with classical precision and elegance, he thoroughly describes the two principal forms of mental disturbances: melancholia and mania, complete with their special and their subordinate manifestations, in exact order, with diligence, erudition, and practical skill. This work ought to be read even today by all who have a taste for sterling quality and are looking for good models among the doctors of the past. Clearly, Sennert is a child of his age and is still entirely imbued with the spirit of Galen, but he makes full use of all that was good in antiquity; thus Sennert's works contain the kernel of diagnostics, semiotics, prognostics, and methods of treatment of antiquity, combined with his own observations and those of his close predecessors. In its time this work was what P. Frank's Epitome is in ours, and if we wish to learn something from the ancients, it should always be at hand. In a truly childish spirit Sennert still attributed melancholia and mania to the influence of demons, and it is not without psychological interest to read his explanations thereof. His materia medica is the richest that can be imagined and deserves to be used even in our own days.

§ 124. We shall close this line of our predecessors with the great Hermann Boerhaave (b. 1668), this Galen of the new era, since even in the late 18th century his fame and his spirit were still alive in the minds of physicians. However, as regards our own science and art, his achievements are not superior to those of Sennert, except for the humoral subtleties which he raised to their acme. He, too, deals with melancholia and mania only and, like his predecessors, attributes the former to black bile (Aphor. de cogn. et cur. morb., § 1117), holding, like so many ancients, the latter ( §1119) to be merely a more acute grade of melancholia. His descriptions as well as his cures for both disorders are greatly inferior to those of Sennert, and it is obvious that neither the art nor the science of the psyche made any substantial progress at his time. He owes his fame as a doctor of the psyche to the Haarlem anecdote, which was mechanically repeated perhaps a hundred times but not even once checked.

Chapter Four

MODERN TIMES, THE ITALIAN, FRENCH, ENGLISH, AND GERMAN SCHOOLS

§ 125. Thus, the seed of the medicine of the psyche took root and, through a simple stem, developed more widely. From the times of Hippocrates to the times of Boerhaave the only recognized cause was bile, the only recognized effect was melancholia and mania, while the only recognized cure was the removal of the harmful. And since doctors of all nations and at all times were in agreement (except for a few isolated views to the contrary) on the bodily origin and methods of treatment of these diseases, these were not separated from the group of common diseases or treated as a separate branch of medical theory and practice. Therefore there were no special monographs — let alone a special system — on the particular kinds of psychic disturbances up to the end of the period discussed in the preceding chapters. Due to Galen's influence physicians of all nations were brothers. National differences did not result in differences in ideas through the 17th century, but in the 18th there were many changes. On the one hand, the spirit became freer, but on the other, national traits acquired a hold on the physicians. These traits gave rise to schools of medicine, as formerly to schools of painting. Many branches of the new medicine grew out of the trunk of the old. There arose a French, an English, an Italian, and a German theory and practice. The old subject matter assumed new forms, and these forms were more or less pure or mixed, deep or superficial, one-sided or many-sided, free or bound, according to the character of each nation. The Italian loves the old, the Frenchman the new, the Englishman solid ground, the German everything. This unmistakable imprint is borne by the medicine of our own days. The Italians have stood still, the French made a leap forward, the English hold their ground, while the Germans are in search of a place of their own. We shall now follow the medicine of the psyche in this characteristic sequence of events.

§ 126. The Italians, in accordance with their national character, have remained faithful to the medicine of antiquity. Consequently they have few writers in this field, but one classical representative of their spirit is Vincenzo Chiarugi. His treatise Della pazzia in genere e in specie, trattato medicoanalitico, con 'aria centuria di osservazioni appeared in 1793-1794 in Florence, in three parts. He made an extensive, ordered compilation of the materials contributed by classical antiquity, the Italian school after the rebirth of the sciences, and of the contributions of nosologists living before him (ending in Cullen) to the classification of mental disturbances, taking these achievements as the given, the existing, ones. After some critical selection, he enriched this material with the results of his own investigations and observations, carried out in the spirit of antiquity, and the resulting treatise is a very valuable whole. It is indispensable to anyone who desires to study traditional systematics and to have the abundant material of all ages in a concentrated form. The first part deals with general pathology and the therapy of insanity, the second with special nosology, while the third contains critical nosology and the so-called hundred observations. According to this writer, insanity (pazzia) is a chronic, persistent confusion of the reason, manifesting itself either as melancholia, which is partial insanity, always limited to one or more objects, or as mania, that is, general insanity, accompanied by rages and by a bold execution of the demands of the will. Insanity may also manifest itself as idiocy, which is a general or nearly general insanity, with irregular periods of active perception and willpower, but essentially without fluctuations of temperament. To this writer, melancholia, mania, and idiocy are general; these he subdivides first into several species, and then further into varieties. Thus, the first species of melancholia is true melancholia, that is, melancholia accompanied by fear and sadness. Varieties of this species are: a) with respect to the object: nostalgia, religious melancholia, erotomania, etc.; b) different grades: the misanthropica, the errabunda, and the attonita. The second species of melancholy is the false, the pseudomelancholy, in which the patient is quiet and merry. (Where is the logic in this? ) Its varieties are Al. moria, M. saltans, amatoria, M. enthusiastica, and AI. fanatica. The third species is raging melancholia, that is, one accompanied by occasional rages and aggression. Its varieties are M. anglica and Al. antipathica. He fully agrees with Cullen on the cause of what he calls insanity. According to Cullen, insanity is always the result of a physical injury to the brain (excitement* and collapse,* see below). Chiaruggi concludes that the species of insanity were mistakenly called diseases of the soul or diseases of the spirit, for the soul is not a material being and its nature and substance remain unchanged. Thus it is not subject to changes such as afflict matter and are the cause of diseases. (For a more detailed discussion of these questions see our treatise on the advances in the medicine of the psyche in most recent times Neuestes Journal der Erfindungen, Theorien etc., Vol. II, No. 1, p. 87 ff.) Consequently, his treatment of insanity is exclusively somatic, that is, the remedies he administers are such that alter the condition and the activity of the bodily organism. The observations quoted in the work are all designed to support this view and this manner of treatment. (See: Neuestes Journal etc., Vol. I, No. 4, p. 382 ff.) Blister plasters and warm baths rank highly in his favor.

We have said enough for the reader to have some idea of the spirit in which Chiarugi worked. The reader himself will be able to deduce from all that has been said how far we agree with this writer, whose work is very valuable in many respects, including his excellent scholarship.

* lin English in the original text.]

§ 127. In France, the transition from the old to the new is due to the famous scholarly writer Lorry, whose works are even now considered to be classic. His book De melancholia et morbis melancholicis, Tome II, Paris, 1764, is instructive in more ways than one. Firstly, it deals not only with the pathology and therapy of that disease and its forms which we now know as melancholia but with all the diseased affections which manifest themselves in disturbed perception and motion. These diseases were attributed by the ancients partly to the intemperies* — which were not material but consisted of overtension and relaxation of solid fibers — and partly to the effects of the black bile. Secondly, this book represents a complete compilation of the views of the ancients on these questions. Thus, for example, it contains the most exact data on hellebore applications by the ancients that can be found in extant writings. Thirdly, the book demonstrates how easily an intelligent and scholarly man can be tempted to build an entire theoretical and practical system on the basis of a few abstract notions, such as those that elastic fibers and black bile are the causes of disease, and to place the sum total of real, natural manifestations on the apex of these dreamed-up principles. This is why the work, despite some clear-headed details and instances of lucid insight into nature and its workings, is mostly a barren tissue of narrow-minded, superficial, quite general views and rules of deportment. As concerns theory, it gives no true picture of the genesis, course, and termination of the manifestations of diseases, and for technique it presents no well-founded, consistent, definite sets of procedures. When we read the work we feel that we are walking through a thick fog in which objects appear only as shadows: no sharp, clear outlines, no solid ground anywhere. It is surprising that Lorry, who was able to evoke the presence of the ancients so vividly, should have followed them only where they were most wanting, namely, in the principles governing interpretation, but not in their incomparable faithful observation of nature and description of the observed material. But then again this is really not so surprising, since Lorry was a Frenchman, and the French spirit is satisfied with empty appearances more often than it would be prepared to admit. This is why the work, with all its scholarship and subtlety, is quite unsatisfactory in its descriptions of genuine theory and technique. The elements of the disease are chaotically scattered about instead of being coalesced into solid formations, while the curative principles are not scooped up from the organic depth, but are merely skimmed off the surface.

* [Disproportion between the four "humors": blood, choler, phlegm and "melancholy."1

§ 128. Other French writers lack Lorry's thorough scholarship but share with him his superficial point of view, although not invariably his principles. It would be useless to enumerate all these writers, and few who lived before Pinel deserve special mention. Thus, Le Camus (11Vdecine de l'esprit, Paris, 1769) attributed the genesis and the cure of what he called diseases of the reason to bodily mechanisms.

Dufour (Sur les fonctions et les maladies de l'entendement human?, German translation, Leipzig, 1786), too, lacks true understanding or power of interpretation of the disturbances of the life of the soul. Like many of his predecessors and successors, he subdivides such disturbances into idiocy, melancholia, and insanity or frenzy and describes all these forms in a very incomplete and confused manner. According to this writer, the reason that these disorders are so seldom cured is that their origin was always sought in the brain, and the treatment was thus mistakenly directed at the brain. The true seat of the disease is in most cases the abdomen: constipation, hardening of the liver, spleen, etc., and the treatment should therefore be directed at these organs. This writer, too, regards man as a mere machine endowed with reason and his mental life as arising out of his bodily constitution; his conception is superficial and, like many others, he erroneously attempts to study man from the outside inwards.

Daquin (La philosophic de la folie, Chambery, 1791 ; 2nd ed. 1804), whose work contains much empty verbiage, presents a summary of several kinds and degrees of disturbed mental life. Though these are superficial, they are essentially correct. He does not use the names melancholia or mania (to which non-use we do not object) but compares all states of mental disturbance with a sane mental life or, in other words, a state in which man "recognizes the truth" (la raison est la connoissance du vrai). Under the collective name folie he understands a state of mind which is the opposite of reason; this condition includes the state of fou furieux (frenzy), fou tranquille (melancholia), of extravagant (madness and folly), of insense (quiet insanity), imbecile (imbecility), and demence (idiocy). We would approve of this approach were it not for his narrow-minded adoption of the views of Cullen in looking for the cause of all these conditions in either overstimulation or depression of the brain. Daquin should rather have studied some of the instructive case histories when he himself relates of mental lives gone astray, with their positive or negative effects on the bodily organism in which they produce various diseased reactions. Instead, he soon abandons the search in the depths of the psyche and remains content with superficial pathology and therapy. His principal remedy is humane, a mild treatment of the patients and agreement with their perverted notion, a kind of etre fou avec eux which, however, he carries rather too far. We may be unable to make a proper study or to gain a full understanding of such conditions, but that is certainly no reason why we should participate in them, and in any case this may not be good for every physician. However, the only purpose of this recommendation is to accustom the patient to the doctor and effect his attachment to him, and it must be admitted that the arousal of confidence and affection is the first step in any cure. Daquin does not totally reject somatic treatment by bleeding, blister plaster, etc., applied at the right time, but considers exercise in the fresh air, work, distraction, and affectionate handling to be the main remedies. But many things may constitute conditiones sine quibus non and yet they are not the principal matter. Daquin made very thorough observations on the effect of the moon on the mentally disturbed, and his careful work, performed over many years, fully convinced him that such an influence exists. According to his tables, violent patients become more violent and depressed patients more depressed at new moon and full moon, and their condition varies with the different phases of the moon. His remarks are a welcome contribution to the study of cosmic influences which affect such patients.

§ 129. As we have discussed this precursor of the idea of the so-called "moral" treatment, we shall now turn to the physician who expressed this idea with the utmost clarity. This is Pinel, in his famous Traite medicophilosophique sur l'alienation mentale, Paris, 1801. (A new, enlarged edition has just appeared.) As regards systematic and thorough presentation of the contents, the book does not live up to its title. Pinel distinguishes between the following kinds of disturbed mental life: melancholia or delirium exclusively directed at one object, mania without delirium (Pinel is the first to have given a clear definition of this kind of disorder), madness with delirium, folly (demence) or cessation of thinking, and idiocy (idiotisme) or the suppression of reasoning power and will power. However, his descriptions are neither accurate nor complete. He begins by placing the manifestations of different forms of diseases under one heading, then he makes light of the most important questions by superficial comments and leaves those readers who desire better explanations unsatisfied. He is a typical French writer in that nothing is firmly retained, the most important subjects are abandoned as soon as they are mentioned for the first time, and so no subject is thoroughly discussed. He often neglects the very things he wished to mention and speaks of completely different subjects. (For our factual proof of this, see Neuestes bourn. d. Erf. etc., Vol. 2, No. 1,-p. 99.) In spite of these and other deficiencies, however, we have much to be grateful for to our gallant Pinel, with regard to both observation and practice. His active, all-embracing spirit leaves no question of potential interest to a doctor of the psyche untouched or (after a fashion) unexplained. He was also one of the first to occupy himself with the policy and the supervision of lunatic asylums. His treatment of patients is rather negative. His principle is wait-and-see, and he persistently stresses the need for friendly, mild, or sometimes stern and severe, but always humane treatment. He applies physical remedies only with the greatest caution. Thus, he is greatly opposed to bleeding and allows it only in exceptional cases. Nor is he much in favor of baths, be they cold or hot. If anything at all, he advocates lukewarm baths. When physical remedies are applied, he rightly insists on distinguishing between the different cases. Thus, the greatest precautions must be taken in administering a dripping bath* and any other so-called heroic remedies, such as drastic purgatives, camphor, or narcotics. He greatly favors gentle laxatives (neutral salts in chicory steam extract) as a remedy against the attacks of what he calls periodic madness. He keeps repeating: "what the art cannot achieve, time will." His pupil Esquirol distinguished himself by his contributions to the characterization of mental disturbances and by his notes on the effect of the passions on such disturbances and is well known as a successful doctor of the psyche in general. The principles and treatment that he applies at his private institute are those of his master.

* In German: "Tropfbad." The exact meaning could not be ascertained, perhaps the reference is to what was known as "continuous bath"; a bath lasting several hours during which the water is maintained at body temperature by continuous dripping of hot water.]

§ 130. Our last positive reference is to Amard (Traite analitique de le folic et des moyens de la guerir, Lyon, 1807), who is in partial agreement with Pinel, but his methods and practice often are very different from those of the latter. He follows Pinel's system of forms, except for melancholia. His descriptions of case histories, too, follow those of his mentor. The cases he himself has presented are rather sketchy, but the rest of the contents of his treatise is very rich. He is clear-sighted on the subject of the connection between the various mental disturbances and the systems and organs of the human body; in this he seems to be guided by Bichat. The nervous system of organic life, the major sympathic nerve, is the carrier of mania without delirium, melancholia, and hypochondria, all of which have their origin in the abdomen. But mania with delirium, folly, and idiocy have their origin in the brain. If this statement can be shown to be true, it can be of considerable practical value; his other remarks on other systems and organs are also interesting. Thus, Amard notes that the mucus membranes of the abdomen are affected in diseases of the psyche: such patients tend to secrete more mucus and to have worms. He also considers the skin system as having three aspects: as an absorbing system, not very active in the mentally disturbed, therefore with a diminished susceptibility to infection; as nerve tissue, lacking sensitivity; as an arterial capillary system, resisting the cold. His studies on the origins of mental diseases are excellent. Amard begins by rejecting many commonly held opinions and then shows how excesses, passions, immoderate exertions of all kinds, etc., bring about the destruction of mental life. He considers curing from three points of view: the natural cure, the moral cure, and the physical cure. Like Pinel, he is an advocate of natural and moral treatment, but trusts physical remedies more than Pinel and discusses their kinds and applications very exactly and in the right spirit; for example, bleeding, purgatives and emetics, baths, cramp-loosening remedies, etc. His therapeutic as well as his prognostic hints bear the imprint of truth and show, like everything else, that the author knows how to appreciate and to utilize everything of value which had already been discovered before him, but knows how to avoid the pitfalls of his predecessors. In the conciseness of his treatise and the thoroughness of his studies we gladly admit that this author does not conform to what we described above as being of the typically French character; only in the last section, how to recognize concealed madness, do we notice a lack of thoroughness.

§ 131. We shall now proceed from the French to their hostile neighbors. According to the reports reaching us from the various institutes of the English, both the public and the private ones for the care and healing of the mentally disturbed, and according to the reputation of the cures effected there and the repute of the physicians — including cleric doctors who have chosen these patients as the objects of both practical treatment and theoretical study — as well as according to the great number of English writers on the subject of mental disturbances, according to all this we should expect that the English would provide much information on the medicine of the psyche. In reality, however, these expectations are fulfilled only in part. Travelers to England find that the institutes in English cities, particularly in London, are just like at home (tout comme chez nous). This is only to be expected in closed rooms, where the two principal conditions for return to health, fresh air and exercise, are lacking. But even the institutes located in the country, where these two conditions are available, are ruled dot so much by art and science as by nature and empiricism. For example, we hear of Willis, who helped so many patients to regain their health, but all these were probably cases in which fresh air, occupation, orderly life, and human( treatment were sufficient remedy. As regards English writers on the subject it will be best to present a brief survey of those among them that art outstanding.

§ 132. The creator and founder of the theory and the practice of psychological medicine in England, which in the earlier times of Willis (senior), Sydenham, etc. were not yet generally recognized, is undoubtedly William Cullen. His influence was not confined to England but was also very marked outside that country. We know, for example, that Chiarugi published his record of antiquated scholarship in the form of Cullen's opinions. Cullen (Anfangsgriinde des practischen Arzneywissenschaft) (Rudiments of the Practical Medical Sciences) discarded first of all the hallucinationes and morositates of earlier nosologists and confined his attention to mental disturbances which he names vcsaniis and which were called by Vogel paranoias. To Cullen, perversion or weakness in the power of discernment (delirium and fatuitas) are the two main varieties of vesania in the waking state (for he extends these disturbances to the sleeping state as well), and they are without fever (insanity). According to him the emotions of anger or fear (mania and melancholia) originated from these diseased notions. The origin of the diseased notions themselves is excessive excitement or depression (collapse) of the brain activity, or, as he calls it, nervous power. This is the basis for his treating mania and melancholia as the two main species of insanity. This treatment involves a vague concept which was later more clearly named excitability by his pupil John Brown. Credit for the contrast between the stimulation and depression of the activity of the brain must, however, remain principally with Cullen; this was recognized by Perfect, of whom more anon. It may be said in general that Cullen's contribution to the advance of nosology of mental disturbances was considerable, and that his methods, here and elsewhere, are exemplary, since his modesty and caution prevented him from proceeding further in his decisions and explanations than was warranted by unequivocal observations. He was satisfied with simple conclusions and preferred to leave obscure questions unanswered. For the rest, his concepts and guidelines for the classification were constructed on the basis of the surface of observation, and he has no inkling of how to plough the depth of observation, or he would not have assumed that the fear displayed in melancholia or the anger in rage are exclusively due to perverted notions, whereas the diseased perceptions and desires, just as the diseased notion, firstly generate one another in a mutual relation, and secondly are together deeply rooted in the disturbed mental life, the derangement of which manifests itself in the derangement of the physical organism. It follows that Cullen's treatment of such conditions has no intrinsic foundation but is purely symptomatic; that this, too, has its merits, we do not deny. This description of Cullen is also true of all other English practitioners, as we shall soon see.

§ 132. Two other good men, Arnold and Crichton, share with Cullen the effort to bring light into the darkness of the disturbed mental life. The work of the former (Observations on the nature, kinds, causes and prevention of insanity, lunacy, or madness, Leicester, 1782-1786) comprises two parts, the first dealing with the nosology, the second with the etiology of madness. Arnold, though a pupil of Cullen, is reproved by his master for recognizing too many kinds of insanity. We, however, would not find this a fault if these differentiations were borne out by nature. But this is not so, as can be seen even from the incorrectness of the principle of subdivision of mental disturbances according to their origin from the sphere of feeling or from the sphere of thinking (ideal and notional insanity), whereas in truth these conditions are merely one-sided and abstract ideas, first advanced by Locke (Essay on Human Understanding). For here feeling and thinking were not taken as opposites, as one juxtaposes temperament and spirit. That would have been a relation true to life, leading directly to the idea of diseases of the temperament and diseases of the spirit. Nay, feeling here means simply sensual perception as one element of consciousness, of which reason is the other. Thus, Arnold is speaking merely of disorder in the faculty of imagination, which is usually viewed as the seat of mental disturbances. This is precisely the one-sided, misconceived, dead abstraction which is the proton pseydos of his entire genealogical tree of genera and species of diseases. Nevertheless, we are much indebted to the excellent Arnold — excluding his partisan presentation — for the abundance of the material presented. No other writer of any nation was a more thorough and exhaustive compiler of the manifestations of the diseased psyche described in old and new literature, of the many findings obtained by dissections, and of etiological data, including historical documentation. In this respect he stands head and shoulders above the others and will remain for a long time the chief source for quotations for other authors, just as he has been for a long time now.

§ 134. Crichton (cf. Neuest. Journ. d. Erfind., Vol. II, No. 1, p. 76 ff.) is generally thought to be the most thorough, keen, and scholarly English writer on disturbances of the soul. His treatise An Inquiry into the Nature and Origine of Mental Derangement etc., London, 1798, comprises three volumes: 1. Studies of corporeal reasons for mental disturbances; 2. natural history of forces of temperament, and descriptions of diseases to which they are subject; 3. passions from the aspect of their being the cause of derangement of the spirit, their kinds, and bodily effects. The book terminates with a survey of all the mental disturbances. The author explains complex manifestations in terms of the simplest ones (that is, the high manifestations by the lowest) and the unnatural in terms of the natural manifestations. This method, since it is itself unnatural, must necessarily lead to artificial results. For nature in general, and especially organic nature which is the nature of life and of the soul, does not permit the explanation of any one manifestation by inference from another one. The glance must be directed at the whole, at the underlying correlations and the varying modifications of its many manifestations; what is needed is not analysis and abstraction but a more penetrating glance. Since we do not approve of the individual components of the procedure, we cannot agree with the overall conclusion, which is that

"the general character of all mental derangement is insanity, that is, acceptance of erroneous perceptions as reality. Since all perception originates in the nerves, and the action of the nerves is determined by the activity of the vessels, it immediately follows that the origin of all insanity is to be sought in the vessels. The general affection of the vessels produces general insanity, due to the effect of the vessels on the nervous system, that is to say: over stimulation of the vessels produces raging mania, while their slackening produces mild mania, and a general suppression of their activity produces melancholia. Partial affection of the vessels and, through them, the nerves (e.g. due to diseased bowels such as liver, mesentery gland, spleen) produce partial disturbances of the mind, either illusions or debilities. The former include hypochondria, demonomania, and vertigo, and the latter idiocy, impaired memory, and impaired powers of discernment and of imagination."

We encounter here a large number of one-sided views, the refutation of which would require a book by itself. We shall merely remark that insanity as described by the author is only a form of mental derangement; that it is a one-sided view to consider the vessels as the seat of mental derangement, since an irritation of the vascular system is just as often the effect as the cause of irritation of the nerves; and that experience — which teaches us that both excitation and depression of the vascular system very often manifest themselves by physical symptoms only, without any mental disturbances — shows us that it is paradoxical to infer from the gradualness or decline of the irritation in the vascular system whether the disease is raging mania, mild mania, or melancholia, because: firstly these disorders of the psyche are dissimilar not only in degree but also in kind; secondly a slackening of the vascular system subsequent to its irritation might he expected to produce a cure rather than a new disease; thirdly the total suppression of the activity of the vessels assumed by Crichton to be responsible for melancholia is a self-destructive hypothesis, since the result would be death. Finally, it is quite illegitimate to assume that the diseased manifestations classed by Crichton as illusions and debilities should be the result of a partial affection of the vessels, since it is unfathomable that they are not unaccompanied by general disturbances in the organism, since, in any case, they are either not mental disturbances at all (like hypochondria, vertigo, weakness of memory, etc.) or else are total and not partial mental disturbances (as demonomania, idiocy). We cannot, therefore, join in the praise given to Crichton by Pinel, Reil, and Hoffbauer but readily acknowledge his sobriety, simplicity, keen intelligence, and scholarship, and most of all his unusually humane attitude in appraising the views and recognizing the merits of others, which is not at all typical of most Englishmen.

§ 135. The list of theorizing physicians extends to Harper and his paper A Treatise on the real cause and cure of insanity etc., London, 1789. Without having the least knowledge of psychology, this writer claims that "madness is a disease of the soul which is not caused by any bodily irritation." The soul is to him "a thing of sensitive imagination, which experiences pleasure or pain through its imagination. Each pleasant imagination requires an unpleasant one, and vice-versa, for the sake of bringing about the moral equilibrium which is the peace of mind. If now the mind is occupied with one object only, to the exclusion of others, this equilibrium is disturbed, that one object becomes the central point, sucks up all others into itself like a whirlpool, and insanity results. The passions are responsible for such effects: love, ambition, greediness, pride, gambling, fear, jealousy, religious fantasy, etc." In this way mental disturbances are explained purely mechanically and by the law of the lever. What then is being advocated in this work? "Madness can be prevented by moderation of passions, and in general by a regular alternation of work and pleasure." Already existing madness "is cured by somatic and psychological treatments. As regards the former, the nervous system must be toned, the activities of bodily organs prompted, and all unnatural irritations limited. As regards the latter, one should try to eliminate hostile mental irritation, the desires of the patient should not be opposed, and attempts must be made to reduce too intense an activity of his soul." These prescriptions, as given by the author, can only be realized on paper. But Harper compensates us for these barren, one-sided statements by giving a paradox and bringing forward facts in its support, namely, " ... that madness is not produced by any bodily effects or properties. Neither organic injuries to the brain, nor high fevers with delirium, nor rabies, nor frequent indulgence in drugs and stupefying agents, nor frequent convulsions, etc., produce madness. Chronically diseased states of the abdomen may bring about hypochondria and a touch of melancholia, but no madness." We believe that this paradox, if properly viewed (cf. Neuest. Journ. d. Erf , Vol. I, No. 3, p. 294, note), represents the best opinion that Harper's writings were to offer.

§ 136. As practitioners, however, the English are excellent. They are guided by their empirical attitude and are not led astray. They observe, they retain the most immediate and the most necessary, and even if they do not follow all the details of an orthodox medical procedure they pave the way by which straying nature is often intercepted and led back to the right path. Almost instinctively do these doctors treat the patient properly, that is, with Ate regard to his personality; they employ mildness or severity, especially the latter, which if applied at the right time makes the patient fear and respect them. A shining example of such art of treatment was given by Willis, more than by any other physician.

In this connection, we shall first mention the practitioner W. Pargeter. According to his work Observations on maniacal disorders, London, 1792, the psychological treatment of patients, which he refers to as management or government, is the most important aspect of the treatment; it consists in a psychological rapport, a personal superiority of the doctor over the patient as transpires from case histories with which he supports this contention. He puts more trust in the "winning over of the patient" than in medicaments but states that this is an art which can be mastered by long experience and careful observation only. "It consists in the following: the doctor must employ every moment spent with the patient to achieve superiority over him and to make him submissive through the application of mildness or severity according to circumstances. If he misses the first suitable opportunity, he will later find it very difficult, not impossible, to achieve this aim, especially if he himself displays signs of fear." Pargeter's own procedure, to catch the eye of the patient immediately on entering the sickroom and, holding it steadfastly, to attract to patient to him, as it were magnetically, is extraordinary and deserves to be followed. But it requires a great measure of energy on the part of the physician. After thus "tying the patients to himself by the glance of the eye," he could make even the most refractory patients do anything he wished them to in the way of medical treatment. He did not neglect physical remedies, such as purgatives, emetics, bleeding, douching, blister plaster, baths, etc., and even discusses the results obtained with them and the proper conditions for their application. He follows the views of Cullen in the theory of the conditions of these diseases but his own descriptions of diseases arc insufficient and incomplete, in spite of the many poetic quotations.

§ 137. To the good practitioners belongs also Ferriar, whose work New observations etc. (2nd volume, 2nd part) includes a number of observations, particularly on the application of mercury against disturbances of the soul, diseases in which this medicament usually proved to be quite ineffective. He also gives an incomplete description of the conditions which are externally evident as mania or melancholia. He attributes the former to mistaken and confused ideas or notions, while he assumes that the characteristic feature of the latter is an exclusive dominance of one idea (as opposed to confusion of ideas). The superficiality of his approach is evident. But enough of this!

A more important personality is the Nestor of English practitioners, W. Perfect. His work Select Cases in the Different Species of Insanity, Lunacy or Madness etc., Rochester, 1787 (the third, much enlarged edition appeared under the title: Annals of Insanity etc., 1803) is a thesaurus of observed and treated case histories of very different origins. Most of these were treated by the author with great success. The first edition contains 61 case histories, the latest edition contains many more. These include the case of an 11-year-old boy suffering from alternating fits of melancholia, madness, and frenzy, for no apparent reason. This is particularly interesting, as it was probably an unknown disease, tending to develop into a zoomagnetic state, which could be treated and cured by Perfect's own method only. This method is almost completely empirical. Bleedings, douches, kali tartaricum, mixtures of camphor with nitre, camphorized opium tincture, etc., were combined with a suitable diet and psychological treatment, applied as required — as already mentioned, with much success. How can we explain this? The answer is that, owing to his direct empirical approach, Perfect observed the most obvious effects — and not causes — worked by the hostile powers in the organism. He at first sought to eliminate the most blatant organic disturbances, namely, the effects of these hostile powers (though he did not recognize them as such) which in any case substantially check these forces. Thus the inner equilibrium of the diseased soul is, by means of counter stimulation, at least partly restored. Furthermore, he himself had great confidence in the remedies he prescribed, and was able to inspire confidence in his patients by his very personality. This may yet prove to be the principal factor in a successful cure; for we may eventually find that the strong-minded physician, without knowing or even desiring it, exerts a kind of magic on his patients that we shall provisionally equate with magnetism, until we have learned more of its true nature. In short, Perfect is one of the most fortunate physicians, if not one of the most clear-sighted, as can be seen when reading his case histories. He habitually mistakes the effects of disturbances, which are already present and active and which form the essence of the diseased condition, for the immediate cause and the nature of the disease itself. Thus, for example, a female patient may be suffering from irregular menses, while another one, in childbed, may have disturbances in milk secretion; the result may be mania in both cases. To Perfect, the disturbance of these two functions is the fixed point and the center of the disease which determines all his indications and treatment. We have already said that this approach is very advantageous for a practitioner, for it is the immediate effect which can be eliminated; but it is a grave error as regards diagnosis. For the nature of a disease is indicated only by its elements, and we must remember that the elements of the disturbed mental life — here mania — were there even before the affection of the uterus or of the breasts. Man is always the result of his entire life. Whatever affects him, influences him in accordance with his psychological attitude and temperament. A menstruating woman, or a woman in childbed, who has always been demanding and morbidly passionate, and who is now, moreover, corporeally sensitive, becomes directly affected in her temperament by anger, irritation, jealousy, etc. The elements of mania are present; they meet together, and the disease is produced, which immediately results in disturbances of the bodily functions. It is not the disturbed secretions which have caused the mania, but mania in its state of formation has interfered with the secretions. But not only Perfect, many other doctors, too, are guilty of this grave ysteron proteron. The restitution of the secretions will not eliminate the cause of the disease, that is, the disease itself, but will merely comprise an effective counter- stimulant, applied at the most suitable location. This often has a beneficial effect on the disturbed mental life itself. We must accordingly not be surprised to see other English practitioners follow in the footsteps of Perfect, who is one of the best of them.

[Perfect wonders how physical cures to a spiritual problem could cure. We would ask the same question, since with the modern eye, know for certain, what Heinroth only guessed at. All of the treatments used by Perfect are today dismissed as quackery. His answer is the placebo effect of the positive attitude of the physician. Both ideas are well documented, standard concepts taught in the first week of modern medical school]

§ 138. Of the others, we mention only Haslam, Cox, and Marshal. J. Haslam (Observations on Insanity etc., London, 1798) gives the following definition of insanity: "It consists of a wrongful combination of ordinary thoughts and a firm faith in the rightfulness of this combination; this is commonly accompanied by exalted or depressed states of the temperament." Haslam does not consider the latter states to be the essential feature of insanity but only the state of the reason. He mentions mania and melancholia as different forms of insanity, but does not consider them to be opposite diseases. "Reason is equally disturbed in both, and they differ only in the different accompanying states of temperament. There is, moreover, no difference in their treatment." But we maintain the contrary: the diseased ideas are but the result of the diseased states of temperament which must be regarded as being the main feature in these two cases, but as these two cases are opposite they must also be treated in opposite manners. For is depression the same as exaltation, or fear the same as rage? Haslam's symptomatology has some truth in it but is one-sided and confused. He spent much time and effort in dissecting the cadavers of mentally disturbed persons. The usefulness of such a procedure cannot as yet be decided; at present, all that we can say is that any attempt of this kind should he welcomed. What we disapprove of in these studies is, however, the exclusive attention to the brain and its surroundings. The dissector found in all 29 cases described that the brain and the brain membranes were always affected. As regards etiology, Haslam shares the common view that assumes both physical and moral causes. Regarding the former, Haslam persists in the error of his predecessors and regards organic manifestations caused by psychological degeneration to be the causes of the derangement, the nucleus of which had been present for a long time and only needed fertilization. As an example we shall take the "habit of drinking." Nobody makes a habit of inebriating himself unless his spirit and his temperament, and also the conditions in which he lives, give rise to a tendency to seek self-oblivion, and even self-destruction and destruction of consciousness. The disorderly, the dissolute, the reckless person, and he who gradually destroys his spirit, his body, and his possessions by constant abuse is the potential drunk and asylum inmate. Veins swollen with thick, bad blood and dulled or oversensitive nerves are merely the external result of a perverted mental life that has long been present in the individual in the form of unreason, and the organic irritation produced from the same source merely determines the external tendency and the final form of manifestation of the disease. Thus, Haslam very rightly says that "most of the moral causes can probably be traced back to errors in upbringing, which plant the seeds of unreason in the young spirit, and these sprout forth under the most insignificant influence. The educators of the young should make it their business to discipline not only the reason, but also the passions and the temper of their pupils. Man should be told, while there is still time, that every cause has a certain definite effect, and, in general, should not be allowed to acquire a fixed, insuperable tendency to desire temporal and earthly things." Obviously, if this could be done, no lunatic asylums would be needed, and the medicine of the psyche could be replaced by the hygiene of the psyche. Haslam is very cautious as regards prognosis, since he recognizes the difficulties involved, and makes the significant remark that in the large Bethlem's Hospital in London, where he was employed, "I generally know little of what becomes of the discharged patients, but relapses are noted in some of those cured. Thus, out of the 389 patients which were admitted during the past two years, 53 patients had been in the institution before." What then are we to think of the records of cures? And again he states that "by no means are all the patients brought back to the institution." Haslam concluded from a thorough study of the list that the cure depends directly on the age of the patient and indirectly on the duration of the disorder, so that those who have been sick for over a year can be cured only rarely. The cure itself is sharply divided by Haslam into means for restraining the patient, and the treatment of the disease by administering medicaments. He makes the very noteworthy remark that even patients who are blind to their own transgressions very distinctly notice the faults of others, and thus also those of their physician. The physician should therefore first and foremost restrain himself and should seek to gain the confidence, trust, and obedience of the patients through his mental superiority, calm, and dignity. "Weakness of character or of spirit, insincere, inconsistent behavior, even if accompanied by truly tyrannical severity, can only result in antipathy and contempt." Treatment with medicaments is not Haslam's strongest point. He seems to put his trust chiefly in bleeding, and here his point of view is opposed to that of many other practitioners; his indications for bleeding are also very superficial and uncertain. His other materia medica is insufficient; he speaks only of purges, emetics, camphor, and cold baths. All these are described in an unsatisfactory, superficial manner, even though he was not short of opportunities for observing the effects of such treatments. Here Haslam differs from other English practitioners who dwell on this point too much rather than too little.

§ 139. J. M. Cox (Practical Observations on Insanity etc., London, 1806, 2nd edition) presents a long list of medicaments and other remedies, including a description and appreciation of the swing, accompanied by several historical data. His views on and experience with the various medicaments that are being administered to mental patients are incorporated in the series of case histories, which all begin with a historic description of the onset of mental confusion, its course and termination, followed by an investigation of the causes, and a prognosis and diagnosis of the mental disorder. Cox, like many of his predecessors, seems to err principally in assuming that the particular form of development of insanity proper (as a separate form of the disease) — which we classified as a disease of the temperament marked by exaltation, and to which we therefore assigned a separate sphere within the wide field of mental disturbances is the general norm for the course of all psychic diseases. This would obviously mean that insanity is always the same disease, showing only unimportant modifications and variations. We absolutely disagree with this. As regards the causes (moments) of disease, Cox, like others, also errs in confusing them with the external bodily symptoms, in the same way as was discussed earlier herein. For the so-called immediate cause Cox does not look in the brain, as others do, but in the vascular system that is, in the condition of the vessels of the brain. This view is at least partially correct if we ignore the confused notion of the "immediate" cause. In general, this writer consistently refuses to enter theoretical reasoning but follows the line of accurate observation of the manifestation of the disease and also of the progress of the cure. It cannot be stressed too often that this is in fact the best method in all empirical work. Cox is a sober, accurate observer, and his remarks, in particular on the various medicaments, contain much that is true and practically useful. His observations on the effect of digitalis in various cases of insanity are especially worth noting. This effect seems to some extent to confirm his views on the diseased condition of the vascular system in this illness, even though here, as usual, the connection is only partial and relative. Of exaggeration and partiality, Cox is guilty in the chapter describing the wonders of the swing, which he tried out on numerous occasions. He cannot praise it enough and all but recommends it as a universal remedy against all forms of insanity. We do not wish to deny the powerful effects of this violent remedy whenever applied, and its beneficial effect in some cases, but we must recommend that its application be considerably restricted. We would like to see this remedy properly investigated and the swing applied with the greatest caution, although in Germany, too, it has found enthusiastic partisans. This question will be elaborated later in this book. In conclusion, Cox must be acknowledged as one of the leading English practitioners, whose efforts invariably merit careful attention. Less satisfactory are his remarks on the issue of medical certificates and medical opinions in cases of diseased intellect. These may indeed be suitable for the formal English system but arc not in accordance with our own ideas on forensic medicine.

§ 140. A. Marshal, although a practitioner, was only active in anatomical investigations on diseased conditions of the psyche, which he carried out to obtain pathological results. His work The Morbid Anatomy of the Brain etc., London, 1815, contains many observations made on cadavers, mainly those of mentally disturbed individuals who died at Bethlem Hospital, and especially of patients who had figured on the list of incurables on account of the long duration of their disease. He found in almost all cases a morbid condition of the brain and its surroundings, especially of the brain vessels. This induced him to study the vessel system in general, and the heart in particular, which never lacked rewarding information. Thus he concluded that the disturbances of brain functions — because as such he regarded what he termed maniacal disorders or (as others call them) insanity — are invariably related to and interconnected in the most exact manner with a morbid condition of either the heart and the vessels in general or the brain vessels in particular. In his view it is not the cortical substance but the medullary substance which, being the organ of sensation, memory, power of decision, and even of the will and emotions, deviates from the normality of its functions and causes many diseased manifestations in the sphere of mental activities. This remark, which was also less definitely stated by others, is very important and must be further confirmed if it is to acquire even a relative value in certain cases of mental disturbances. In any case, we must not forget to ask: what, however, is the cause for the diseased condition of the heart and of the vessels, or of the brain vessels alone — a condition which others, even in very careful investigations often even failed to notice. If we were to make a detailed study of the past life of the patient, prior to the complete derangement of his psyche, we would perhaps find that the key to the organic degeneration of the brain and of the vessels lies in this life itself, in its wrong conduction, its excesses and debauches. We would then also find that it is not the mutually opposite polarities that make the soul sick but the deviation from the norm, namely by upsetting organic life. For when all is said — organic disturbances are only the effect, notwithstanding the prevailing tendency to regard it as the cause. Thus it can also be gauged from the extent of the disturbances of organic life how far the neglect of the soul has proceeded — the depth of this neglect being in many cases the true reason for the incurability of the disease.

§ 141. We shall conclude by mentioning the monograph on religious melancholia by B. Fawcet (Observations on the Nature, Causes, and Cure of Melancholy etc., Shrewsbury, 1780). Fawcet was not a physician but a minister; however, his work represents a practical contribution and must not remain unmentioned. Fawcet's list of specific reasons for melancholia, "High-flown thoughts and emotions of temperament; too deep an impression produced by earthly losses and frustrated hopes; anxious worry or morbid disquiet; excessive fear, inertia," etc. gives a very clear picture of a man who has strayed from the straight path of mental life and is an exact case in point of our own view — the view that has just been outlined (§ 140) and has repeatedly been presented above — namely, that all these manifestations cannot take place in a healthy soul, and that it is futile to look for causes of melancholia in the body when they are so obviously to be found in the soul, even though we do not deny that organic life, having been affected by the soul, may become co-affected or may react to them. Another moot point is Fawcet's statement, which is in extraordinary self-contradiction, that melancholia is a bodily evil. This only shows how strong is the temptation to make the visible the reason for the invisible and to mistake the effect, which is first noticed, for the cause, which is more deeply hidden from sight. Fawcet distinguishes three degrees of melancholia: depression, fearful timidity, and despair. Although we concede that melancholia appears in different grades, we must note that these three states can also appear in the absence of any melancholia. The main feature of melancholia is loss of freedom and of power of decision, as in all mental disturbances. Fawcet gives an excellent description of the symptoms of religious melancholia, but his intellectual and moral remedies, which take up a large part of his book, would prove quite ineffective against an already raging disease. It does not appear as if Fawcet has had own experience in the matter, or he would surely have proposed a more definite and complete method and would have described the cases he had actually treated. However, he can be considered as a pioneer in this kind of monograph.

§ 142. The above-presented views on the theoretical and practical views of English doctors should suffice as sample and record of their art and science and give the reader an idea of the nature and the extent of the influence they have had on the medicine of the psyche. It is evident that their contribution to technique, rather than theory, is considerable, and the modern school of German doctors is putting their methods and rules of the art to the best use. We shall mention this again in the final sections of this historical survey. First, however, we must take an at least superficial glance at the work of German physicians and general philosophers on the science of the medicine of the psyche.

§ 143. After earlier, feeble attempts, the first German who deserves mention is Weikard the much-praised and much-abused author of the "Philosophic Physician" (Der Philos. Arzt, Frankfurt, Hanau, and Leipzig, 1782). As is well known, the third volume of this treatise is an outline of what he refers to as "philosophical art of medicine" or, more correctly, psychiatry. He subdivides the diseases of the soul into diseases of the spirit and diseases of the temperament and discusses them one by one, in accordance with their essential nature, occurrence, symptoms, and causes. He quotes examples and case histories, and ends by giving both physical and psychological treatment procedures. A more detailed appreciation of this work of genius will be found else where (cf. Neuestes Journ d. Erfindungen etc., Vol. II, No. 2, pp. 142 ff.). Here we shall merely note that he achieved as much as was possible for his point of view and for the time in which he lived, and deserves to be read even now, despite the fact that his views lack unity (for he forgets the mainspring of freedom, in whose magic circle all the manifestations of the psyche are located), and his description of sensory- perceptual relationships is not unbiased and not free of abstract-mechanical ideas. At present, this brave man would best be refuted by being surpassed. If his fundamental principles had been reinforced and construction on these foundations continued, progress would have been more impressive than it is today.

The next physician to deserve mention is J. B. Ehrhard, who pioneered further studies on the medicine of the psyche in Germany. In Wagner's Beytrdgen zur Anthropologic etc., Vol. I, Vienna, 1794, pp. 100-143; Vol. II, pp. 1-66, and in Hufeland's Journ. d. pract. Arzneykunden, Vol. XIV, No. 2, pp. 64-90, he outlined his theoretical and practical views on the diseases of the psyche. He followed the example of the older nosologists and defined the scope of such diseases much more broadly than we would ourselves. His class of derangements* includes disturbed perception (hallucinationes), disturbed inclinations (morositates), and disturbed actions (deliria). It is thus clear that his concept of derangement is, at the same time, very broad and very one-sided, since it cannot even be applied to the individual genera of the order deliria (Cullen's and others' vesaniae) but only to that genus in which derangement of reason (Verstandesverritchung) is the main feature, i.e., derangement (Verriicktheit) proper, which may manifest itself as craziness (Aberwitz), dementia (Wahnwitz) or folly (Narrheit).** Ehrhard merely deals with what he calls the delirii, which he sums up in the designation senselessness (Unsinnigkeit), in which he distinguishes between idiocy (Sinnlosigkeit (BlOdsinn)), melancholia, folly, and frenzy. In his papers he describes the theoretical and technical features of these different forms often incorrectly; he treats certain important questions superficially or not at all, while he lingers over minor, irrelevant questions. Nevertheless, there is much that is good and useful in his work, while some parts may even be considered excellent and exemplary. These include his discussion on folly: diagnostic comparison of this disease with melancholia and insanity; the development of man's dormant tendency to folly; his remarks on self-possession; and finally the cure of folly itself; and his discussion of melancholia: diagnostic comparison of this disease with madness*** (paraphrosyne) and with hypochondria; the ingenious description and pathogeny of the so-called idees fixes (which is the only pathogeny in which he was successful). Thus Ehrhard, too, is a brave pioneer, who shows us by those of his attempts which are successful, if not what is, at least what may come to be the future medicine of the psyche (cf. my detailed appreciations of Ehrhard's views in Neuesten Journ. d. Erf. etc., Vol. II, No. 2, pp. 150-193).

The third in this trio of precursors of German medicine of the psyche is J. G. Langermann. As is well known, his inaugural dissertation De methodo cognoscendi curandique animi inorbos stabilienda, Jena, 1797, was considered to be a classical text for the recognition and treatment of diseases of the psyche not only following its appearance, but for a long time afterwards. The author begins by giving a superficial, though lengthy, account of the history of psychological medicine and then presents his own principles concerning the correct method in the medicine of the psyche, which, he insists, should be based on observation and induction alone. These principles are: "1) Search for external differences which, being due to different causes, provide the proper criteria for a correct subdivision of the diseases. 2) Deduction of the causes and their effects from the symptoms. 3) Collection and utilization of all isolated remarks for the purpose of recognition and treatment of the diseases of the soul." We may note that the elements of these postulates are somewhat heterogeneous and are not all equally important. The first principle is important, since it results in the recognition of the physiognomies of mental disturbances and introduces a finer differentiation thereof, even though leaving their reasons unexplained. The second principle, however, is an uncertain guide, for symptoms only show that they exist and not why; and they can be due to a combination of causes which are entirely hidden from the eye of the observer. The third principle, finally, cannot be included in the method, since it already presupposes the right method or else is only looking for it. In trying to apply his principles, however, and in the execution of his method, Langermann is often forced to extend the limits of his principles in order to give content to the method. Thus, he begins with a so-called experience concept of the soul, based on its individual powers but lacking precisely those which make the soul what it is: reason and freedom. As a result, the ideas of health and disease of the soul which he builds on these foundations are not merely one-sided and confused but simply wrong. For while postulating that the health of the soul signifies a harmony between its different activities while the disturbance of this harmony results in a disease of the soul, he forgets that which generates this harmony, without which harmony is not conceivable, and that of which harmony is only the external manifestation, namely, freedom. The existence of freedom, that is, of the efficacy of reason, is the only condition of health, just as its absence causes disease of the soul. Thus, Langermann omits the essential. Were it not so, his definition of disease of the soul would be the best we have. It is as follows: "A disease of the soul is an involuntary, persistent, or frequently recurring disorder (perturbatio) or divestiture (privatio) of the thinking and willpower by an originally mentally healthy individual, either with reference to a single object or to the entire consciousness and activity, accompanied by exaltation or depression of the imagination and the feeling." An originally healthy individual, however, will never sink into such a state, precisely because a healthy soul means a free and independent soul, that is, a soul governed by reason. Langermann then subdivides soul diseases into idiopathic and sympathetic, i.e., into true and apparent, soul diseases. This is a grave offense against logic and against nature, which is the same thing. However, we entirely agree with Langermann when he says of the true (idiopathic) soul diseases that they are either fantastic or pathetic, in other words, that the diseased state of the psyche is marked by exaltation or depression. According to Langermann, Linne already noted this, and he was an accurate observer. Langermann further advises that any assessment of diseases of the psyche must take into full account the bodily constitution, temperament, and psychological character of the patient. We agree with all this, except for the last point, since this is conceived in a very one-sided manner, as the main emphasis is here laid on the imagination, a quality which Langermann considers to be most important, since through it alone a man is truly human. However, it is possible to have a vivid imagination and still be an unreasonable brute. Pathology and therapy of the psyche are treated by Langermann only superficially, but one of his remarks on therapy is perhaps the most important feature of his entire work, namely, that in order to cure the mentally sick, one must study the rules, means, and devices by which educators develop the souls of children, stimulate, exercise, and form their intelligence, dominate their passions, and correct their bad habits. Langermann has the merit of novelty and of thought stimulation for his pamphlet resulted in the publication of many others, which we shall not take space here to mention, and had a marked influence on the keen, ambitious Reil.

* [In German: "Verrtickungen."]

** [These and other similar expressions are used inconsistently throughout the book and have nothing in common with their modern German or English usage.]

***[In German "Irrsinn," a term used here for the first time in the hook.]

§ 144. We shall leave aside the detailed or sketchy attempts of philosophizing and, especially, "kantizing" physicians who tried in their own publications or periodicals to find a philosophical or abstract aspect of the different branches of the medicine of the psyche. Similarly, we shall omit the immature efforts of certain students of the new discipline of natural philosophy. All these efforts, though made with the laudable intention of shedding more light on this dark domain, contributed nothing to the true theory and technique of mental disturbances. These cries in the wilderness were soon forgotten, and their starting assumptions were soon abandoned. We prefer to use the little space still left us to give a very brief account of the ideas, views, and proposals made by men whose literary or practical efforts, or both, made a lasting impression on their contemporaries engaged in the same profession or art, and who imparted, or are about to impart, its specific character to the German medicine of the psyche. In the preceding pages we outlined the growth of the medicine of the psyche in Germany by presenting a trio of brave men, one of whom was inspired by a bold spirit of innovation, the other by the spirit of subtle investigation, and the third had the spirit of a true practitioner.

In the following pages we shall follow the further development of this branch of medicine by presenting another trio of similar personalities: Reil, who resembles the innovator Weikard, Hoffbauer, who resembles the subtle Ehrhard, and Horn, who resembles the practical Langermann, even though the views of the latter were made public only at second hand. For a good reason we shall begin with Hoffbauer, who will be followed by Reil and then by Horn.

§ 145. J. L. Hoffbauer, who had already acquired renown in more than one field of science, was, due to his enquiring and systematic intellect, attracted to the medicine of the psyche as well. We shall omit the works performed in collaboration with Reil, as well as that which, in our view is his best work

Die Psychologie in ihren Hauptanwendungen auf die Rechtspflege etc.

(Psychology from the Aspect of Its Main Applications in the Administration of Justice), Halle, 1808, which we shall discuss in another connection, and shall confine our attention to his study Untersuchungen nber die Krankheiten der Seele and die verwandten Zustande (Studies on the Diseases of the Soul and Related Conditions), Halle, 1802-1807. The first part contains general considerations on diseases of the soul and their classification. The second part lists diseases of individual capacities of temperament with suggestions on their psychological treatment. The third part specifically deals with insanity and other forms of dementia, and also includes suggestions for their therapy by psychological means. It would be impossible to summarize this extensive treatise briefly and critically, and we shall therefore confine ourselves to the fundamental concepts of the author and attempt to present them to the reader in their proper light. It is important to note that this entire study begins with the attention and its degeneration into absent-mindedness and preoccupation, because this shows us at once that the point of view of the author is superficial. Whoever attempts to investigate and determine mental disturbances on the basis of certain external manifestations is from his very first step on a false trail. All organic manifestations must be interpreted organically, i.e., from the interior outwards; this is even more true of manifestations originating from a purely internal, psychological, free principle and which cannot be explained without the most thorough knowledge of this principle. For what particular disturbances, what degeneration of his soul life, would make a man absent-minded or preoccupied? And from here onward the author applies his method of particularization and fragmentation, which then follows us like a tormenting spirit throughout the book, and which is truly a vampire feeding on life, since life is an entity and can only be understood through a living point of view. The harmful effects produced by this method can unmistakably be seen in Hoffbauer's definition and classification of diseases of the soul. According to him, a disease of the soul is "a condition in which the capacities of the soul are manifested in a manner which is contrary to nature and involuntary." It is the latter symptom which, in the view of the author, distinguishes the diseases of the soul from moral defects, that is, from sin and vice. If Hoffbauer had not concentrated his attention on the external manifestations of the internal nature of the psyche, which all have organic causes, but rather on the inner, the nature of the soul on its free, moral nature, he would have refrained from pronouncing such a definition with all its corollaries. The soul cannot become diseased if its freedom is not affected; it is nothing if not a free entity, and its manifestation in the unfree state in different forms is the very core of its disease. All the capacities of the soul are related to its freedom, and should they become detached from it, they become nothing but phenomena of a higher organism. A student of the soul, so far from being allowed to separate out the practical defects from the diseases of the soul, has the obligation to consider the latter as the cause of the former, since in the absence of such an attitude the entire web of soul diseases has no support and remains floating in the air. Hoffbauer differentiates between diseases of the soul by their seat, that is, by their capacities. "Either a single capacity is affected by itself, or else the mutual relationships between the capacities are no longer natural." He names those diseases that are manifested in a disturbed relationship between two capacities, derangements. To determine with more exactitude diseases Of the first kind, Hoffbauer distinguishes between two kinds of soul capacities: those which can and those which cannot be imagined as existing separately from the body. He calls the former capacities of the spirit, while the latter are called capacities of the soul, in the narrow meaning of the word. Soul diseases are grouped by him in three corresponding classes: 1) diseases of the inner capacity of the soul per se, or diseases of the mind; 2) diseases of the mutual relationship between the capacities, or derangements; 3) diseases of the external capacity of the soul, that is, of the community of body and soul: diseases of the soul in the narrow meaning of the word. We admit to being reluctant to peruse such a chaos of soul and diseases of the soul. We can see nothing here save arbitrariness and narrow-minded abstractions and dry, dead, fruitless fragmentation. Only a dead structure can be erected on such a lifeless foundation. And this is indeed what we declare Hoffbauer's entire theory of disturbances of the soul to be, though wrought with so much subtle intelligence, with such an abundance of words, and — what pleases us much more to say — characterized by so apt details, so subtle comments, and so poignant traits etc. as to constitute a wealth of instructive and useful material. Or are we wrong in maintaining that Hoffbauer's spirit is lacking in spirit and his soul is lacking is soul? The essence of the human spirit is reason, and the essence of the human soul is freedom; and both are ignored in the entire book. Because in it, the innermost man, the psyche, is considered as a mere automaton, which like a machine, a clockwork, or a mill, is composed of individual parts which can become sick and must then be repaired. But this is not how man lives, not how he becomes sick, and not how he is being restored. Only freedom lives in the man as man; the soul falls sick only in relation to its freedom, and only in relation to its freedom must it be cured. Memory, reason, imagination, etc., all these can become organically sick, individually or in relation to each other; but organic disease is not soul disease even though it is often caused by or connected with the latter; but organic disease can often be cured without curing the soul — both in chronic and in acute cases. The second part of the work deals with this kind of organic diseases (in accordance with our own definition) and with mental diseases (as defined by the author). For it deals with diseases of the powers of imagination, feeling, and desire. Is all this termed "soul" by the author?! And is soul conceivable independent of the body?! These diseases include, firstly, diseases of the senses (dullness and illusions), of reason (stupidity and idiocy), imagination (feebleness thereof), and memory (weakness thereof). Secondly, there are diseases of the capacity for feeling: gloom, despondence, ill humor, which then becomes folly. (The reader may recall Ehrhard's "folly originating from melancholia"; this is only one of the many points of resemblance between Ehrhard and Hoffbauer.) Finally, he describes diseases of the capacity for desire, saying much about tarantism, St. Vitus' dance, St. John's dance. Finally, as a postscript which is also an introduction, there is something on rage, frenzy, and anger. Here the author mixes together the most heterogeneous elements and names their category "spirit": affections of the senses, affections of the brain itself, inasmuch as this organ determines the so-called functions of the spirit proper and inasmuch as memory, power of discernment, imagination, etc., depend on its constitution, the strength and activity of its vessels, the vitality of the afferent blood supply, etc. Symptomatic disturbances of isolated, organic activities of the spirit are presented by the author as real diseases of the mind itself. He also places the affections of feelings and spirit in the region of the mind, the task of the latter being at the same time only the forming of views, concepts, decisions, and ideas. Even sickly irritations of muscles and nerves, unrelated to any effect exerted by the spirit, become diseases of the spirit under the pen of Hoffbauer. Whoever finds consistency, orderliness, unity, and truth in all this, even concerning the manifestations of diseased life, will do so at his own risk and peril, for we cannot agree with him. The third part, finally, deals with derangements* in the particular sense in which this term is employed by Hoffbauer, namely, a distorted mutual relationship between the individual capacities of the soul. "If the individual aspects of the perception capacity are not in a proper relationship to the capacity for feeling and desire, then there appear the various manifestations of derangement, such as insanity, folly, rage, frenzy, fury, etc." This view bears the hallmark of mechanicism and of exclusively regarding conditions mechanical, and thus — of one-sidedness. Many persons are predominantly guided by intellect, imagination, or feeling throughout their lives and are accordingly known as men of intellect, men of imagination, or men of feeling, without being in the least insane. It is not so much the task of reason to hold the individual activities and conditions of the soul in a mechanical equilibrium as to inspire them, individually and all together, with the spirit of truth, the spirit of leading a holy existence. Perception, thought, and action should be holy. It is only when a man abandons reason, thinks, acts, and feels without reason, that he runs the danger of becoming foolish, manic, insane, etc., and will surely become so if he persists in his unreasonableness. Thus, it is the lack of reason and its effect on t he feelings, thoughts, and activities of men which is responsible for these diseased conditions, and not the incorrect proportion between the activities of the psyche and its states. Hoffbauer's concept of the so-called derangements is therefore based on a grave error. However, this was inevitable: Hoffbauer had to resort to these mechanical artificialities since he had refused to acknowledge the existence of a "moral man," that is, the capacity of man to be moral or to be guided by reason, although man can only descend to a diseased mental condition if he has lost that which made him human, namely, his reason, and it is this unreason or loss of freedom which is always the essence of the disease, while the question of which province of the soul happens to become affected is purely accidental. How difficult it is for Hoffbauer to move about in the restricted world of his own making is apparent from his interpretation of insanity, which is the main subject of the last part of his book. To him, insanity is "a derangement in the proportion between the senses and the power of imagination." This is a dead analysis of a dead notion, not a living interpretation of a living condition. According to him, the origin of what lie calls insanity may be both: either dullness of the senses or eccentric phantasy. Both ideas are meaningless. The first is based on a false conclusion drawn from a correct observation, or rather on a false analogy with the dreams which are initially experienced when the external senses are falling asleep. Dreaming does not originate from the dulling of the senses but is due to sufficient fantasy still being left to continue a kind of waking life even in sleep; for when this remainder of the mental-plastic matter [sic], which the day has left in sleep, has become exhausted, the dream, too, disappears and proper sleep ensues. No more can an eccentric fantasy produce insanity: for such a tension is already one of the symptoms of insanity, i.e., of this state of "permanent trance" as we should like to call insanity, whereas to produce insanity, it takes an entire eccentric life, and one kindled by profound passions. Hoffbauer then distinguishes between different kinds of insanity, all of which are merely incidental features and do not characterize the very nature of insanity. Thus he distinguishes between partial and total insanity. The existence of partial insanity we altogether deny; for if it is the belief of a patient that, say, his feet are made of glass, then he is an altogether disturbed man who has become engrossed by this false idea, and absorbs it with all his being so that he is in no way partially, but totally, ill. The differentiation between delusory and chimeric insanity is also illegitimate, for all insanity is delusion and all delusion is chimera, i.e., fancy. If this fancy concerns ideas and conditions (and not objects), it is no longer insanity but folly,* and no longer concerns the imagination but the reason.

[In German: "Verrikkungen."I MODERN "fimEs 91

The means employed by Hoffbauer for the cure of insanity and mental diseases in general are just as much an abstraction as his conception of the diseased states in general and in particular, and do not constitute any scientific therapy proper. But we must not continue in this way lest we become as verbose as Hoffbauer himself, and must content ourselves with the final remark that he displays more talent in abstract psychology than in presenting a lively description and, consequently, that he did not get as much to the bottom of the subject of so-called diseases of the soul and related conditions (not even as concerns fundamental concepts) as many believe, but that his method has initiated — laudably though not successfully — a more careful investigation of these conditions than has been made before his attempts.

§ 146. We now turn to Reil. The ideas advanced by this tireless, high-aiming worker at various periods of time are scattered over various publications. Their gist is reflected in his work Rhapsodien iiber die Anwendung der psychischen Kurmethode auf Geisteszerriittungen (Rhapsody on the Application of the Psychological Method of Cure to Mental Disturbances), Halle, 1803. Here is the very "heart" of Reil's psychological medicine, if we may borrow an expression which the author, who passed away prematurely, was fond of using. We can here only emphasize the fundamental ideas which permeate and animate all his work. This publication is well known and indeed deserves to be so. To some extent it has been utilized, as will be seen below. Except for the early English writers (especially Arnold on the historical aspect) and for Hoffbauer, whose influence in the field of analysis cannot be denied), Reil is guided only by his own views on the life of the brain and of the nerves, in particular by his own ideas on the sense of general well-being,** the dimensions of which reach to the outermost periphery of consciousness, while its essence is consciousness itself. With the degeneration of consciousness and of clear, sensible attention into absent-mindedness or preoccupation, conditions are created which result in the first case in folly, in the second in fixed insanity or melancholia, which latter in turn may give rise to apathetic or restless insanity (melancholia attonita or erratica). The highest degree of loss of sensibility is rage or frenzy, while its lowest energy plane is idiocy, which may either be organic, that is, it may be due to disorganization of the brain, or dynamic, i.e. due to the extinction of its excitability. Idiocy, rage, folly, and fixed insanity can be treated in two ways: directly by removing the results and indirctly by removing the causes, after which organic nature itself removes the effect. But whatever the method employed, even physical remedies act on the psyche, namely, by stimulation of the soul and by establishment of the equilibrium of the disproportionally excited activities of the psyche. If the origin of the disintegration of the spirit is not in the psyche but in the affection of the brain resulting from stimulation of the phrenitic region, the solar plexus, or the reproductive organs, or else if the vegetative matter is deficient, then the first measure should be to remove the bodily hindrances that were responsible for the disease of the soul organ. But even somatic treatment is assisted by suitable treatment of the psyche, and "it is not even impossible for patients with incurable disorganization inside the brain or outside it to be cured from their insanity by psychic treatment or at least for the insanity of the attacks to be abated" — an extraordinary statement, the truth of which may be decided some time in the future. In any case, it depends on the kind of psychic treatment employed. The psychic remedies derive their name only because of their effect. They act either through the sense of general well-being or through the sense organs: directly on the capacity for feeling and imagination, indirectly on the capacity for desire, by modification of the sense of general well-being and the sense organs, namely: positively by stimulation and negatively by sedation. Indirectly, stimulation can also pacify excitation, while sedatives can give rise to a new activity. This last idea deserves much attention, especially since it was put to use in the practice by others and must be respected as Reil's property. The positive healing method, application of soul stimulants, is especially recommended in listlessness, asthenia, and catalepsy of the soul organ; but it can also be used in sedation, in accordance with the law of deflection. Psychic remedies may be subdivided into three classes, in accordance with their main constituents: the first is that which affects the general sense of well-being by pleasure, dullness, or pain. The second contains the phenomena which act upon the senses, such as music. The third class comprises all signs and symbols, especially speech and writing, since these are the media through which our views, conceptions, decisions, feelings, desires, etc., are transferred onto the patients as external powers. Before any cure, the patient must be rendered receptive to it by the application of psychological means, partly in order to arouse self-possession and partly to produce obedience. The means must be suited to the individual nature of the patient, to the kind and degree of his affliction, to his upbringing, his feelings, briefly, to all the traits of his character. The next stage is to eliminate the most remote reasons for the disturbance of the mind, both the external objects and the inner state of the man himself, that is to say, the physical, sensual, intellectual, and moral forces which adversely affect him. At the same time it is also necessary to consider the various forms of the disturbance of the spirit itself, inasmuch as these forms differ in their nature. The melancholic, the fool, the raging maniac, the idiot, each one of these must be treated differently, the main difference being the sthenic or asthenic nature of these affections. Convalescence must be particularly closely supervised. However, all treatment must be preceded by an expedient organization of the lunatic asylum as an institution devoted to curing the patients. This idea is presented here in an exemplary manner. We should point out that Reil's classification of the groups of diseases could have been more sharply outlined, and that Reil, with his keen gift for observation, could have avoided several errors made by his predecessors, both the local and the foreign ones. For example, he should not have made derangement of reason the essential feature of all mental disturbances. We must, nevertheless, concede that nobody has given more serious thought to the foundations of the science of psychological medicine proper and to its practical organization. And though his views and his proposals are imperfect, and some of them are not even practicable, they are still a very powerful stimulus for further work in this field, and we do not hesitate to acknowlege Reil as the founder of psychological medicine proper. The unruly tendrils of the vine he planted have already been pruned by another's hand, and a healthy stem will grow in good time.

[In German: "Wahnwitz."]

[In arch. German: "das Gemeingefuhl."]

§ 147. For we are of the opinion that Dr. Horn in Berlin is even now removing the excrescences from Reil's teachings, and — while retaining the simple principle of affecting the general well-being and at the same time applying the successful experiments of the English in his pain-inflicting method — is following a simple and sure path, even though this does not lead to the ultimate goal. Although Dr. Horn has not yet offered us a presentation of his theory and technique, the fundamental principles are no doubt reflected in the laudable work of one of his pupils, Herr Sandtmann. His paper Nonnulla de quibusdam remediis ad animi morbos curandos summo cum fructu adhibendis, Berlin, 1817, which we have already mentioned elsewhere, contains more than its title indicates, for it does not only speak of remedies but also of their manner of application. The description of these remedies, in conjunction with or in contrast to the orthodox procedures, is the main subject of the book. The book demonstrates, firstly, that the treatment of diseased conditions of the psyche according to their remote causes or according to the symptoms of hypersthenia and asthenia is inadequate; secondly, that the psychological method, which acts directly on the disordered mental powers by encouragement, direction of the emotions, and exercise of the mental powers, and is therefore known as the direct psychic method, is only applicable in mild cases and during convalescence. Therefore, the method which can be advantageously applied in all cases, at all times, and under all circumstances is the method known as the indirect-psychological, or deflective, or antagonistic, or pain-inflicting method. For, according to Sandtmann, in all these diseases the brain power is either depressed or unnaturally excited, and as a result the peripheral nervous activity has decreased, owing to either weakness or to excessive stimulation of the central organ. If this activity is awakened, intensified, and brought back to life, then, by the law of antagonism, the activity of the central organ will be intensified if it has subsided, as in idiocy, and pacified if it has been excited by a sick imagination, emotion, or desires, as in melancholia and mania. This antagonistic effect is most reliably and most powerfully produced by a painful stimulation of the general sense of well-being. The sphere of this sense, except for the central organ, resides in the entire organism especially in the ganglia and the epidermal system; both these systems are quite insensitive in all diseased conditions of the soul. Thus, the antagonism supplies the actual leverage for the elimination of abnormal conditions of the soul. In applying this method it is very useful, nay, necessary, to combine a suitable bodily with a suitable mental regime, which consists in supplying or withdrawing vital somatic and psychological stimuli. This method, which represents the central point of the entire work, is partly negative, partly positive. The negative part is that whereby the patient is deprived of things he has been accustomed to receive: food, air, light, freedom of motion, etc. The positive part comprises all bodily stimulants which painfully affect the general well-being. These might be internal or external. To the internal antagonistic remedies belong purgatives producing nausea and vomiting and medicaments stimulating salivation; to the external ones belong all the means which produce intense irritation of the skin and stimulate the peripheral activity: intense tickling, sternutators, the nettle whip, artificially produced skin diseases, cauterizing and burning means, baths (preferably cold), drenchings, showers, immersion. The external antagonistic remedies also include suspension in ropes, rotation in a circle, etc. All these efforts, negative and positive, internal and external, mechanical and surgical, have only one purpose and one effect: to restore the activity which was weakened or unnaturally intensified in the central organ to the organs situated outside the center and to the periphery in general, and thus to resore the disturbed harmony between the organic activities; briefly, to lead the psycho-organic life back to normal. And thus, according to the author, the difficult task of psychiatry can be solved by applying the simple method of antagonism, or the indirect psychic method — inasmuch as it is at all solvable. For the author very rightly rejects from the very outset all unreasonable demands made on the art of psychiatry in a domain which is so often beyond the bounds of any art, and where the physician faces insuperable difficulties. Anyone with any experience of psychiatry must wholeheartedly agree with the author regarding these difficulties as well as regarding the imperfections of the causal and symptomatic method. Nor are there any valid objections to the application of the indirect psychological method in all cases in which something may be achieved by counterstimulation; and the attempt made by the author to lay special stress on this method and to present it as fully as possible must be thankfully acknowledged. We ourselves obtained excellent results by applying the method to many cases of insane melancholia, rage, and even secondary idiocy, but we cannot admit that it is the sacra anchora, or the best and only method. In its own way, the method is just as one-sided, incomplete, and inadequate as the causal and symptomatic method. It treats the diseased life of the psyche quite mechanically, as if by the law of the lever, and is thus guilty of grave error, as proved by experience. For there are just as many, if not more, curable patients who react to the physician's efforts to coerce and discipline them (in order to neutralize the central irritation by a peripheral one) by becoming only more unruly and even more refractory, or even by sinking into the abyss of self-absorption, as there are patients who return to normal, at least for a certain period of time, as a result of this treatment. The reason is obvious: the cases are not the same. Even healthy individuals — children or adults, men or women — are not affected in the same way by coercion and pain. Some of them can be humbled by this method, others cannot. This is because man (quite apart from constitution, temperament, upbringing, education or miseducation, fate, and weakness of his character — all of which alters the conditions very much) is not a mechanical being but has his own will which may either oppose all constraint and all pain, even at the cost of his life, or else may obey even the feeblest stimulation. "Kein Mensch muss miissen" says Lessing's Nathan the Wise. How true this is show the results of severe treatment inflicted on stubborn individuals, sick or healthy.

*"No man is forced to be forced".

We ourselves have seen cases in which psychic patients, who had a very fair chance of recovery, did not respond to the perfectly proper application of the indirect psychological method by obeying, even less by recovering; instead, they wore themselves out, driven by an inner urge of self-destruction. Did not members of the school which yielded this work come across similar cases, too? There is also another reason, just as important, which lies in the nature of the diseased condition itself, namely, that the theoretical principle on which the indirect psychological method is based has been derived from one-sided observation. Not all forms of diseases of the psyche indicate an unnaturally excited and intensified activity of the central organ. Even Sandtmann makes an exception in the case of idiocy (and many psychically morbid states which approach idiocy, such as silliness, chronic confusion, etc.). Mania and insanity in the strict meaning of the word (acute and chronic trance states) admittedly represent the condition described by the author in a perfectly unmistakable manner, but an exactly opposite condition is encountered in pure melancholia, in partial dementia, in apathy not accompanied by impairment of reason or temperament (Platner's amentia occulta): a condition of paralysis, opposed to that of excitement, if the term paralysis may be used in the context of psychic manifestations. Now paralysis is not merely depression but complete escape or disappearance of the vital principle. In such a case, or, rather, in all such cases, the indirect psychological method is not applicable and is even harmful. It is harmful, firstly, because theoretically any peripheral antagonistic stimulation of the general sense of well-being by pain, fear, fright, etc., can only further exhaust the weakened inner vitality of the central organ. Secondly, experience shows (as reported by many observers) that the result of unwarranted application of the method is not only further degeneration of the patient to the condition of idiocy but also the wearing out of his vegetative powers. These reservations must be made regarding the method, even if we agree with the author that the source of all kinds of diseased conditions of the psyche is the disparity between the central organ and the peripheral activities. But this principle itself is only a hypothesis, and several counterhypotheses are equally possible, such as those which are consider the condition of the intestines in the abdomen and of the entire vascular system. If these conditions are considered too, what then? But all these (surely justified) objections notwithstanding, the view of Horn as presented by Sandtmann is extremely attractive for empirical medical treatment, since it is so simple, so easily understood, so reassuring, that one is never hesitant or unsure whether to apply it in any given case, especially as its not infrequent successes seem to confirm and to establish its truth. In this respect the theory resembles that of Brown in that it is also based on a natural law, albeit on a different one; and no doubt both theories will find wide, if only temporary, acceptance.

§ 148. We have thus followed the medicine of the psyche to its latest results, which, limited though they are, represent the most that can be achieved as long as the science is content to remain empirical. Whoever accepts this point of view needs no other views and no further progress. The excellent Horn has pronounced the highest and simplest, though not always applicable, principle of the empirical school for the treatment of diseased conditions of the psyche. Both the principle and its applications have been described here, possibly in too much detail. This is the last, ripest fruit in the history of the medicine of the psyche; it is the goal of many successful and unsuccessful attempts made over thousands of years, and undoubtedly represents the triumph of empiricism in this field. This concludes the history of the medicine of the psyche insofar as progress can be empirically achieved. Whatever may follow in the coming years can only be the continued application of that highest principle, and a more accurate determination of the degree and kind of its application. We have climbed to the peak of the mountatin, and now our eyes must only get accustomed to the misty landscape far away. Horn's views mark the end of an era of psychological medicine. In the meantime this study has no further history; and we, on our part, shall try to introduce a new period of this history by following a newly selected thread, or, better, by just preparing the beginning of this thread. The human spirit cannot stand still. No sooner has it reached a haven than it immediately breaks anchor to leap again into the hazardous waves of the sea of research. It meets new cliffs, and it must brave new storms; but it cannot do otherwise, for it was not born to be content. The security it desires is beyond the sphere confined within the barriers. It dares to break through these barriers at the risk of committing new errors; but experience has shown that new errors lead to new, higher truths. And thus we solemnly take leave of empiricism, for we are looking for theory, and with it, for a perfect technique. Whoever refuses to inquire any further may stay in the field which we are now about to leave, but not before we have provided ourselves with all we may require on our further journey. Experience is the first element of theory. We do not deny its value, but shall try to supply its deficiency, namely, spiritual perfection. Our course is the rational standpoint, and our password is reason.

Section Two

Theory of the mental disturbances of mental life

I. ELEMENTS

Chapter One

SOMETHING ABOUT THE ELEMENTS OF DISTURBANCES OF THE SOUL IN GENERAL

§ 149. Any natural phenomenon, anything conditional, is subject to certain conditions and exists through them, and these conditions are known as its elements. Our immediate task is to understand the many elements of disturbances of the soul and to define them in all their variety. The word "cause" (unlike the concept "cause," which was not even known till now) has been used wrongly to denote the different moments or conditions — for short, the different elements — of morbid states; thus, as many causes were listed as one found — or believed to have found — elements. Our profound German language, which was created for use by philosophers, should dispense with the word cause* in all scientific research, for this word is self-contradictory. An object is a thing; and there exists no primary (arch) thing, because the primary is that which is unthinged, [i.e. not of the physical realm]** [absolute] — the spirit. Even less permissible is it to speak of causes (in the plural) of a thing or a manifestation, since a thing is produced only by the totality of its conditions; i.e., the thing, or nature thereof, is the cause itself. It is only in this relative meaning that the word "cause" [Ursache] has a sense, in that it describes the thing in relation to the totality of its conditions. Thus, a single condition, a single element of a thing, of a manifestation, should not be referred to as cause. (See my Beytriige zur Krankheitslehre, pp. 75 ff.)

* [In German: "Ursache"; literally: "arch object.")

** [In German: "das Unbedingte"; literally: "the unthinged." Wrongly translated "unconditional"]

§ 150. In our search for the conditions or elements of mental disturbances we must first concentrate our attention on the nature of the soul itself. Like any other natural manifestation, the soul is a force which can be excited by stimuli. It differs from other natural forces only in the manner of its manifestation, in the way in which it is affected by stimuli, and in the way in which it reacts to them. The soul is a free force which, though it may he excited by stimuli, is not necessarily determined by them. The soul has the capacity and the duty of exercising self-determination. Self-determination is its innate activity, its character, its nature. The first moment of the awakened soul life is an act of self-determination; and the soul life consists, consciously or unconsciously, of nothing but such acts. The soul, the ego of man, thus enters the world being bound to an organic apparatus which renders it sensitive to stimuli and capable of reacting to them, in order that it might grow in the world and become an independent rational being. What we refer to as body is only the outward manifestation of the ego or of the soul, expressed and existing in spatial form, unconsciously obeying the laws of creative force, but filled and permeated by the same life in which the soul gains awareness of itself; indeed, the body is one with this life, separated from direct consciousness only by the night of corporeality and manifesting itself only indirectly, by sensations and self-feeling, as an essential but external part of the ego or of the soul. The self-feeling (the general sensation of being) permeates the entire body, making each part of the body the property of the soul and man an integral ego which is partly corporeal and partly spiritual. The ego, the spiritual-corporeal man, is only alive inasmuch as he is inspired by a soul, feels and perceives, and feels and perceives himself as one integral individual. The feeling is the intermediary, the link joining body and soul, the witness to the unity of body and soul — one being, divided only in the double existence of unconscious natural necessity and self-conscious freedom. For this reason and by virtue of this unity of the visible (corporeal) and the invisible (spiritual), both existences are mutually stimulated and motivated.

§ 151. Thus, when studying any possible disturbances of mental life, we have to regard man, who is a partly corporeal and partly spiritual being, as one indivisible whole, as an individual, and when searching for the conditions of these disturbances, we must consider his bodily as well as his spiritual nature. From the very outset, we must recognize the difference or, rather, the hierarchy existing between the two, namely, that the body is not to be regarded as something independent or something destined to be independent, but only as an organ of the soul, or as a soul which has assumed the form of an organ, which bodily appears as a being estranged from itself, a being unconsciously serving itself, which, however, for this very reason cannot be imagined separate from the soul but must always be considered in relation to it. This point of view has never yet been adopted, but is nevertheless the only point of view that can lead to a really useful theory of mental disturbances.

§ 152. For if we tentatively assume that the body is the materialized soul which has entered the darkness of corporeality, we firstly facilitate the explanation of the mutual interaction between body and soul: for since the body was born of the soul and thus is a part of it, the soul can act on the body, and the body, which is of the same origin, can react on the soul. Secondly, it becomes clear that the body is the servant of the soul, since the soul has produced the body, in its organic variety, in order that it might serve its purposes, according to its needs and its destiny. Though this producing was done by a merely unconscious creative force which itself is only a tool of a higher law and an inscrutable wisdom consciousness of its own existence is brought about by its product and tool, the body, and by the body's reactions upon it. Once we become conscious of ourselves and achieve a clear conception of this consciousness, we must no longer doubt the truth of this relationship. On the contrary, we must firmly believe that, as surely as we are conscious beings and as we carry our body in our consciousness — though as if it were the shadow part of our existence — just so we must admit the fact that, even though the development of the consciousness is preceded by bodily organization, the existing soul is not the product of the body, but conversely: the bodily organism is the product, the visible, external growth of the originally invisible, creative, internal force, which is called soul precisely because it is invisible and internal, and which carries in itself, prior to all development, the laws and natural tendencies for a life of the highest integrity, a life of reason. Thus, a life of reason must necessarily be the reference point of each individual, and any other relationship must be subordinate to it.

§ 153. This forces us to conclude that any man, no matter how low his development, is still absolutely reasonable, free, and thus responsive to moral considerations alone, and must be so considered and so respected. This conception of man is altogether different from the common viewpoint according to which the soul, in particular the soul as a moral force, is considered to be a satellite of the corporeal life and is often altogether ignored when discussing the well-being and condition of man. The new conception will be accepted by very few, unless it is put in its proper light; for it is customary to sharply separate the physical and moral aspects of man.

§ 154. But there is nothing that is exclusively physical in man; rather, his entire being is, as it were, immersed in his moral tendency and participates in it from the moment that he becomes human, that is, conscious, to the moment when his consciousness becomes extinct. For consciousness is nothing but reason itself at different degrees of development (§ 36) and is the carrier of all the conditions of human life, be they physical, esthetic, intellectual, or moral. All these conditions bear the holy imprint of approval or disapproval of reason, in the form of happy or unhappy sensations. We cannot even eat or drink, speak or remain silent, think, feel or decide, without being subject to the judgment of reason. All human activity, all human life, briefly, every human condition either does or does not conform to reason; judgment is passed in every case, be it one of commission or omission. Whatever concerns man, whatever reaches his consciousness, affects him as a reasonable being; whatever he does is tried and judged by the reason within him. A man can only gain grace or fall from grace; their is no middle way of existence for him; for reason, that is, full consciousness, is an element of his soul life; he may possess it and be blessed in the union with it or not possess it and he unblessed in the separation from it.

§ 155. The destiny of man is not this earth. A man is not an animal, except when his consciousness is undeveloped, and then he is no longer human. Although he is not aware of it, man is dedicated to the Deity as soon as he enters this world; and his consciousness, his reason, lead him towards the Deity. That this so rarely happens is his own fault; and this guilt gives rise to all evils that beset him, including the disturbances of the soul. Indeed, all his evils, strictly speaking, comprise the nourishment of these disturbances. The germ of these disturbances forms wherever the most guilt is amassed. This cannot be understood unless man is considered as an integral entity — an entity in his vitality, maintaining contact with reason at all extensive and intensive moments of its life. Nothing in man is just body but all in him is life which manifests itself as feelings, senses, and desires that are borne in his consciousness, issue from his consciousness, and radiate back into it. This is our conception of man, namely, one life, in which corporeal and mental states are inextricably intertwined. And these states can be touched only when they are alive, when they are feeling, so that each time they are touched, the contact directly affects the consciousness and the laws by which it is governed, turning the entire life of man into soul life, even if the man be the least educated, crudest, and most corrupt; for all human life is a chain of ideas, and ideas are nothing but the activity of the soul, that is, the action and the life of the soul, however confused, dull, or oppressed it may be. Whatever reaches the body of man, for example food and drink, light and air, heat and cold, the combined power of the elements, the whole influence of nature, affects and excites the receptivity of the body and through it, immediately and directly, the receptivity of the soul and the soul itself. This activates the play of the soul's forces that are inherent in feelings, ideas, and desires — either according to reason or against it, depending on whether the soul life has grown to independence and freedom or is dependent on and subject to external forces. The latter can only occur if the soul has degenerated, though neglect or abuse of its capacity for self- determination.

§ 156. The fundamental law of the soul and of soul life is the law of freedom: for the essence of the soul is freedom; while the source of its preservation, the element of its life, and thus also the condition and the law thereof, is reason. Nature has created man to be free only on condition; he can be free in actual fact through reason, if he obeys it, if he impresses it on his capacity for self-determination, his capacity for freedom, if he makes it the principle which governs this capacity. "Only the moral man (the man of reason) is free," rightly says Schiller; and each deviation from reason is a step towards the domain of nonfreedom, in which mental disturbances have their origin. But man has a propensity for deviating from freedom, which is known as the propensity to evil, and which could also be named a propensity to indolence; for the essence of reason is pure activity, and evil, which is the exact opposite of reason, is absolute indolence. Thus, man's reason and evil are conversely related: the more reason, the less evil, and vice versa. The field of conflict of these two principles is the freely floating human life itself, the free man who can himself decide which side he will take, whether he will devote his life to reason or to evil, to pure activity (spirit, light) or to absolute indolence (matter, darkness). Most people live in a twilight which contains both very dark and lighter sites; but whoever has lost his reason altogether, must live in total darkness. And it is the genesis of this darkness which we shall now follow in detail.

* [The state (presence or absence) of epidemic diseases.)

§ 157. However, before we do so, we should critically glance at what the doctors usually regard to be the elements of insanity (vesania), or its so-called causes, both the preliminary and the incidental causes, as well as the product of both, the so-called immediate cause, which is usually held to be identical with the disease itself. We shall list them in the manner that this was done by one of the recent, extremely careful compilers. We begin with the preliminary signs. "Climate, season, epidemic constitution,* age, sex, imperfect development of the skull, of the senses, incipient puberty, menses, pregnancy, childbirth, menopause, congenital and innate defects, affections of glands, temperament, bodily constitution, upbringing, neglected education, burning infatuation,* temperamental tendencies, way of life, intense concentration on a single object, etc." On this we have to comment that the physically healthy man can stand any climate and any season without suffering adverse effects; the epidemic constitution does either not affect him at all or else can only produce in him the disease which is epidemic (for the results of wrong treatment, or even of the illness itself, such as weakness, paralysis, etc., cannot be blamed on the epidemy, and if we see — after typhoid fever, for example — that insanity, idiocy, etc., are produced, their source lies deeper). Age and sex, say the delicate constitution and sensitiveness of youth or of the female sex, are natural qualities and cannot produce soul disturbances, or else we would have to consider every natural quality of man, nay, his existence itself, as a source of such disturbances. The imperfect development of the skull, and the imperfect development of the brain itself associated therewith, prevents the soul life from the outset from reaching maturity and maintains the man thus affected at the level of an animal; it thus cannot drive out reason, since reason was not there in the first place. Incipient puberty, menstruation, pregnancy, childbed, inasmuch as they affect healthy individuals, do not result in any diseases at all, let alone mental disturbances; even insofar as they enhance irritability and thus exert a moral effect, they will not derange a healthy, strong disposition, even in the presence of additional external influences; for if it were else, insanity, melancholia, rage, etc., would be more frequent in such cases, since external influences, such as fright, anger, worry, etc., are so frequent. But if mental disturbances are actually manifested under such circumstances, the conclusion must be that such individuals had formerly been anything but mentally healthy but had already been morally depraved and needed only an external stimulus to bring some form of mental disturbance to the fore. A congenital predisposition, for instance toward mania, melancholia, etc., has often been contested; however, the possibility that just as physical, and therefore also psychical inclinations are transmitted from parent to child, so too is the propensity to a mental disposition favorable to such disturbances transmitted — just as the parental temperaments themselves are transmitted to the child — cannot be ruled out. But in such cases this disposition must be regarded as a mere moral stimulus, which can be resisted by moral strength, and thus is not a true tendency to become afflicted with a definite form of mental disturbance. No one can seriously consider affections of the glands to constitute a predisposition to insanity, etc., just because tumors of neck glands have been observed in mentally disturbed patients; it is enough to reflect on the large number of other conditions that must be fulfilled for such diseased somatic conditions to first arise and then serve as stimuli of diseases of the psyche. Temperament and bodily constitution as such, unless they have already been unhealthily affected by other influences, cannot be considered to comprise disposition of disease at all, since they are natural qualities. Upbringing may very often pave the way for mental disorders but must not in itself be regarded as predisposition to such disturbances: for many wrongly brought-up individuals have grown up to be good men, while others have degenerated although they have had the best possible upbringing. True, a wrongful or an altogether neglected cultivation of spiritual powers is an incalculable disadvantage; however, its precondition is so marked a deviation from the right, that is, from the moral way of life, that it is the fruit of a perverted soul life rather than a preparatory stage to it and to the accompanying mental disturbances. A burning infatuation, unless accompanied by a vivid excitability of the capacity for desire, cannot have the latter's adverse effects, but if it is accompanied by this capacity for desire, then it is this capacity for desire rather than the infatuation that is morally degenerated: for phantasy merely serves the capacity for desire. Bad habits are merely external manifestations of moral degeneration, and this also shows clearly that the real predispositions to mental disorders always have moral degeneration as their origin. In the same manner, the way of life depends on whether the temper is moral or immoral and is only an external manifestation thereof. Intense concentration on a single object, finally, even if it is habitual, depends on the accompanying interest, that is, on the moral temperament; whoever has his thoughts permanently fixed on any one object, without being able to free himself from it, is already sick in mind, and no premises for the disease by this morbid habit are involved. If the bodily and mental constitutions are sound, concentrated thinking has no ill effect and does not go beyond its proper limits, since moderation is the law which is obeyed by all bodily and mentally healthy men. If the limit is, however, exceeded, and adverse effects, such as mental derangement, dementia, etc., result, then concentrated thinking cannot be considered as a predisposition to these evils, but rather as a result of a life which has deviated from the moral track and which is bodily and mentally degenerate. Our thoughts depend on our passions more than we think, and the passions are not so much the result of the bodily temperament as it is this temperament which is continually acted upon by the soul life and receives the temperature thereof. True, secondarily the temperament thus may gain predominance over the soul life, but only through the fault of the soul life. It follows from this survey of the particular dispositions that we must not concentrate on details but must contemplate human life as one whole in all its aspects. The particular is nothing without the general, while the general is nothing without the associating idea.

* [Sexual fantasies.]

§ 158. That much for the preliminary causes. As regards the second, the so-called incidental causes of so-called madness (the compiler mentioned in the preceding section calls them stimulating or exciting causes, in contradistinction to diathesis which is a well-chosen appellation for the predisposing or preliminary causes mentioned above), we must criticize them, firstly, for their particularizing conception, which unconnected with man's whole life is fruitless, since such causes only become meaningful in relation to life; secondly, for separating, here too, between the physical and the mental stimuli, which is futile, since all stimulation should in this context be regarded only as psychic agents (§§150-154). The listing of these stimuli is nevertheless useful, as it shows us in how many different manners human life can be affected, excited, or depressed by external and internal influences. The following incidental causes or stimulating moments are listed: "Remorse; hasty vows; temptation; fanaticism; political revolutions; good or bad luck; nostalgic memories of a happy past; disappointed hopes; gambling; unhappy love; poor marital and economic conditions; shame; fear; fright; anger; studying objects which vividly excite the imagination; insomnia; immoderate exercise; long-lasting periods of repose; hunger; loss of blood; drunkenness; sunstroke; effect of the moon; cold; suppressed sweating; unsatisfactory sexual life; onanism; excessive sexual activity; arrested lactation; diseases of the abdomen, especially diseases of the bile; flatulence; worms; earlier diseases such as intermittent fever; present diseases; inflammation of the brain; apoplexy; catalepsy; teething difficulties; colic; acute dysentery; erysipelas; latent acute and chronic skin rash; suppression of natural blood evacuations*; pellagra; plica polonia cropped short; abscesses healed too quickly; head injuries; insects; persistent exhaustion following convalescence; medicaments; so-called love potions; associating with the insane." If each of these so-called incidental causes is separately examined, it will be seen that it can be regarded as an "insanity"- causing stimulant only if the entire life of the patient was faultily spent. Each and every one of these so-called causes will prove to be stimulants able to produce such a far-reaching effect only provided the patient, due to a wrongly conducted life, has not only acquired the susceptibility to disease but a true diathesis thereto. Let us assume, for example, that a man can be cast into the abyss of insanity, melancholia, etc., by the crushing force of his awakened conscience: what kind of life must he have led, and what degeneration of the physical and mental life must have resulted, how certainly must insanity, melancholia, etc., already have been dormant if the mere lightning flash of the conscience is to have produced such an effect. The only way in which this could have happened was that the man was seized by a horror of the night which reigned in him and which was revealed for one brief moment by this lightning flash. He then lost his mind in the shock of realizing what he had become. Most people will admit this, and will acknowledge that such results can be produced by one or the other stimulus of the psyche only if the life is already disrupted, but will not admit that a wrongly led life is, if not a necessary, at least a decisive factor, even where physical stimuli are present. Thus, for example, disturbed lactation, acute and chronic skin rashes, suppression of natural blood evacuations, too rapidly healed tumors, head injuries, etc., would not seem to require a psychological or temperamental predisposition but could be fully effective merely by interfering with the life of the brain and of the nerves. But upon closer examination of these "excitatory moments," together with their attendant conditions, it will be seen that they cannot be explained save in terms of the life of the psyche. For what are these so-called bodily stimulations and affections but the results of an unhealthy mental life? The passionate disposition, the wrongheadedness, the stubbornness, and the irritability of many women, even when not in childbed, is well known. If these women with their mental asthenia or hypersthenia are now brought to childbed, is it surprising that small inconveniences will drive them out of their minds and thus produce a disorder in their bodily functions? Badly tended mental life needs only the slightest incident to bring on organic disturbances, such as impaired lactation; but the insanity, etc., which may follow must have been latent for a long time. Again, it can be said that similar results are produced by latent acute and chronic skin rashes, without the psyche being at fault. But then go and observe the patient! What is it then that gives rise to this latency? or to the rashes in general? Is then an overloaded stomach, a defective diet, malfunctions of the digestive organs, upset stomach juices, flushing and colds, this entire cycle of ill-advised activities with their manifold adverse effects on the functioning of organs and on vital functions, which in turn endanger body and soul, — is then all this evidence of an ordered mental life? or is it not rather proof that the economy of the psyche is disordered? Since these results of incautiousness, recklessness, which such bodily ills — and particularly skin rashes — almost always are, suddenly, against all laws of nature, disappear, we must again ask: what offenses, what anomalies of the psyche must have gone before? There must have been enormous neglect, thoughtlessness, haste, passion, or in brief, the perversion of the soul must have been very great, to lead to such confusion and so much contrariness in the exterior vital activity. Nor are we convinced that latent skin rashes of all kinds must necessarily endanger the life of the brain and of the nerves; rather, it seems to us that the irritation invariably appears on the weakest parts of the body only. The same can be said of the suppression of normal blood effusions, which have also been blamed for inducing mental disturbance. But we must first seek the reasons behind these effusions. Let us take hemorrhoids as an example. Are they the result of a well-ordered life or of a satisfactory physical and psychic regime? Age, heredity, etc., may contribute to the ill, but the ill itself does not arise in the absence of excesses, neglect, recklessness, etc. It is intemperance, gluttony, a completely disordered, dissolute life, that do eventually bring about such desperate cures on the part of nature, which are truly no compliment to the human life thus affected. Yet how can the unnatural order of things, thus established, be again disturbed? Only by ever greater deviations from the norm, from the psychological norm: excessive effort, exhaustion, disturbance of daily routine, a life which is driven to and fro by passions, a harassed, fear-driven life, with neither peace nor rest, without clear vision or security. It is of dire necessity that our bodily nature is bound to our spiritual, temperamental, and moral nature. If we were more attentive, we would indeed notice this everywhere. But we have said enough, and all that remains is to remark that diseased processes taking place in the body do not always result in actual disturbances of the soul. Observations in this field have not been carried out far enough, since we are as yet by no means clear as to the actual nature of true mental disturbances. We have not even found a proper explanation for the psychic reflexes of bodily disorders, e.g., the delirium in fever, especially that experienced so frequently by children, for short, reflexes which only briefly touch the mental life but are not based on it and are not properly rooted in it. Let us then not be deluded by these seemingly purely somatic affections. "Bile, worms, insects, etc.," all this is easily said, but we must not forget to inquire into the conditions giving rise to these apparently somatic or somatically active powers. When we do, we shall find that the chief importance was often placed on what were really unimportant details and accidentals. This cannot be stressed too strongly or too often, and this is why we have taken so much time saying it; for a correct point of view on this matter is indispensable to a sound judgment on the whole.

* [Pathological bleedings, see below.]

§ 159. We must now speak of the so-called immediate causes of the so-called madness. The views held on this subject, from antiquity to our own days, are almost ridiculous: black and yellow bile; the melancholic juices in general; the darkened spirits of life; malignant demons; the moon; excessive elasticity of brain moisture; diseased congestion of the cerebral vessels; sthenia or asthenia (excitement and collapse) of the brain (even though these two ideas are not without importance); each of these has at one or the other time been held to constitute the immediate cause, and the immediate cause was usually confused with the disease itself. This list also includes the most recent speculations on idiopathic affections of the vascular system, especially those of the heart, giving rise to the sympathetic affections of the brain and its special life, which result in mania, melancholia, etc. There are further the many diseased states of the brain, its membranes, vessels, bony surroundings, etc.; but the latter have, for some time now, at least been regarded as results rather than causes of the affections of the brain life. It is indeed not difficult to see that major derangements of human life in general, and of the life of the brain in particular, must first exist before they can produce such disturbances in the organization of the brain and its vicinity as is often found by dissection. Albeit it is just as well-known that the most violent and prolonged manifestations of madness are often unaccompanied by any morbid alteration in the brain or in its adjacent parts. One of the most diligent compilers in this field is the Englishman Arnold, who is of ten quoted and whose work can not be too highly praised. His observations, which are most exact and complete, led him, too, to the conclusion that there is every reason to believe that such diseased organic conditions are the effect rather than the cause of mental disturbances. In any case, it is felt by the impartial and cautious Arnold and several other, more recent, writers to be best not to insist too much on an exact knowledge of the immediate cause of "insanity in genere." In fact, Arnold refuses to make any distinction between the preliminary and occasional causes, since the two are interconnected and one cannot be imagined without the other. He therefore merely speaks of a remote and of an immediate cause; the nature of this immediate cause, he considers, as already said, to be beyond the pale of the human genius, and the bliss of studying it is not given to man. This is true if we define the immediate cause in a manner which a priori precludes any solution, that is, if we abandon life and cling to an abstraction without a real, natural, truly living foundation. A pathological definition of the immediate cause is an airy concept which can only be conceived by a misdirected intellect. A disease, like everything else, is born by procreation, and this truth has already been pronounced by many a good man; but it is important that this conception be clearly defined and all its elements clearly understood, which is not yet the case. Interpretation proceeding from the outside inwards has always been the proton pseydo, due to which neither the life nor the spirit could be properly understood or evaluated. The mode of all creation is that of procreation; but the latter is based on the juxtaposition of its elements. Union of two opposites in a third entity is the formula for any procreation. What is important is to recognize clearly and to observe in detail the opposite elements and the bond between them. We are now about to do this, after this apparent detour, in order to erect further structures on the foundation of the result thus obtained.

§ 160. This detour had to be made to show that the elements of mental disturbances, if understood as up till now, are nothing but superficial fragments which can never give rise to a clear integral whole. The predisposing moments were not and could not be combined into any relationship or any unity, since they were considered without having reference to any inner connection. The excitatory moments (incidental causes) were again defined without any relationship to the former elements, so that no living union between the two could be imagined. This false idea was further propounded by the ysteron proteron of mistaking effects for causes. Briefly, all efforts at discovering the causal moments of soul disturbances resulted in mere chaos. This had to be demonstrated here in order to clear the way and avoid errors. But just as there is at least a negative gain in every vain effort, so we have learned from past experience that the question cannot be understood from the outside inwards but must be understood from the inside outwards, if understanding is at all possible. We shall now see. We have not merely compared but identified the genesis of mental disturbances with procreation. Now who are the parents in this family? Obviously, it is the soul itself which is the mother since these pseudoproducts of life are in it and emanate from it. Neither is the sire too hard to identify: it is the evil with which the soul mates after it has been approached by evil in one of its guises. More difficult is it to deduce the mode of this mating; but analogy here, too, helps us out. The soul and the evil are united, as the sexes are always united, through love. The love of the soul for evil is known as the inclination for evil, which is a very expressive word, since the soul can only unite with evil by inclining and sinking. The union of a soul with evil is always a fall which is caused by this inclination.

Through it the soul is pulled downward towards evil; for evil inhabits the abyss of darkness. Thus, the soul of all disturbed persons is darkened, though in a sense different from that understood by the spiritualist doctors of the past. The soul, being the property of evil, has escaped from the kingdom of light and is now bound by the fetters of darkness. The act, the moment when the soul becomes the property of evil, is the act of conception and procreation of a mental disturbance. The product differs, depending on the different moods of the soul and the form in which the evil is received. In this way the elements of all mental disturbances are produced; they are called: mood of the soul and determining stimulus. It is clear that the first must be considered as the internal element and the second as the external element of the soul disturbance. Both these elements and their mutual relationship will now be discussed in detail.

Chapter Two

THE MOOD OF THE SOUL AS THE INNER ELEMENT OF SOUL DISTURBANCES

§ 161. The womb [wherein conception takes place] of the soul is the heart, for short — the inner nature which is receptive to joy and sorrow; it is also the seat of the mood of the soul. As soon as man has learned to feel his self, he begins to desire and to strive, and his desires and his struggles accompany him throughout his entire life, unless the inner mechanism of his life, his soul life, is hindered in its activity or is deviated from its natural path by the various pressures or shocks encountered. When this happens, a soul disturbance results; but much must happen before the temperament becomes so highly sensitized to such pressures or shocks that it is plunged into a mood from which mental disturbances can arise. We shall follow the changes in the mood of the soul up to this stage but shall first try to understand and define their meaning, causes, and character, and the conditions which are associated with the mood of the soul.

§ 162. The seat of the mood of the soul, as just stated, is the temperament, the heart, the feeling, or whatever other name we wish to give to the inner receptivity of man to joy and sorrow. The receptive, the desirous, the striving man in his natural state is never indifferent. He may have achieved, at least for the time being, the object of his desire; or he may be expecting and hoping to do so; or he may have been disappointed in his hopes; or else his heart's desire, which he has already gained, is taken away from him again; for short: his feeling, the mood of his temperament, is always joy or sorrow, hope or longing, anxiety, fear, or worry, and these states, permanent or temporary, are the manifestations of the mood of his soul. The manner in which the temperament is being affected thus depends on the state of the mood of the soul.

§ 163. There are men who, though not quite indifferent or dull, are not markedly affected by joy or sorrow. Others will shout with joy or dissolve in tears at the slightest provocation, and others again are moved by few things only, but these the more deeply and lastingly. All this indicates that there is something that decides the moods of the soul: this is the degree of vitality of the temperament, for it is this which determines if an even-tempered (not indifferent) quiescence, or violent outbursts, or else a deep, lasting impressionability is the main feature and color of the mood of the soul. But these degrees of the mood of the soul, even-tempered, easily moved, or deeply affected, do not yet fully express its nature. Not every temperament is moved by every object; the soul is plunged into a special mood only by things to which it is particularly receptive. The even-tempered man is not very strongly affected by either superficial or fundamental things; the ebullient man is more readily affected from the outside, the ponderous man from the inside. The second determinant of the mood of the soul is thus the receptivity of the temperament. These two determinants of the mood of the soul must be keenly observed, since they are of great importance in the genesis of soul disturbances.

§ 164. Firstly: what is the source of the greater or lesser vitality, of the slighter or temporary, or of the hard to evoke and longer lasting affection of the temperament, in short, of the strength or weakness of the mood of the soul? It is clear that we have here the effect of the so-called temperament, and with it of the bodily organism; for it can no longer be doubted that the temperament depends on the organic nature and on the interplay of its individual members, even though we are not yet able to explain but merely surmise how the temperament is determined by the organic basis. It is sufficient to observe that the stronger or weaker energy and excitability of the disposition is closely related to the so-called phlegmatic, sanguinic, choleric, etc., temperaments. The geniality of the phlegmatic, the outbursts of the sanguinic, the burning passion of the choleric, the deep inner life of the melancholic — all these clearly indicate the soure of the different moods of the soul: the organic life. Does this mean that the true, the innermost soul life, the life of the heart and of the temperament, is the product of bodily life? Would the life of the nerves and of vessels in its manifold relations — for it surely must be they which form the basis for the moods of the temperament, which are so closely related with the soul — then comprise the true basis of human desires and strivings? The reader who has followed our earlier expositions on human life in general, and who can clearly understand how corporeal and soul life are created by the same creative force, which merely branches out, as it were, in opposite directions — here through plastic-organic formations in space, there through feelings and consciousness in time — will not be surprised to learn that the mood of the soul itself is determined by the so-called temperament and its organic basis, and that, moreover, the entire soul life is supplied with the material aspect of its activity, which is force, by the bodily organism, which is its source. Thus, the more vivid the organic life, the more vivid the mood of the soul, and vice versa. This is confirmed by experience, and cannot be refuted by any demonstration. Lack of nourishment, sleeplessness, exhaustion of bodily forces by all kinds of exertions and by debauch etc., and the consequent feeling of emptiness, weakness, dullness, pathological irritability, bad mood, disorder and discomfort of the entire soul life, and even discontent, dejection, fearfulness, uneasiness, anxiety, despondency, or even despair — the same parameters as those where loss of life is caused by loss of strength — all these are the clearest proof of the dependence of soul life on bodily life. We may again note that there is nothing in this to encourage materialism, since the creative, the active agent, which gives strength or withdraws it, is not the soulless body but the individual force itself which partly manifests itself as the organ and partly exerts its awareness of itself in the organ and through it. Once it has become aware of itself, the individual force knows that the organ is a necessary condition for its activity and existence in the finite life. In other words, it is through the organ that it receives its nourishment and the stimulus of its continued activity, and existence in the finite; that it is the organ which maintains it in its mutual relation with the outer world. But the individual force also knows that the organ (the body) is nothing without it, that the organ is merely the external manifestation of the individual force, just as internally it appears as soul, and also that this external manifestation cannot exist without it, the inner force, but that the inner force can perceive itself as soul only inasmuch as it is present as organ. It follows that while the organ is a determinant for the manifestation of the soul, the determinant of the organ is the creative force which is carried and inspirited by an idea. A different organ corresponds to a different soul; a healthy organ to a healthy soul, an unhealthy organ to an unhealthy soul. If the creative force of the parents was healthy, the healthy body of the child will develop a healthy soul, which is the acme and the purpose of life, and which is also entrusted with the care of the organ, but not in a manner as if the care of its organ were its only task, since the body is only a means for the development and perfection of the soul. Obviously, the mood of the soul will depend on the mood of the body, but the maintenance of the proper organic mood is the business of the soul, and no one can complain of an organically caused bad mood of the soul, since anyone who has reached maturity has received a rudder which he can use to sail towards a permanent healthy mood of the soul: reason, which is nothing but life perceived and reflected through its pure lawfulness. In the very manner in which this lawfulness is expressed in the arrangement of the organism, it echoes back in the feeling in the consciousness as the voice of the conscience which is like the compass of life. This is why conscience is the center of harmony in the phenomenon of human life, and it cannot be separated from the connection between the corporeal and the spiritual purposes of life. The mood of the soul is never detached from the conscience by which it legitimizes its existence which, although it is bodily determined, it is not a mere reflex of bodily life. But for the time being our reflections must follow another direction, and we shall content ourselves with having found the reason for the different degrees of vitality of the mood of the soul, as one of its elements. This reason, thus found, is the temperament, the mood of the bodily life.

§ 165. We must now explain the second determinant of the mood of the soul: the receptivity of the disposition. Human disposition is receptive to two sources of influence and can draw its nourishment from either, but so that it may open itself to the one but not draw upon the other. These two sources are named reason and sense, and their objects are God and the world. He whose disposition lives for the world cannot live for God, and vice versa. The mood of the soul which is born of the Divine disposition is the most magnificent achievement open to man: it is the true health of the soul, of which we have already spoken as being the normal state, in contradistinction to all the abnormalities. Since it is our purpose here to derive the genesis of soul disturbances by considering all its elements, the true health of the soul now will no longer be considered. The more attention should now be given to the receptivity of the disposition to the second source. There is a natural relationship between the temperament and the senses (sensuality), for both originate from the same source: the bodily nature of man. It should, therefore, cause no surprise that the receptivity of the disposition is naturally inclined to the side from which it receives its natural vitality (the vitality of the temperament), namely, the side of corporeality, that of the life of the senses, of a worldly life. This explains why the entire disposition of man is usually absorbed in the life of the world and of the senses, even when his entire soul is seemingly engaged in higher matters, such as the arts or sciences. This may appear paradoxical, but it should be remembered that all science and art are constrained to the service of the world. For neither arts nor sciences aim at the highest for the sake of the highest, but in order to confine it in the limited circle of the world and enjoy it in its worldly form in the worldly sphere. Neither science nor art leads the disposition nearer to God nor do they produce a godly mood of the soul but draw it away from God and fetter it to reason and sense. Hence, the pride of the scientist and of the artist; hence, the often very ungodly lives and existences, and the very ungodly moods of the soul which accompany the highest scientific and artistic efforts. Hence, also, the dissatisfaction of the disposition which afflicts even those who are seriously dedicated to arts and sciences and hope to quench their eternal thirst at these two sources. And it is only superior beings who live on this higher plane, for most men are content to remain in the lower sphere of possessions and existence, and their whole soul, their whole temperament, clings to the objects found within these spheres. Therefore it is their need to be nourished by the world that characterizes the receptivity of their disposition, and it is the dependence of the soul's mood on external conditions which is the key to the nature of their receptivity. Owing to this dependence, the receptivity of their disposition acquires the nature of a penchant, a downward inclination towards a center of gravity. Thus, every mood of the soul which is determined by this kind of receptivity becomes fettered; the soul itself is overwhelmed by the pressure of this penchant, and its resulting quality is known as egoism. Thus, we have egoism as the second moment of the mood of the soul: it is its form (insofar as there is a connection between the mood of the soul and the disturbance of the soul), while the degree of vitality of the temperament is the first, the material moment.

§ 166. It can thus be taken as a rule that the mood of the soul of anyone whose disposition is not oriented towards the godly will have the nature and color of the joy or sorrow related to egoism and to the vitality of the temperament, depending on whether his disposition is or is not satisfied. But since in this sphere satisfaction is never complete and is never lasting, we may also assume that, as a rule, the character of this mood of the soul will be negative, and will manifest itself variably as smarting longing, as painful striving, as restless anticipation, as a feeling of being carried away in spite of oneself, as dissatisfaction, despondence, depression, anxiety, and despair. In general, as soon as the soul fails to draw its nourishment from the source of purity and goodness, which is — experience teaches us — the exceptional case, the character of its mood will be that of hesitation and insecurity, and of inability to maintain its self-reliance or to offer resistance to the storms and temptations of life.

§ 167. The mood of the soul is closely connected with two kinds of states of the individual: the psychic and the somatic. This is only natural, since the whole man must be affected by the mood of the soul, and this explains why we have to consider these points here. We shall discuss the psychic aspect first. Every feeling, every sensation of the heart, is naturally and closely connected with picturing something in one's thoughts, on the one hand, and with stimulation and activity by an urge or by an act of will, on the other. It is impossible to feel joy or sorrow, longing or hope, fear or hate, without relating all these feelings to the imagination of an object abstract or concrete, and without feeling attracted to or repelled by this object. We can thus say with justification that our thinking — our intellectual nature in general — and our wanting are guided by the sensations of our heart. As a man loves, so does he live, that is, so does he think and act. This leads to very important conclusions on the mood of the soul itself. For we see that it is the lever of our entire life and is a point from which the particular opinions and actions of man, and the continuous threads of his life manifestations, must be viewed and evaluated. An always even-tempered, not easily affected mood of the soul will produce nothing great, comprehensive, profound, be it in the province of the good or in that of the bad; a changeable mood will not achieve a firm, forceful system of thoughts and actions; whereas a deeply passionate mood of the soul will be capable of the highest heroism and the lowest baseness. Often a whole life will not be enough to yield a mood giving rise to marked success, while just as often a mood lasting but for one moment will decide the fate of an entire life and produce results affecting — favorably or disastrously — entire nations and epochs. Briefly, we see that the mood of the soul is the hinge around which revolve the thoughts and actions of men. Therefore one cannot describe the nature and influence of this mood with enough circumspection and comprehensiveness.

§168. The second aspect of this influence is the somatic one. Everybody knows from experience that while the mood of the soul is partly dependent on the body, the body is also dependent on the soul. Strictly speaking, if the bodily mood can only influence the soul, it is only because it is itself a product of the soul inasmuch as the soul determines the organ of the bodily mood. For whenever we blame our body on being in a bad mood of the soul, we must remember that our physical condition is generally in our own hands, since it is almost exclusively dependent on our way of life, which in turn depends on our own reason or unreason. The direct effect of the mood of the soul on the state of the body has been recognized for a long time and has been experienced by everybody. The effects of the emotional state, passions, imagination, intensive thinking, or of total spiritual inertia on our entire somatic nature as well as on individual bodily organs have been noted by many excellent observers who have described them in sufficient detail. While we shall refrain from all superflous repetitions, we shall merely note that if even unimportant and temporary moods of the soul are not without effect on the bodily life, this must be the more so in respect of the more significant and lasting moods as, for example, the effect of oppressive worry or prolonged grief, which can destroy the body in the course of time. The vascular system, the nervous system, the brain, the heart, the liver, etc., experience the effects of an unwise, self-destructive life of desire or worry, and it is no wonder if pathological dissections of these individuals after their death reveal organic anomalies in those systems or organs which we tend to list as cause rather than result of the trouble. But enough of this, to avoid either repeating or anticipating ourselves.

§ 169. The disposition of man can mature from many standpoints, in many directions, and in many complexities to a mood of the soul in which the germ of a soul disturbance is already latently present and only needs fertilization by a stimulus in order to grow, more quickly or more slowly, and to manifest itself in a living form, that is, in the shape of a definite illness. The various standpoints depend on the various temperaments. One standpoint is determined by the indolence of the phlegmatic, another one by the vacillations and fickleness of the sanguine, yet another one- by the brooding thoughts of the melancholic, and another one, finally, by the impetuous violence of the choleric. The different directions are determined by the different receptivities of the dispositions, according to the different temperaments. The indolent disposition is most receptive to peace and quiet and is disinclined toward all effort of the spirit, the will, the body, and the soul, and all its desires and actions are directed at maintaining its peace and securing its material existence. This direction of the disposition and the mood of the soul which occupies this standpoint give rise to two powerful causes of mental disturbances: avarice and cowardice. When these two have gained sway over the entire disposition and have become the dominant mood of the soul, a powerful stimulant is sufficient to unhinge the entire soul. The vacillating and fickle disposition is particularly receptive to stimulation of the senses, to change, and in fact to everything external. It is directed towards life in the outer world and thirst for pleasure and vanity are, once they become the dominant mood of the soul, the points of contact at which an external stimulus is liable to produce many kinds of mental disturbances. The brooding disposition is receptive only to inner stimuli, and its direction is towards the inner world of thoughts and feelings. When this mood has become firmly rooted, the ground for serious mental disturbance is prepared by pondering and suspicion, and it only needs an external stimulus to transform this abundantly available material into definite forms of mental disturbance. The violent, strongly mobile disposition is receptive only to powerful external and internal influences. Quite unlike the phlegmatic temperament, the choleric temperament implies a lively intellectual activity and a strong will. The direction of these two properties leads, in accordance with the receptivity of the living mood of the soul, towards all aspects of life, but conceives only their poignant moments. The violence and duration of hate, love, acquisitiveness, and thirst for power, which at the height of this mood are often intertwined or else appear alternately, lay the foundation of the most outstanding soul disturbances, and the igniting spark of a stimulus is all that is needed is for these disturbances to grow rapidly and to appear as the most terrible forms of mental diseases. Finally, there are the different complexities in which human disposition can become entangled as if they were a labyrinth, so that the presently current mood of the soul, however uncomplex it may appear if seen as a momentary manifestation, is, nevertheless, to be explained by the interaction between the many different moments of life in the course of a lifetime. For here we must consider everything that might affect the human disposition, directly or indirectly, and list the many different influences that have been classified as either predisposing or incidental causes. If it seems unwarranted to list any single such influence as cause, the manifold influences taken together, nevertheless, carry considerable weight and affect the soul mood very poignantly. Here every somatic and psychic moment, no matter how remote, has its own share and effect: climate, air and soil, time relationships, place of birth, environment, heredity, upbringing (that is, whether the education was natural or unnatural, whether the spirit, disposition, inclinations, and willpower were educated or neglected), social intercourse, reading, idleness or pointless activity, way of living, debauches of all kinds, lucky or unlucky events. To these may be added several illnesses or morbid dispositions due to a perverted way of life: syphilitic manifestations, gout, hemorroids, upset digestion, and disorders of the vascular and nervous systems. Finally, we should add intellectual and bodily efforts, insomnia, exciting or depressing feelings of all kinds: love, anger, jealousy, pride, arrogance, vanity, ambition, unsuccessful speculations, disappointed hopes, grief, worry, fear, anxiety, despair. All these are enemies which are dangerous already when they appear singly and are almost insurmountable when they come together to attack man, sometimes unexpectedly from ambush, sometimes openly and with brute force, in order to rob him of his dearest treasure, his superiority to animals, his claim to the free kingdom of the spirit. How often they indeed succeed is born out by the institutions of custody, which hardly ever have room to accommodate all the afflicted. All these moments may be very numerous, and their threads may entangledly unite into a web of effects, but they all meet in the unification point of the mood of the soul, and however different they are, in it they fuse together into a single effect until a degree of exaltation or depression of the disposition is produced in which nothing more is needed than a stimulus to the will, spirit, or disposition itself in order that various forms of mental disturbances might manifest themselves. As the form of a tree is created from the seed by soil and water, light and air, and as the foreign elements attracted by the individual force fuse together to create the own, inner life of the plant, so the disposition, the seat of the mood of the soul, grows under the influences to which it is exposed during its entire life, which it assimilates in accordance with its inner nature and its free will to produce the leaves, flowers, and fruits of either growth or decay. For everything in the world and everything in life either purifies man's spirit to solid beauty or else wipes out the traits of his original image; and while some men have an almost divine image and only fail in daring to tear the few remaining threads which bind them to the ground, others cling to the anchor of reason only by a thin thread and only a single pull is needed to tear this only thread for such men to enter the labyrinth of unreason from which it is usually hard and often impossible to emerge. This pull, this impetus, this stimulus, which fertilizes and brings to life the seed of disease, will be considered next, now that we have closely enough examined the birthplace of the disease, i.e. the mood of the soul itself, being the inner element of this birthplace.

Chapter Three

STIMULUS AS THE EXTERNAL ELEMENT OF THE DISTURBANCES OF SOUL LIFE

§ 170. A stimulus is anything which excites man to react from his inside out, whether it comes from outside or has been kindled in the interior of man himself. For example, phantasms, thoughts, feelings, inclinations, are stimuli which develop inside man, often without any external cause, and produce a reaction. If, therefore, mental disturbances, too, are produced in this way without any apparent external reason, it should not be concluded that they have arisen without any stimulus or external elements, for such an element is definitely postulated in every case to be producing mental disturbances, just as one generally postulates a product to be formed by opposing factors; and in this case the phantasies, thoughts, feelings, etc., are considered to be external stimuli for the reaction which they produce in the soul. As a rule, however, a true external stimulus is responsible for the genesis of disturbances of the soul, and upon careful observation, such a stimulus will always be found, if only the conditions of life of the individual who has fallen victim to the disturbance is known. Thus, fear, fright, love, hate, pride, vanity, all kinds of interests such as possessions, politics, religion, etc., may all produce a reaction in a disposition which is receptive to mental disturbances. Unfaithfulness of a beloved person, loss of possessions, even a sudden and unexpected enrichment with possessions, an insult offered by a hated enemy, etc., all these affect the suitably receptive disposition as a spark acts on dry timber and can therefore rightly be considered as stimuli, that is, the external elements, of a mental disturbance.

§ 171. But whatever the kind of this stimulus, and whatever its mode of action, its effect can only be moral, as pointed out above (Chapter One); here the word moral is used in the sense that it affects the free nature or the free will of man, just as the words chemical, or mechanical, or organic are used to denote effects and manifestations belonging to other spheres of life. Thus, we have included in this group even physical stimuli, insofar as they operate as moral agents and bring about a moral reaction. For example, bad weather, or a festive meal, or the twilight of a spring evening with the fragrance of blossoms and song of nightingales are to many people moral stimuli, even though their elements are purely physical. Indeed, there obtains a mysterious relationship between the world and man, by virtue of which everything that is finite and that is particular appeals to his tendency to live in the finite and in the particular. As a result, man, forgetting his higher destiny or even never rising to full awareness of it in the first place, surrenders himself to the limitations of the finite and is fettered by it. Once he is held fast by the might of the finite, it is as though his entire being has degenerated, the wings of his free nature have become clipped, and his entire life has become a sin. Thus, all men appear to be spellbound by a natural magic and held by it, often without their knowledge and against their will. What we earlier (§ 156 and § 160) called evil, indolence, matter, the corporeality or darkness, the sensuality — in contradistinction to the good, the pure activity, the spirit, the light, and the reason — this appears as the magic and spell which lies over the world when man enters it. The earth exerts a powerful attraction by the natural force of gravity. If now the opposing force in man, which is reason, fails to gain sway or is not, at least, given a say, then man falls prey to earthly forces and everything he touches becomes a stimulus and a temptation to evil. The ferment of this evil, finally, or, rather, from the very beginning, as soon as he is consecrated, lies in man himself, namely in his egoism, in his propensity to become something special. He cannot free himself from this propensity unless he pays homage to reason, being the divine principle of light. Thus, if the life of man is spent in the service of earthly things, if the force of this life becomes the dominant force of attraction and his feelings, thoughts, and decisions become attached to the finite so that he becomes receptive and sensitive to the finite only, then the stimulus, the decisive force of the finite, may gain an influence over him which is strong enough to lift his freedom from its pivot and carry him off to the kingdom of unfreedom. But since everything that exists and that happens must obey specific laws, this fact of human life must also obey its own laws. We shall now describe the possible ways in which the stimulus becomes the external element of mental disturbances.

§ 172. We have compared the genesis of mental disturbances to an act of procreation, or rather to the nature of this act, in which the fusion of two factors or elements results in the formation of one product that unites both. We have assumed that the first of the two elements, the feminine, maternal element, contains the bulk of the material in the mood of the soul ready for germination. It is only awaiting fertilization. This, as we have seen, is effected by the stimulus, which is thus the fertilizing principle. The manner of this fertilization will be discussed later; for the time being we shall consider its nature. Briefly, this nature is not merely similar to, but is closely related to miasma. The idea that the generation of diseases by miasmas is comparable to the process of generation itself is not new. In the miasma, the idea of a disease which is transmitted from one individual to another, or existence, as the support, the bearer, the maintainer of life — as God. Whoever relies on money and finds his salvation in it clearly need not look for anything else, has no other purpose in life, and money is his god. Can anyone deny it? The idea of money has displaced the idea of Divinity, rules in place of it, and with its magnetic scepter reigns over the lands of men. Whoever worships it has renounced the Holy Ghost and is sacrificing to the Unholy Spirit, who lures him to perdition by way of apparent grace. How many have already gone mad over acquired or lost so-called wealth! and how many more will thus become insane in future! And the same applies to all other demons which are buzzing around mankind and always busily laying traps for it.

§ 174. The principle and the stimulus of evil affect men in two ways, just as all poison works in two opposite manners: positively or negatively, stupefyingly of paralyzingly. A life affected by the first kind is distinguished by exaltation and that affected by the second, by depression. At this juncture we must limit our exposition on these influences to the nature of the active force. The stimulus, being a procreative force, must always be a real and active potency, except that the manner of its inspiritedness, if one may call it that, is variegated, even opposed to itself. Everywhere in nature we find this opposition between the expansive and contractive principles; and all physical and psychic stimuli, which also influence life in the natural state and on behalf of this state, consist of these principles. The same is true of the stimuli which produce disease. We do not yet speak of stimuli which produce purely somatic diseases but examine here the double nature of the psychological stimuli. We thus notice that the nature of a positive stimulus always expresses something bound, something existing and perfect: beauty, freedom of existence; for example, it may express, the idea of a property or possession which secures one's livelihood, such as an actual or potential main lottery prize. The negative stimulus, on the other hand, always involves something which is disintegrating or has disintegrated, or something which is doomed to destruction; thus, the death of a beloved person, the wreck of a ship carrying our possessions, an insult to our self-respect or reputation by slander or by exposure of a petty crime that had remained concealed for a long time, etc., all these are conditions or objects which, like a corrosive poison, destroy life by their negative power.

§ 175. We may contend that all these positive and negative stimuli are products of our conception and are thus not existing in the things Outside of us or in their conditions. One may contend that it lies only in our from a cosmic relation to the individual, is concentrated, as it were. Nothing in nature is isolated: everything is correlated and has its polar and equalizing relationships. General and particular qualities, elemental and organic relations, all depend on one another; and in the same way, the world in general and man are interlocked in a truly spiritual and living relationship. This is particularly true in the sphere created by man himself: the earth, insofar as it bears the imprint of human relationships. The kingdom of humanity has accordingly received the most fitting name of "world," since traces of human thought, feelings, and inclinations can be found all over the earth, and these traces are always mediated by man himself. Wherever he may be, man is always affected by man, directly or indirectly, and this contact is the essence of all stimuli of soul disturbances. Corruption has spread widely throughout humanity ever since the time of creation. Men infect one another and transplant the original corruption from one to another. Original sin exists, but no one must become corrupted or become a slave to unreason. But the atmosphere of the human kingdom is poisoned, and the name of this miasma is stimulus to evil. How is it created?

§ 173. It [the stimulus to evil] strides through countries, it clings to objects and their mutual relationships in the form of ideas which, when honestly but blindly believed in, were called spirits or demons and were said to possess the power of mischief, which is perfectly true. It is no mere image, and even less a hyperbole, to say that these spirits have usurped control over the earth and that all those who are mentally disturbed have become so through their power. They all have a common starting point, a main principle to which they are subordinated: selfishness. This most evil of all evil ideas is present in the most remote and in the closest human relations; it is absorbed with the mother's milk and finds a fertile soil in the human heart. This poison contaminates the air which we breathe and is absorbed with each breath, without our knowing it or admitting it to ourselves. Our senses, our reason, our imagination, our feelings, are infected with selfishness, and it appears in a variety of guises to merge with the nature of man. The ideas of money, power, possession, pleasure, etc., are such guises and are the subservient spirits of this great Beelzebub. They are all struggling against the good spirit in order to destroy it and its kingdom among men. Indeed, they seem to have been successful among a great many. We shall prove this contention by means of a single example: the idea of money. Money in itself is a useful invention in human intercourse and human business, but the idea which accompanies it and which animates it has already brought ruin to a large number of people. This idea hallmarks money as the basis of human conception that a lottery ticket becomes a positive stimulus and the loss of a friend a negative one. That may be so; but this conception arises out of the properties of the outside conditions and their related ideas which not we invested in them. The idea of a gain which is linked to the lottery prize was there before we conceived of it; it affected us, we absorbed it and thus created in us what is only its afterimage. In the same way are the sentiments and inclinations toward us of our friend not a product of our conception: we merely perceived and reshaped what was already there, prior to our conceiving of it, as a result, the effect of something existing outside ourselves and corresponding to our conception. Similarly, the loss of a friend or the disintegration of something which had been there is something existing outside of us in reality which has a negative effect upon us. Thus we see that both the positive and the negative stimuli are real. But we must yet inquire if everything that is external stimulus is also evil, and, if this is not the case, how we are to recognize the truly evil in the stimulus and the stimulus to evil.

§ 176. Since John Brown is perfectly correct in saying that there is no life without excitability and no excitation without stimuli, it would be foolish to assume that every stimulus, or every external stimulus, must be evil. For is not a man stimulated from outside to good just as often as to evil? Moreover, the stimulus to evil often originates not from objects but from men. Someone with a tendency to stealing feels an urge to steal on seeing a role of gold coins in a strange room. But a harlot casting lustful glances, or a sensuous painting, or a salacious novel — everything in the nature of a temptation in general — bears also the character of evil, and inasmuch that it stimulates, it stimulates to evil. These examples show the nature of the evil contained in an external stimulus: the imprint of sin, that is, of human fall from grace. And now all at once we can contemplate the scope of the kingdom of evil outside ourselves: it is the domain of human activity. This does not mean that all human activity must be evil, but that evil can occur only in the sphere of human activity. Everything outside us is either the kingdom of nature or the kingdom of man; and since nature is not evil, every trace of the evil around us must have been produced by human free will. And this in in fact so. The apple of sin is handed on from one generation to the next, and each generation infects the next one. The word and the deed which advance through time produce good or produce evil if the spirit of evil is in them; a bad example is more effective than a good one, for it is easier for a man to fall than to rise. Air and light are filled with the arrows of evil which men themselves shoot at each other. It is thus not surprising that so much outside of us becomes an evil stimulus and a stimulus to evil. All passions, follies, and vices, all prejudice, all meanness, all malice, all wickedness, all dishonesty of individuals and the masses, and all effects, results, and products of perverted activities, and perverted life in general, are just so many spurs to evil, so many weights imposed on the soul to pull it down into the kingdom of gravity, darkness, and slavery.

§ 177. But we must not forget that the stimulus will not adhere where there is no receptivity, and that man with his natural propensity for evil meets it half way. Thus, each individual feels himself pulled down towards the kingdom of gravity with more or less force, once hither, once thither. How, then, does it happen that living this persistently sinful life some men sink completely, often without ever rising again, while others, though near the brink of the abyss, are nevertheless capable of preserving their consciousness and their free will? Since we have assumed that all disturbances of the soul life originate from two elements, the mood of the soul and the stimulus, and since these elements are ever active in man without, however, invariably producing soul disturbances, it follows that there must be something else which affects and aids these elements in producing mental disturbances; the two elements must therefore be in a special relationship, and it is this relationship which we must now locate and determine. But there is another question which as yet awaits clarification: how are the various forms of mental disturbances caused according to the varying nature of this relationship which is necessary (and has indeed materialized) to produce the disturbance?

Chapter Four

THE RELATIONSHIP BETWEEN MOOD OF THE SOUL AND STIMULUS THAT WILL PRODUCE SOUL DISTURBANCES IN GENERAL AND THEIR PARTICULAR FORMS

§ 178. Who can explain the mystery of procreation? It also commands the genesis of mental disturbances. Just as in the act of reproduction of animals and plants one sex postulates the other, just as they both must have reached puberty, must both — the fertilizing and the conceiving principle — be harmonically tempered and equally tensioned, must be made to one another's measure, as it were; just as they must — meeting in the moment of union with no interfering forces entering between them, attracted to one another by the same urge — become completely absorbed one with the other, the one infusing with all its might, the other conceiving with unfailing readiness; just as only thus the mysterious act of fusion and neutralization can take place — so it must also be maintained if the mood of the soul as the female principle and the stimulus as the male principle are to beget their offspring: mental disturbance.

§ 179. Even if a human disposition has fully surrendered to some passion, folly or even vice; even if life has left the straight path and follows many a devious track, so that it is stimulated by various disharmonies and oppressed by many limitations; even if in a life thus disordered the natural order and the sound relationships between the organs and their activities are disrupted in more than one way, the result may be a life led in misery, a life divided against itself, lacking true joy or satisfaction, gradually ebbing away, and finally worn out by a bodily disease. But unless a powerful stimulus gains sway over this sick soul and pulls it into the sphere of an actual disturbance of the soul, only the inclination to evil will persist, and the life of this individual, though joyless, dreary, and oppressed, will not be devoid of consciousness and free will. Moreover, even a mighty stimulus, though it may affect a disposition, excite or depress it, for example, by way of unexpected good or bad tidings, such as a large inheritance, the death, or worse, faithlessness of a beloved person, this stimulus will impinge on a strong, well-ordered disposition only to the effect that the latter will be moved but will not become unhinged. Thus, the presence of both elements is the first condition for the generation of a mental disturbance.

§ 180. Secondly, a mental disturbance will not arise unless there is a certain ripeness of temperament and a sufficient strength of the stimulus. Body and soul can be neglected from youth; riper age may build on these foundations; man may become degraded in every respect, and the mood of his soul may tend more and more towards the dark abyss, towards hell, deliverance from which is so rarely found and is so hard to find; his temper may harbor unclean sensations, his imagination unclean images, his reason perverted, corrupt views; his power of action may be influenced by a strong desire for evil and indifference to good; sufficiently powerful external stimuli exist in abundance, and yet there is no mental disturbance proper. Why not? Because the diseased temperament still clings with a part of its being to the source of nourishment for all living beings; isolated rays of light still penetrate this darkness and bring moments of warmth and light into this degenerate life; occasionally this living being adopts the right view of things and steps a few paces away from the brink of perdition and nearer to the steady path. This oscillation between good and evil prevents evil from gaining full victory, though it may still be active and wreak damage both as a tendency and as a stimulus. It may also be that although no prompting is left in the mood of the soul towards better and higher things, there is enough fear of downfall and destruction to prevent a total overthrow of the laws of order and, in particular, to prevent neglect of the body and to ensure proper care of it; in short, it is prudence that saves the situation. Thus, no soul disturbance takes place, despite all transgressions and crimes, until this last dam is also torn down, which does sometimes happen. A feeling of self- respect, a love for life, etc., can also prevent mental disturbances. Briefly, as long as there is still a resisting force stronger than the pull towards the abyss, the temperament and the mood of the soul can be maintained this side of the line of freedom. It is only once all counter stimuli that are capable of exerting a counterweight have become dulled, and once the force of self-determination has lost all its momenta, that the mood of the soul is ripe for mental disturbance and the procreating stimulus will find full receptivity. But this stimulus must be strong enough to, firstly, overcome any remaining internal resistance and, secondly, penetrate the mood of the soul and not merely scratch its surface, so that the nature of this stimulus will become the nature of the mood of the soul. There is no longer any freedom of disposition, no more free will. The soul has been taken over by the extraneous stimulus and becomes torn out of itself as if by a mechanical force or else compressed within itself, depending on whether the stimulus is positive or negative. Let us imagine a female individual with a vivid temperament and a voluptuous body, which two properties cause the receptive part of the psyche, namely, the senses, the imagination, the capacity and the need to be affected by feelings, to become the dominant determining factors, while the forces of reason, the calm judgment, and the capacity of self-determination become naturally weaker. Let us further imagine a neglected upbringing, free play given to the whims of the moment and to imagination, the absence of a strict and clean occupational regime, indulgence in light reading which flatters the senses and the imagination, a stimulating social life, theaters, balls, in short, all the joys of the merry world. And the resulting mood of the soul will be one in which love, in alliance with the senses, imagination, and feelings, fills her with sweet longings and gains sway over her. Imagine a passionate virgin, who is unable to restrain herself, give herself to her lover; she is devoted to him, and lives only for him, but he abandons her for another. In such a case both the mood of the soul and the stimulus are sufficient to produce a mental disturbance, as testified by countless annals of youthful love. This is what we mean when we speak of the ripeness of the mood of the soul and of the strength of the stimulus.

§ 181. Thirdly, the kinds of the mood of the soul and of the stimulus must be suited to one another. They must meet in harmony. If, in the case just described, it is not the unfaithfulness of a lover by which the young maiden is hit but, say, the loss of her father's fortune or the death of the beloved mother or sister, then the result will be pain and grief, but not a disturbance of the soul; on the contrary, love will soothe the painful wounds of the heart. Everyone is receptive only to those things which have captured his heart: the miser to money, the proud man to honor, the vain man to trinkets, the irascible man to insult, the weak man to fear. The mood of the soul (§169) has always a definite point of view at which it is most vulnerable and a certain direction in which it can most easily be thrown off balance. Every life becomes concentrated at some point of striving or counter- striving, which is never without its definite stimulus, positive or negative; wherever it so happens that a mood and a stimulus of suitable kinds and suitable measures meet and that the law of gravity gains ascendency in this soul, a soul disturbance is almost a foregone conclusion, unless prevented by external forces.

§ 182. Man is not a plaything of circumstances. If all the misfortunes and all the ruin which are made possible by human recklessness and negligence actually were to come to pass, the measure of the resulting general and individual destruction and waste would be much greater than it really is. Whoever believes in a wise and kindly Providence can clearly see that the forces of good are stronger than the forces of evil. It is only human recklessness that, in spite of all warnings and counter efforts, often ensures the victory of evil. And yet, how often is evil frustrated! Human life is often guided towards standpoints and directions other than those of its own inclination, against its own knowledge and against its own will: not rarely is the soul transformed without any volitional act; the exciting or paralyzing stimuli are destroyed or considerably weakened by counter stimuli, neutralizing one or the other precondition for an anticipated mental disturbance. A memory, apparently accidentally — yet significantly — recalled from earlier days, a previously acquired skill which comes back spontaneously or is recalled to life at just the right moment, a condition of physical exhaustion which counteracts a tension about to produce a mental disturbance, an excitation occurring just at the time when the oppressed, paralyzed temperament is on the point of surrender — all these alter the mood of the soul and put the enemy to flight. The same is true of stimuli: depressive stimuli often counteract excitatory ones, and vice versa. Happiness and unhappiness, joy and sorrow, often compensate each other in their effects on human life. A mood of the soul in a state of exalted tension may become depressed by negative external stimuli; another, which is close to total paralysis, is brought back to equilibrium by positive external stimuli. Just as external happenings may bring about mental disturbance if the soul is in a suitable mood, so they may also prevent it. Human activities and human relations are so numerous that unpredictable results may be produced. And it is those things that are not predictable which frustrate the most reliable calculations.

§ 183. But if there is no obstacle, if all the conditions are fulfilled, mental disturbances are generated in two ways: suddenly or gradually. There is a sudden or a gradual exaltation, and a sudden or a gradual depression. In either case, the result is always neutralization of the stimulating principle and of the mood of the soul. The concept of neutralization is well known: it is the union of opposite elements to form a third element in which the two are contained but are no longer recognizable. So do all mental disturbances arise. The product thus formed is nothing rigid or dead: it is a germ, that is, an entity of opposite activities, which does not fail to grow more or less rapidly and to assume definite features, unless prevented in some way. What we usually observe is the developed form, or the form in that is in the course of vivid development, and we thus fail to grasp or become aware of the idea of its being a germ, though its presence is betrayed indirectly or at least by external signs. For the moment at which unfreedom makes its appearance and clearly manifests itself by unnatural, i.e., unreasonable, actions, behavior, words, glances, or gestures, that is the moment of this procreation. From this moment on, the man has lost claim to the kingdom of freedom, to the kingdom of the spirits, at least for as long as he remains in this cycle. He is an automaton: his thinking, his sensation, his activity, proceed in a mechanical manner, no matter whether it appears as if they were determined by himself. They are in fact determined by urgent impulses only, if they are controlled at all. But very often his state is characterized by his having lost even the semblance of self-determination, and his entire soul complex appears to be either totally tied up or altogether dissipated. Briefly, the principle of freedom, and thus also the reasoning capacity, have fled from him at the very moment of union between the full-blown stimulus and the mental-disturbance-ripe mood of the soul. Like sick plants and animals, man too develops a secondary organization. Thus soul disturbance grows on the ground and soil of consciousness in many forms which depend on the details of the conditions. The life of the psyche is no longer something which advances towards a definite goal, towards the development of reason. It moves in a circle, or oscillates between opposite points, or converges all its activities at a central point without periphery, or else flows apart in a periphery without a central point; briefly, it obeys the laws of the forces of attraction and repulsion, of mechanical equilibrium, and of gravity. The various forms of mental disturbances develop according to these patterns of the general and fundamental laws of nature and undergo various modifications, depending on which particular law happens to predominate and tip the scale. It is the laws which govern these modifications, and the genesis of the various forms themselves, which we must now study.

[Heinroth is arguing that free will choices can cause a man to become insane where a man therein has forfeited his freewill. This concept of "freewill lost" of the insane explains his methods of treating insanity that he discusses later.]

§ 184. When we cast a critical glance at the historical survey of mental disturbances, we see that there is still general confusion and obscurity in the ideas held on this subject. In nature there is always order; even in destruction, there is always a rule, even in deviations from rules; even secondary growths obey an organic law. Nothing is abandoned to chance or lost in a chaotic generality; everything tends to assume a special, definite form and obey special, definite laws. This is also true of mental disturbances. Research in this field has not been deep enough, not versatile enough, but has been content either to scrape the surface or else has one-sidedly stuck to a few prominent points. Nobody has yet penetrated the depth of these manifestations, and no one has ever considered at once both their general and particular features; no one has yet sorted out and compared by the principles inherent in whatever needs sorting out and comparing; no distinction has ever been made between morbid processes in this field and the products and residues of these processes. Everything has been mixed together: forms, stages, transformations, moments of inhibition and moments of activity, the very beginning and the very end. It is therefore not surprising if a man who, seeing only the confusion of the various manifestations of mental disturbances and thus holding also their very nature to be mere confusion, comes to the conclusion that everything else is accidental. Nor is it surprising if another man, unable to deny definite differences in the nature of these disturbances because on more careful observation he did in fact notice them, does yet fail to grasp their genre and inherent conditions, does yet fail to understand their nature but judges them on the base of selective moments of manifestation, and thus also fails to interrelate them in the proper manner. Just as in the somatic field there is not simply a disease, or diseases in general, but everything is definite disease and definite form of morbidity, different for different systems and organs, and differing by generically and specifically different interrelations, by type and complexity of development, etc., so it is in respect of diseased states of the psyche, and it is the understanding of the psychic-organic life in its subdivisions, the mutual connection between its activities, their necessary interrelationships, the mutual interplay of forces with receptivity or spontaneity that matters if one wants to detect an order even in this chaos, unity even in this fragmentation, and a consistent law even amid these leaps and bounces. But, as we have already said on many occasions, this cannot be done by mechanical uniting or dividing, or by mere accumulation of material, but only by studying the fundamental unity and then proceeding from this unity to the different, in all those directions definitely indicated by the differences. We shall now introduce the different forms of mental disturbances as the concluding stage in our study of the elements.

§ 185. In the instant the state of unfreedom commences, described by a man who had been cured of his insanity, striking as if two sparks had suddenly clashed, this act of procreation affects partly the degree of mental activity and partly the kind thereof. (We are speaking here of a sudden genesis of mental disturbance.) The mood of the soul becomes either excited or depressed. Either one of these moods, if it is retained in the course of the disease, or, if it is not quite permanent, is still the main feature of it, follows an ordered pattern in which a series of morbid manifestations has another series of morbid manifestations as its counterpart. Briefly, depending on whether we have exaltation or depression, all mental disturbances (in the first instance) can be divided into two main orders. The objection which is sometimes made that going by this criterion, some disturbances may belong to both orders, for a patient may alternately manifest exaltation and depression, as for example many a maniac may part of the time be quite dull or idiotic, we have already countered by saying that in the case of variability, it is the main feature that counts and gives the keynote of the diseased state. Thus, for example, despite all relaxation, which may even reach the stage of idiocy, mania is still mania, and no maniac can be called an idiot, no matter how long he may remain in this state of relaxation, except when all traces of mania fade and become replaced by permanent manifestations of idiocy. In that case, however, the morbid state has changed its character and must be redefined. But there is yet another possible case, namely, complication of idiocy by mania, when the disease belongs neither to the first nor to the second, but to a new, third order. And since cases of complications of two opposite orders of diseases are quite frequent, the establishment of a third order is justified. Thus, if the permanent state of loss of freedom in general (permanent unreason, vesania) determines the class of soul disturbances, the predominating state of exaltation or depression, or the mixed state, determines their order. For each soul disturbance, besides showing the general feature of permanent loss of freedom, must also display one of the above three characteristics. This follows from the fact that the soul, being a force, has intensity or relaxation, or both, alternatively.

[Bi-polar disorder existed 200 years ago but is an example of an artificial classification of a mental disorder today. It is in fact a combination of two actions that involve socially unacceptable hyperactivity (manic) and unhappiness with the current state of one's life (depressive).]

§ 186. But these features, the general and the particular, do not yet establish a system of forms. They merely form a space within which the forms may be elaborated; but this space is subdivided, with the particular forms occupying particular subdivisions. What then is the origin of these forms themselves? We have said (§185) that the moment of creation of the state of unfreedom affects partly the grade and partly the kind of activity of the soul. Now, there are no kinds of soul activities other than those of disposition, spirit, and will, since it is these that differ from each other in the way they affect our consciousness. The sensations of joy or sorrow, the creation of views and concepts, and the making of effective decisions, these different activities of the soul are so sharply separated in our consciousness and are distinguished by so definite features that they cannot possibly be confused with one another. If the moment of creation of the unfree state affects a kind of soul activity — and it must affect it since the soul always pursues some kind of activity — then the only question which remains is which kind: an activity of the disposition, of the spirit, or of the will? For one of these activities must always take place, exclusively or predominantly at any conscious moment. That particular activity, now, which happens to be affected at the instant when the unfreedom has entered the consciousness -- and one of them must be affected, since it constitutes the consciousness — must necessarily assume the character of unfreedom, so that it emerges either in the sphere of exaltation or in that of depression or of a mixture of both, as the rising form of disease. Let us assume, for example, that the temperament (disposition) which was affected by the soul disturbance and removed to the unfree state was inflamed with love; the result will be a disease of the disposition; but since this can only assume an exalted, or a depressive, or a mixed character, everything will depend on the state of the elements — stimulus and mood of the soul — when they created the unfreedom. One form of the disease will be the result of the exalted state, another of the depressive, and yet another of the mixed state; for a sincere and intensely loving disposition is, in the words of a poet who also knew human nature, always "shouting for joy to high heaven, or sorrowful unto very death." If there is pure exaltation, the disposition carries the imagination away with it and we have true insanity; in pure depression, in which imagination is dead, and only a sorry trace of reason remains, pure melancholia arises; in the third case we have melancholic insanity or insane melancholia, depending on the prevailing element of the order. It should be clear that it is not only the passion of love which can make the disposition sick, but any passion, and indeed any affection, provided the mood of the soul is favorable to it.

§ 187. This example purports to be more than an example for its own sake; it purports to represent the first genus of mental disturbances and to include diseases of disposition of every order. As we have thus begun, we shall immediately proceed to the other genera of each order. Just as each order has a genus of diseases of disposition, so it has a genus of diseases of the spirit, and another genus of diseases of the will. We shall begin with the genera of the diseases of the spirit.

If the unfree state at the moment of creation of the mental disturbance affects the activity of reason, the latter becomes fixed as dementia if the mood of the soul is exalted, as idiocy if the mood of the soul is depressed, and as confusion if the two elements become mixed. These genera, like all the others, have their species, and it is only the latter which give substance to definite forms of disease, namely by the admixture of activities from other fields. Thus, for example, if a disease of the genus of diseases of the disposition is accompanied by affections of the spirit or of the will, such affections, insofar as they are subordinate to those of the disposition, become specific differences, which manifest themselves in a definite manner in the forms of the disease and give each of them its specific character. The same applies to all others. However, we shall ignore the species for the present and shall merely complete the concept of genera. Genera of the last kind are those of diseases of the will. For if the unfreedom created also affects the will as the predominant activity, there arise, depending on the share of exaltation, depression and mixed state of the mood, the following three genera; respectively: 1) loss of freedom of will with the character of exaltation: genus mania; 2) loss of freedom of will with the character of depression: genus apathy; 3) loss of freedom of will with the mixed character: genus timidity. (The concepts of these genera, like all others, can be more exactly defined only at a later stage of our study.) Thus, we have the class concept as well as the concepts of orders and genera, which can be schematically represented as follows.*

CLASS CONCEPT

Mental disturbances ( Vesania)

Character: permanent loss of freedom and loss of reason

ORDER CONCEPT

Gradual differences in soul activities. (Subordinate concepts:

genera and species, by generic and specific differences of the soul activities, respectively.)

First Order Second Order

Series: exaltations Series: depressions

(Disposition) [Gemuth]

Insanity [Wahnsinn] Melancholia [ Melancholie]

First Genus First Genus

(Disposition) [Gemtith]

Insane melancholia [wahnsinnige

(Disposition) [Gemtith]

First Genus

Melancholic] or Melancholic

insanity [melancholischer Wahnsinn]

Dementia [Verriickthe

(Spirit) [Geist]

Second Genus Second Genus

Idiocy [BIOdsinn]

(Spirit) [Geist]

Confusion [Verwirrtheit]

(Spirit) [Geist]

Second Genus

Third Genus Third Genus

Mania 1Manie]**

(Will) [Wille]

Apathy [Willenlosigkeit]

(Will) [Wille]

Third Order

Series: mixtures

Third Genus

(Will) (Wine]

Timidity [Scheue]

 

* [The table given here is the first attempt at a systematic classification in the book, and the original German nomenclature is included for this reason. As far as possible, the English equivalents given in the table will be consistently used in the remainder of the book.]

** [According to the example given below (see reference of our succeeding footnote), as well as according to the reference to this classification under § 194, this should read rage (Tollheit).]

§ 188. We should now derive and describe the species, that is, the actual specific forms of these genera that can be observed (not to mention subspecies, varieties, and modifications), but these can only be given here quite generally because, firstly, only general guidelines are needed to detect them, and, secondly, some of these species have not yet received definite names or have received more than one name. This is only natural, as no guiding principle was available for the observation. Such a principle must again be based on the different activities of the soul, and lead to the genera already established, in such a manner that the genus as a whole can be subdivided in accordance with the specific activities of the different provinces of the soul involved, to give them the imprint of specific characters, and thus consider them as discrete forms of disease. In so doing, we must not forget the direction of these specific activities towards specific objects, or the way they are affected by specific objects, since these are the chief and characteristic phenomena which make the forms observable. This will be made clear by a few examples. The first genus of the first order, insanity, may receive additional activities of the spirit and the will and thus become a species, a definite, readily observable by the admixture of either dementia or rage [Tollheit];* this results in forms in which insanity is fused either with dementia or with rage. We may add that the admixtures of foreign activities can only come from the same order, for otherwise the activities of the foreign orders would erase the character of the first order and of the genera derived from this first order. Thus, for example, insanity, dementia, and rage belong to the same order, so that dementia and rage can combine with insanity, which is indeed often found to occur. In fact, it is a general experience that mixed forms of a disease are much more frequent than pure forms. But if activities of the second or third order should join insanity, the generic character would not be retained. Thus, for example, one cannot line up idiocy or melancholia — taken to represent the species — under insanity, taken to represent the genus; this is also confirmed by observations. It also follows from the above that each genus can only have four real species: the first species is the pure generic form, which, because of its purity, its very quality of being unmixed with foreign characters, determines the special character. The other three species are obtained by the admixture and subsumption of the other two genera of the same order — either separately or both together. It is thus easy to subdivide each genus into its immediate true species and to make a sharp distinction between the species and the subspecies, etc., although the linkages, amalgamations, arbitrarily bestowed affinities, or however else we choose to call the numerous fundamental compositions of morbid psychic activities, tend to multiply almost as rapidly as the products or materials obtained in chemistry. The analogy with chemistry goes further: there is a remarkable similarity between chemical products and the forms of diseases of the psyche: the former are all derived from two simple elements (those of water) which two give rise to the entire world of chemical phenomena, just as the elements of the soul give rise to all the different forms of morbid soul life.

* [See our preceding footnote.]

§ 189. It has been stated (§ 183) that soul disturbances arise either suddenly, at one blow, or else gradually; we discussed ( §185 ff.) the former case, but subsequently deliberately ignored it. This double manner of genesis of soul disturbances needs further clarification. Strictly speaking, all disturbances of the soul develop slowly, for it takes an entire life, be it a shorter or a longer one, to accumulate the material needed for the future product. It is quite impossible for a man who is strong and healthy in body and soul to be afflicted with any kind of soul disturbance, for he has neither the required mood of the soul nor the receptivity to injury by a psychological stimulus. We emphatically deny that somatically harmful powers per se, such as for example mechanicochemical powers, i.e., a purely bodily affliction of the organism by diseases or by any kind of organic defect, idiopathic and primary, can become a true mental disturbance. Our view is also supported by the English empiricist Harper (§ 135). His above-mentioned study contains a detailed discussion of all cases in which one might be inclined to attribute mental disturbances to purely somatic origins. He proved that in every case the symptoms believed to be those of mental disturbance (insanity) were in actual fact nothing of the sort. All that is needed to convince oneself of the correctness of Harper's statement, with which we fully agree, is unprejudiced observation. Deliria in acute and chronic diseases are, firstly, always symptoms accompanying idiopathic somatic affections; secondly, they are either transient or they are lethal. In the first case the soul life is not disturbed because of their relatively short duration and because they make no demands on the internal economy of the soul; in the second case the soul life is not disturbed because it is extinct, rather, as far as this world is concerned. Mechanical or chemical injuries as well as initially organic affections, too, end in one of the two ways just described. We may consider a blow on the head as an example: the resulting delirium is either transient or lethal. For this reason, true dementia, melancholia, mania, etc., can never be the effect of such injuries. If such forms are nevertheless manifested after such an injury, their psychic foundation must have already been prepared, as will become evident if each such case is thoroughly examined. We do not deny that weakness of memory or of reason are often the aftereffects of such injuries, but such states must not be reckoned to the soul disturbances since they do not display the essential character thereof, namely, loss of freedom. We hope this refutes the objection that soul disturbances may appear suddenly in healthy individuals or shortly after an organic disease, as a result of somatic causes. But this is only a minor point, and we now return to our main question and clarify it more precisely. It concerns this, that despite an almost lifelong psychological and thus also somatic preparation, many soul disturbances manifest themselves suddenly, if the stimulus is so powerful that it shocks the mood of the soul and unhinges it, or else if the mood of the soul itself is so receptive that only a slight stimulus is required to release the soul disturbance like a ripe fruit. Thus can insanity, melancholia, rage, dementia, even idiocy, occur suddenly. An example of a sudden generation of idiocy is given by Pinel: a man who saw his brother fall dead next to him in a battle was stunned by the shock and struck with idiocy (this was probably not really idiocy but melancholia attonita, which is, however, in certain aspects related to idiocy); the third brother, seeing the second brother deprived of his reason, was in turn shocked into being deprived of his own. (It would be necessary to be familiar with the origin and the life of these brothers in order to explain this case by a special, long-nurtured weakness of disposition, which is certainly the true explanation.) The natural law — for we can no longer speak here of the law of freedom — which is operative during this sudden generation of mental disturbances is the law of attraction. The stronger force attracts the weaker, the independent force attracts the receptive force, that is, the stimulus attracts the mood of the soul. The stronger the stimulus and the more receptive the mood of the soul, the more intense and the more rapid will be the union of both these elements, and the deeper and stronger will be the enchainment of the soul — amounting to the loss of freedom and the loss of reason — and the more difficult will it prove for nature and for art to break up this enchainment. As in a chemical process in which the mobile forces merge together and solidify in the bound product and, embracing and penetrating each other, let the light and warmth which were originally theirs escape, so, too, do freedom and reason escape if the forces of the soul are bound by a power of nature. The soul is pulled out of itself into a dream world, or else is pushed back most deeply into itself; the capacity for self-determination has disappeared and has been replaced by the forceful pull of the natural forces. Although this often occurs suddenly, it just as often takes place gradually, but always in obeyance to the same law of attraction. Perennial worry and domestic unhappiness depress the disposition, and unless this pressure be resisted, it will gradually paralyze the force of free resistance and as it becomes ever gloomier outside and about the soul, the inner daylight will finally go out altogether and the disposition will be pulled down by the overwhelming, ever heavier burden of night. The same is true of the pull outwards. This pull, too, can become stronger and stronger; the soul, especially if its carrier, the body, has been slowly poisoned by excesses of all kinds so that it is no longer able to assist it, gradually loses its independence and its power of resistance, until it is finally drawn into the maelstrom from which it can no longer rise to the surface by its own strength.

§ 190. This terminates our exposition on the science of elements, which is a preliminary to the sciences of forms. Forms are created out of the elements, and the relationships between the elements determine the conditions for the creation of forms. If we have been lucky enough to give a correct interpretation of the elements and their relationships, then we are on the right path for interpreting the science of forms. It is difficult not to lose sight of the whole when dwelling on the particular, just as it is hard not to pass the detail over while one clings to the idea. We have tried to satisfy these two conditions of a proper study: we have considered the entire gamut of life as it moves between corporeal and spiritual attitude and activity and life itself as a manifestation of force in corporeal and spiritual spheres, with the mutual effects of both on the mood of the soul as one of the elements of mental disturbances. We have paid due attention to the fact that human life is permanently exposed to external stimuli, which maintain it but which may also poison and destroy it, depending on their nature, the manner of their absorption, and their effect. We have seen how the disposition is attracted by its natural propensity to the finite and to the limited and thus also to the finalizing and the limiting, so that it becomes fettered in the magic circle of the earthly life, dependent on the senses, until it eventually loses its capacity to resist the foreign power, since in the meantime the body, and not only the soul, has become affected and thus the way to a complete destruction of the soul life is laid wide open. We could catch only a preliminary glimpse of the great variety of forms in which this disturbance of the soul can appear: this glimpse was caught by deriving the conditions for these forms from the degree of animation of the soul and the kind of soul activities. We shall now proceed to develop the aspect of these forms for recognition upon observation and to show their many mutual relationships; but before doing so, we should like to make the following final remark. If the part played by the body and its conditions in the genesis of mental disturbances were mentioned in our science of the elements only in passing and as a minor issue, whereas other authors regard the effect of the body on the genesis of morbid states of the psyche and the condition of the body during such states to be the main issue, this was done deliberately, in order to direct the eye of the observer away from a one-sided view of the organic aspect and lead it toward the idea of an integral, undivided life; while it is true that any morbid alteration evokes an organic echo, in this integral life, the sound and note thus echoed originate in and from the soul life. It is thus the soul life which contains the cause and the quality of its own disturbances, and which ever remains the center thereof, the more so as all organic contacts with life, too, concentrate at the focal point of the soul life.

 

II. THE SCIENCE OF FORMS

Chapter One

ORGANON OF THE SCIENCE OF FORMS

§ 191. Although we have preceded the science of forms by the science of elements, having considered the latter to be the foundation of the science of forms, the meaning and the significance of either cannot be grasped if it is believed that the science of forms is completely and exclusively founded on the science of elements. The science of forms, to be sure, rests on the science of elements inasmuch as it could not be imagined without its external relationship, that is, without its relation to the elements, but it develops in accordance with its own laws and is very different in content, namely, descriptive, whereas the science of elements is reflective in content. If in this way the science of elements merely grazes the outermost contours of the science of forms, in other respects it reaches far out, since (§ 79) everything created out of elements has not only a definite form but also a definite content. Since the content is that which qualifies a thing, an object, and since it can only originate from the elements thereof, it follows that the science of elements must necessarily bear on the science of quality. The science of elements thus penetrates the entire theory, if not transcending it; but the role it plays in the science of forms is only a general one, and it is only within the context of the science of quality that we shall be able to discuss the special significance of the science of elements. Within that context, the science of elements, as a key to the science of forms, will afford us a glance into the quality of psychically morbid manifestations. Without form, the quality of no object, no condition, no force, no existence, can be recognized, for the quality and the force are manifested only in the form; but the form can only be understood in terms of the language used in the science of elements. Therein lies the content, the significance, and the importance of the science of forms, and its relation to the science of elements and to the science of quality. The science of forms is thus a necessary intermediate link between the two sciences: that of elements and that of quality. § 192. We have said (§191) that the science of forms has its own laws of development and a descriptive content. Presentation of the former rests with the author, because these must be elaborated from the concept of form itself; but the descriptive content can only be drawn from the thesaurus of medical observation, and it is just as complete, accurate, and faithful, or else as incomplete, superficial, and spurious, as is this very observation. And here we are forced to confess that medical help on this point is largely lacking, however abundant the treasury of medical observations is believed to be. This should not surprise us if we consider the differences between the points of view adopted by physicians of all periods and all nations, as outlined in our critical review of historical medicine. The physicians of antiquity observed only the grossest and most conspicuous features, that is, those arising out of the most advanced and most prominent forms of psychic disease and in this, too, they were less concerned with any systematic arrangement of their descriptions (except for a few sharply distinguishable symptoms) than with the interpretation of their origin. Later physicians were mostly content with copying the writings of their predecessors, and they mostly, in turn, were succeeded by imitators; the most recent writers have, until now, again lost themselves in the search for the causes or else devoted their time to the treatment rather than the description of the forms of diseases. If now — as shown below — a descriptive representation must trace the forms of diseases as though they were plants: from their first germination and their gradual development to their full formation and maturity, and subsequent dissolution in many different outlets; and if the descriptive representation should be such as to illustrate the traits of the disease — once they have been variously interrupted and transformed due to addition and complication — in the same manner as one would illustrate the simple phenomena and natural course of things: how totally has all this been neglected even by those who were known not merely as faithful observers but who had had every intention of presenting a true and complete picture of their observations. And this goes for all: Italians, Frenchmen, Englishmen, and Germans. How superficially does the worthy Chiarugi deal with the forms of diseases whose treatment and its results he describes in his Hundred Observations (for in the book he merely compiles the traits given by the authors)! Or Perfect, who is not inferior to Chiarugi as regards the abundancy of observations: how sketchily, how poorly, does he deal with the forms of diseases, the treatment of which he describes in such great detail; how hastily does he abandon the form to take up the treatment, as though the technique could stand up by itself without a theory and its constituent parts! And if these two physicians may be forgiven their sparse and careless descriptions on account of the great number of case histories they have presented, then what about the others who saw in the analysis of the diseases of the psyche and their vivid representation that which matters most, e.g., Lorry, Pinel, Ferriar, Cox, and others (the Germans so far have written little that is original): how incomplete, how inexact, how inaccurate is their account of the necessary conditions! Lorry failed to give a single case description which we would consider adequate; he begins it, only to lose its thread; he jots down a few features which fail to add up to a whole; and ere one notes it, one is left with nothing but an empty, mechanical reflection instead of the expected concrete presentation. Pinel drew up some lines, but how incomplete, how cursory, how confused they are! Ferriar, despite his declared intention of giving an accurate description of the diseased states of the psyche, is so superficial that his work hardly deserves mention. Cox gave a detailed description of an attack of mania, but his description is confined to the onset of the disease, and he restricts himself to mania, at that — as though a disease had no middle and no end, and as though different forms did not also have different aspects. In this respect, even Cox failed to observe and to distinguish sharply, and thus could not decide whether one or more principal forms of the disease should be postulated. The same applies to others who made similar attempts. The principle qui bene distinguit, bene docet always remains true. And thus we are truly deficient in medical contributions to the science of forms, inasmuch as these consist of properly planned and executed, exhaustive, true observations, and precisely in a domain where careful work is feasible, the harvest is poor. In the meantime we must be satisfied with what is available. Nor should we be too ungrateful for what we have, since we have seen in our historical account that there is good to be found in many writers. In any case, complete, careful, faithful observation in this large domain would not be the work of one man alone: many should join hands, should work with a like mind. This is what impedes observations in other fields as well: namely, that observations are made from so many different standpoints and with so many different purposes. Hence so many contradictions in the observations themselves, since there is a strong tendency to see what one wishes to see. In view of this situation, we ourselves, too, can only present an idea and an outline of the science of forms rather than the complete science itself. We hope, however, that the spoils of our own observations and those of others will suffice to fill the schematic science of forms with some content and to further the science of quality. Now, what is this scheme, and what are the laws governing the development of the science of forms?

§ 193. The science of forms should give a clear, exact, and naturalistic picture of the manners of manifestation of the morbid states of the psyche of the soul disturbances which were determined and rendered into orders and genera. Soul disturbances, like plants on the ground, grow in a motley criss-cross; but, again like plants, they have distinguishing features which enable us to determine their similarities and dissimilarities and classify them down to the individuality of the main species. The task of the science of forms is to present a descriptive scheme for the latter, showing their genesis, their development, their static or transformed state, the coexistence of more than one form of disease, their subsiding into chronic residues, or their termination in recovery or death. Since this complex subject can, however, only be handled by simplification, it is necessary to proceed from the general to the particular and to end at the point where ultimate individuality starts. This individuality has often been quite correctly perceived and defined by observers. Accordingly, the beginning of the science of forms will comprise a historical development of pure species, but it will be complemented by the combinations (mixtures), complications and transformations established for the corresponding other species, down to modifications and varieties. The whole is concluded by a nosological scheme for the species, including a table which shows all the forms compiled in their ramifications. We have thus stated the proper sequence of exposition for this whole; but we have also to supply its point of anchorage in the organon, and this is nothing else but a proper characterization of the genera, in order to ensure the correct determination of the species.

§ 194. We shall begin by recalling the table of the three series for each genus given at the end of the science of the elements (§ 187). The class concept of permanent loss of freedom or of reason in general, i.e. of mental disturbances in general, was subdivided into three order concepts: exaltation, depression, and a mixture of the two. Each of these three order concepts included the morbid states of the three components of the soul: the disposition, the spirit, and the will; thus we obtained three genera in each order, which, in turn, divide into species, subspecies, etc., depending on the determinations valid for them, and which could not yet be discussed in that context, nor can we refer to them for the present. We did, however, give names to the various genera; they were: in the first order (exaltations of hyperstheniae): insanity, dementia, and rage;* in the second order (depressions or astheniae): melancholia, idiocy, apathy; in the third order (mixtures of overstimulation and weakness, that is, those which are partly one and partly the other): insane melancholia, confusion, and timidity.

* [See our footnotes on p. 136.]

 

Below we define the character of each genus, following the same sequence.

First Order, First Genus

1. Insanity

Character: unfree disposition with exaltation of sensations and of the imagination; being beside oneself, daydreaming.

First Order, Second Genus

2. Dementia

Character: unfree spirit, with exaltation of thinking capacity; perverted concepts but unimpaired sensations.

First Order, Third Genus

3. Rage

Character: unfree will with exaltation of same; purely destructive instinct.

Second Order, First Genus

4. Melancholia

Character: unfree disposition with depression of sensations and imagination; melancholy brooding.

Second Order, Second Genus

5. Idiocy

Character: unfree spirit with depression of thinking capacity; lack of comprehending.

Second Order, Third Genus

6. Apathy

Character: unfree will with depression of same; incapacity for making decisions.

Third Order, First Genus

7. Insane melancholia

Character: unfree disposition with alternating incidents of insanity and melancholia.

Third Order, Second Genus

8. Confusion

Character: unfree spirit with confusion of concepts and inability to remember them, accompanied by a weakened perception of the surroundings.

Third Order, Third Genus

9. Timidity

Character: unfree will with panic flight from anything that may be fear-inspiring.

 

§ 195. This seems to be the proper place to defend our classification from explicit or implicit accusations of arbitrariness. We have already said a word or two on the subject, but more must be said to justify our method. All those who consider that the classification outlined here, from the class concept down to species and subspecies, is something arbitrary and forced upon nature, should bear in mind that once a man has sunk into a state of permanent loss of freedom, this cannot have happened otherwise than hypersthenically, or asthenically, or while both conditions are present to some extent. For experience shows that any energy rendered finite, including that of the soul life, involves a certain amount of normal activity. Outside this amount there can only exist a plus or a minus: tension or relaxation, each of them separately or both partially combined. Thus the orders listed by us (which, however, do not yet represent forms but merely the second condition to the form, the first condition thereto being loss of freedom) are directly subject to the laws of nature governing the soul force itself, and any mental disturbances must necessarily occur subject to these laws: this is a proviso of nature. It is by the proviso of nature that the orders, divided into genera, are each traversed by the different soul energies. There are only three such energies, as proved by our own consciousness: disposition (which is usually and picturesquely known as heart), spirit, and will. (Comprehension and imagination belong to the spirit, for the spirit is the creative force in the consciousness, but reason belongs to the entire soul, to the whole man, for it is the law of life that is reflected in the consciousness. See my dissertation: De voluntate medici, medicament° insaniae, Chapter I, § 6, publ. F. C. G. Vogel, Leipzig, 1818.) The third necessary condition for the appearance of a soul disturbance is the affection of one of the soul energies: the disposition, the spirit, or the will. More than one such energy can be affected, and this gives rise to the composite species; but at least one must be affected, for at least one energy in the soul must be active or must be suffering, and it is this necessity which renders the concept of genus of disturbances of the spirit, of the disposition, or of the will as a proviso of nature. But since a sole energy of the soul can merely predominate but can never act or be acted on in isolation, since all energies are organically interlinked, it follows that the accompanying affection of the other energies in the genus necessitates the subdivision of the genera into species, that is, into definite, observable forms of disease, in exactly the same manner as the class concept of general loss of freedom was subdivided by the degree of soul energy into orders, and each order was subdivided by the kind of energy into genera. Now the concepts of class, order, and genus, though founded on real states, yield still no forms for the observation; for nothing that is general can be visualized, and the conditions for visualization must first be completely fulfilled before the real form can become apparent. And only upon disappearance of the general and the onset of the particular can the real form be visualized. Thus, loss of freedom ( Vesania) can never appear otherwise than in a definite shape (form). And the apparent form must be just as different as are the conditions which gave rise to them. In other words: there must be different and definite forms of loss of freedom and soul disturbances; and finally: these different forms are not entirely lawless, that is, formless, but are exactly determined and determinable by their conditions. Whatever is observationally conceived as random and incoherent is in reality by no means random, incoherent, lawless, and anarchic if judged by its own criteria: the lack of order and of form lies in our conception, and it is the latter which is at fault if soul disturbances appear to us as formless and chaotic or else as constringed to fit but one, two, or three forms, or if it seems to us that the independent, the essential state of disease has only one form: insanity, or two forms: mania and melancholia, or three forms: mania, melancholia, and idiocy (or at best a fourth form: foolishness). It follows from our postulate of the conditions that must be fulfilled before an unfreedom can appear that the latter is manifested in one or the other out of a definite number of ways, and that the norms of the manifestation established by the observers are only isolated, detached links of an entire chain, of a totality of forms that is determined by nature itself, but which nature reveals only to those who have made a very cautious but very thorough study of the various groups of symptoms and groups of forms, who have classified with great care, attention, and faithfulness what was apparently random, isolated, and scattered, and who did so by collating phenomena which are invariably found together or which invariably follow each other to form definite groups of symptoms and of forms. These latter are nothing but the expression of the various and variably determined conditions by means of which the state of loss of freedom occurs in reality. The above explained listing of these conditions has, we hope, substantiated our forms classification.

§ 196. Before we conclude this organon of the science of forms, we now only have to outline the scheme we are about to follow with more clarity than has so far been possible. To begin with, we shall list the pure species or forms, which correspond and are subordinate to the above series of genera in the sequence given in § 194. They will be listed, firstly, by their specific character; secondly, by their precursors; thirdly, by their pure, unbroken course through their different stages; fourthly, by the manners of their termination; fifthly, by their semiotic, diagnostic, and prognostic moments. Next we shall list under each single pure species all the other species augmenting it; this, however, can only sketchily be done here. Finally, we shall list the most important subspecies, varieties, and modifications for each series of species. Wherever there is a concurrence of opinion, we shall indicate the nomenclature of the other writers, in particular that of the nosologists. The science of forms will be concluded by a synopsis, presented as a schematic table, with all the ramifications of the complete variety of forms.

Chapter Two

NOSOGRAPHY OF THE SPECIES OR FORMS OF GENERA OF THE FIRST ORDER

First Segment

Forms of the Genus: Insanity (§ 194) (Ecstasis*)

First Species: Pure Insanity (ecstasis simplex)

§ 197. 1. Specific character of pure insanity. The dream life: the patient does not sense the objects which form his environment or which affect him, and is not receptive to them, since he is too much bound up with the objects of his own imagination. Alternatively, his senses perceive things in distorted forms, in distorted conditions, and in distorted relationships, since his imagination draws the sensually perceptible objects into its web and spins its dream and its changing images around these objects. All these images are thus made to hear the imprint of the feeling dominating the patient's disposition and the desires stimulated by this disposition. Vividness and exaltation of unfree ideas, sensations, and desires constitutes the persistent character of pure insanity.

* Every Latin or Greek term not accompanied by the name of an author originates with the author of this book. The form itself will justify the term in every case, even if the term appears to be novel and strange. The author was compelled to coin his own terms wherever he had had no predecessors; in doing so, he borrowed from the Greek rather than the Latin language in most cases, because of the richness of the former compared to the paucity of the latter.

§ 198. 2. Precursors of pure insanity. Exceedingly passionate outbursts, reaching frenzy; oblivion or neglect of all usual business and other occupations; indifference to, or repulsion against, formerly welcome persons or objects; deferment of satisfaction of the natural or customary needs; neglect of one's person, including one's appearance; scatterbrainedness, thoughtlessness, forgetfulness; constant restlessness at all hours of the day and night; sleeplessness; constipation; feverish tension; talking to oneself; complete absent-mindedness — this sequence of precursors of pure insanity takes several days, and the manifestations follow one another in almost imperceptible transitions, not always distinguishable from one another.

§ 199. 3. Individual stages in the course of pure insanity. The beginning (first stage) is comprised by hasty activity, agitated to-and-fro motion without sense or purpose; a strange, conspicuous behavior even towards closest friends; purposeless, irrational questions, assertions, actions, which immediately indicate that the patient is not himself; finally, an unusual, vehement, proud or tender, rapturous, fanciful behavior. This stage, too, lasts for a few days. In the second stage, the patient begins to treat everything around him and belonging to him as objects existing in another environment: he seems to see nonexistent objects, hear nonexistent sounds, and talk to nonexistent persons. Then again he may talk to himself, laugh, cry, sing, recite poetic passages or verses from song books, depending on the degree of his education, or he himself makes up rhymes, or what he thinks are rhymes, sometimes having and sometimes lacking any meaning. Gradually the objects of his insanity draw closer, becoming more crammed and more cohesive. He becomes altogether detached from the outside world, and his condition, which heretofore had remained as if covered up and concealed inside him, becomes now outwardly visible and betrays his inner state: the sensations and the passion which fill it, inflame it, and consume it. He blurts out his innermost thoughts like a drunkard, without any inhibitions. This is the acme of the disease. Now he deems himself to be in possession of the desired object, now he deems himself just robbed of it, now he expects its immediate or future appearance. Pure insanity never appears without a definite object, since it is only such an object which is able to arouse the violent exaltation which makes the patient forget the whole world and conjure up a world of his own. One should think that such a condition cannot persist for long, owing to the very intensity of the affection, that nature would suffer such a high tension for only a short time. Nevertheless, this condition is often observed for several weeks or even several months, though not always at the same intensity, but there are no real intervals of lucidity. If such periods do occur, then the patient is on the way to recovery, or else a transition to another form of mental disturbance is about to take place. The appearance of these lucid intervals constitutes the third stage of the disease. The exhausted nature demands a rest; sleep returns, at least in some measure; the patient takes nourishment with less repulsion, his dreams again include some concepts of the external world; vividly penetrating sensations again result in isolated natural reactions; at times memory is restored, and a sudden wonderment, as if the patient had just been awakened from sleep, announces the return of a sane spirit which, however, is soon spun once more into the dream tissue. But the following day (seldom the same day) or a few days later, a similar moment of lucidity appears, and it may even last for a longer period of time. The entire duration of the period lived through or dreamed through in this way is lost to memory, severed from life, and in the happy event of recovery, the memory of the patient retains only a confused recollection of the principal moments of the diseased state, similar to the recollection one has after a real dream, the details of which have been forgotten.

200. 4. Manners of termination of pure insanity. Once the disease has taken its natural course, remaining in its pure form, without foreign admixtures, with no interference and no interruption, not even by medical treatment, passing through the three stages: the abandonment of the real world, the uninterrupted dream, and the momentary recovery, after three, four, or five weeks, or even after several months, depending on the intensity of the disease and the constitution of the patient, the disease ends in one of the following ways. Either the lucid intervals become increasingly longer and more frequent until the patient has completely recovered his reason and merely suffers for a little while from the inability to think on the one hand, and from an excitable imagination on the other, so that the products of imagination still easily become confused with real objects on reception of very slight external or internal stimuli while the powers of discernment are still too weak to definitely distinguish the true from the imagined, and until, after another period of several weeks, even these last traces of the disease — and thus the disease itself, i.e. the morbidity of the disposition that had caused it in the first place — disappear, from which it follows that the entire disease should be considered as a kind of crisis — or else, this crisis does not proceed to completion, the affliction having been too deep and the effort too great; one of four eventualities then occurs: the patient may recover except for a so-called idee fixe, which actually means that he does not really recover but becomes to a certain degree and in a certain manner deranged, i.e., the residue of the disease passes from the imagination to the intellect; or else the disposition, having has been too deeply affected by the previous affliction and thus upon return of consciousness becoming aware of the very abyss of its misery (feeling, so to say, the measure of the loss it has incurred through insanity), withdraws into itself, broods over its own condition, becomes dead to the world, and loses itself in the dark desert of melancholia, without any particular fixed idea; or else the fixed idea may become united with melancholia, and this is the third case. In the first two cases, recovery may still occur, after some time; in the third — rarely. Most often all three cases pass over into idiocy. Or else, and this is the fourth case, the exertion of the disease, attacking the force of the soul, has at the same time played havoc with the force of the body and with its organization, not merely shaking it, not merely producing morbid changes, but wearing it out: the patient wastes away and dies.

§ 201. 5. Semiotic, diagnostic, and prognostic moments

a. Semiotic moments. The precursors of pure insanity are betrayed by an expression of excessively emotional disposition reflected in the eyes, which have an unusual glitter, move restlessly, or remain fixed on one point; by facial features distorted almost convulsively; by redness of the face extending up to the forehead; by pulsating neck arteries; by a very fast heartbeat; by deep, rapid breathing; by restless movements, and by all the other symptoms listed above (§ 198). The signs of the first stage are, besides the symptoms listed in § 199, an already estranged and distracted glance that begins to become piercing; burning cheeks; pounding of the heart and pulsing of the veins; rapid breathing; hasty, violent, darting movements, as if the body had become lighter; disheveled hair, disordered clothing; constant pacing to and fro or dogged clinging to one spot, usually the window. The symptoms of the second stage are, besides those listed in § 199, all the outward appearances of highest ecstasy: glittering, nay sparkling eyes, which are either listlessly wandering or else stay fixedly staring; a raised or bowed head; a puffy, heated face; a raised, strong, strange-sounding voice; now flurried, now slow and pathetic speech; most unkempt hair and disheveled clothing, or else a bizarre getup of dress and jewelry, especially in the case of women; insensitivity to all external influences; the capacity to go without food and sleep for longer than a normal period, as though the disposition were nourished by something the patient thinks he owns or hopes to own, and which maintains him in a constantly cheerful, happy mood, or rather tension, which is reflected in all his movements, attitudes, gestures, facial expressions, glances, and even wide open eyelids and raised eyebrows. The symptoms of the third stage, other than those mentioned in § 199, are a marked relaxation of all outer tension, the eyes often look natural and scarcely glitter but are often dull; however, they usually are still staring and distracted; sunken eyeballs; pale, drawn features, loss of weight; quiet heartbeat and pulse; calm breathing; return of appetite and of sleep, albeit irregular; quiet movements and facial expressions; softer, more natural, gentler, slower, and rarer speech; recognition of persons, objects, and locations; sensible questions, especially on past events, gradual increase in the general liveliness; gradually returning participation in outer events; or else, after an initial uplift — a relapse of the patient into preoccupation with himself; taciturnity; preoccupation with a single idea; brooding; unwillingness to take up the usual occupations.

b. Diagnostic moments. These moments follow from the specific character of pure insanity (§ 197) and from the absence of signs which are symptomatic of other species of insanity, of the species of the other genera in the hypersthenic series, or of forms of other orders. Thus, we find no trace of perverted notions or perverted judgment, except possibly (§ 200) in the terminal stage of the disease; no trace of an urge of destruction; no trace of an emptiness of the disposition or spirit (except as given in § 200); no extinction of the willpower; and, finally, no trace of the symptoms for the forms of the mixed genera.

c. Prognostic moments. The form of pure insanity is, compared to the other forms of insanity and of other genera of soul disturbances in general, usually of the shortest duration and has the best chances of recovery. But both, duration and termination, depend on the age, sex, constitution, temperament, intensity of the attack, type, and circumstantial effects. As a rule, the duration is shortest and the hope of recovery best in young people rather than in those of more advanced age; in males rather than females; in those having a strong rather than a weak constitution; in those with healthy parents rather than with parents who had suffered from some form of mental disturbance; in those with a sanguine rather than a choleric temperament (phlegmatic and melancholic temperaments do not incline to insanity); in a violent, rapid onset of the disease rather than in an initially mild and only gradually developing case; in the case of a first attack rather than a relapse, especially if the relapses are periodical. The circumstantial effects are varied and exert a strong influence on the duration and manner of termination of the disease. They are: earlier and present mode of life; environment; treatment of the patient; incidental occurrences; corporeal and moral changes and changes of mind. A shorter duration and a more satisfactory manner of termination may be expected in the following cases: if the patient has enjoyed a proper upbringing, especially if it was a religious one — even if later moral corruption and depravation have taken place — rather than if his upbringing was neglected from the start and his morals were perverted at an early age; if the patient is in good physical condition rather than suffering from any of a number of diseases which exhaust, upset, or even disrupt the functions of the organism, such as syphilis — including the medical treatment for it — and the results of onanism or of any intemperance; if his imagination has been maintained free rather than was corrupted by early persistent reading of romantic novels. A genteel or a rich patient who has loving relatives and friends who care for him has more hope of recovery than a lowly and poor one, or one who is not cared for, or is cared for only because it cannot be helped, or under obligation, or a patient whose relatives are actually interested in maintaining him in a state of insanity. The patient who during his disease is remote from his home, from his relatives, and from familiar objects has a better hope of recovery than one who stays at home or in the house of relatives during his sickness — whether this subjects him to their loving care or their disgust — and who is surrounded by various objects which bring back unpleasant memories or nurture harmful moods; this goes also for the wider sense: there is more hope of recovery in a surrounding suited to the condition of the patient, in respect of the location and equipment as well as in respect of the human environment, than in another surrounding. It is the kind of treatment given which constitutes one of the main factors able to either raise or else wreck any hope of convalescence, for this depends on whether the treatment is friendly or unfriendly, too harsh or too yielding, thoughtful or thoughless — briefly, whether it is expedient or inexpedient in general, administered by a knowledgeable, experienced, skillful, and thinking doctor or by an ignorant, inexperienced, awkward, or short-sighted one. Lastly, unexpected and unintended incidences — be they happy or unhappy events — which bear on the mood of the patient and affect his condition, contribute to the good or poor chances of recovery. An unexpected inheritance, the return of absent friends and loved ones, an outbreak of fire, a major political or other revolution, a sudden appearance of frightening objects, etc. — these are examples of such incidents. In the final analysis, the prognosis also depends on the bodily and moral changes and transformations. Thus, symptoms that have also a critical significance in bodily diseases may appear in the second or third stage of the disease, such as: skin rashes, gout, and secretions and discharges from the proper discharging organs or morbid discharges from skin, lungs, kidneys, stomach, digestive tract, salivary glands, blood vessels of the nose, the anus, or the sexual organs. If these had been present prior to the appearance of the mental disturbance in its earlier course, and now only return, then these phenomena are to be interpreted as evidence of the revival of the vital forces and a good omen, especially if they are accompanied by visible changes in the spirit and in the moral disposition of the patient which confirm his return to normality, such as: return of sensibility, lucidity of views and ideas, reawakened interest in external objects and in independent activity in general; further: a certain mildness and mellowness of the disposition, often manifesting itself in weeping, and in general, sadness and grief instead of the former joy and laughter; a mild, calm, and yielding behavior, and signs of interest in the loved persons — all these leave room for a favorable prognosis. Contrariwise: progressive emaciation, loss of strength, traces of hectic fever, nervous asthma, or the appearance of cramps or convulsions, progressive extinction of spiritual activity, a sullen, dejected, dark mood, general indifference or a recalcitrant, unfriendly, irascible, and spiteful behavior, grumbling and abuse, neglect of the life-sustaining needs, weariness of life — all this presages the worst as the most likely outcome.

§ 202. Second Form of Insanity:

Insanity with Dementia (ecstasis paranoia)

1. Specific character. The symptoms of pure insanity are associated with perversion of concepts and judgment, whereby the character of the disease becomes markedly changed. The disease has gained sway over both the intellect and the imagination of the patient; the domain of the disease thus comprises two parts, the field of insanity is narrowed down and reduced, and as a result its form is altogether altered. The dream life appears to be impeded and fragmented and its vividness decreased, and the intervention of the intellect results in partial consciousness. But this partial consciousness is not a healthy one, because the intellect prevents the comprehension and the judgment of correctly perceived sensations. The force of insanity is still predominant and comprises the main character of the disease.

2. Precursors. During a shorter or a longer period before the onset of the disease, the subject suffers from restlessness of the disposition and from very intense but futile and vain meditation and thinking. Finally, his imagination gains sway over his intellect. The diseased-to-be restlessly paces about all day long, is entirely preoccupied with himself and ignores other things, but there is no rational outcome of this activity; he begins various tasks the wrong way, thus creating many contradictions which confuse him even further; he forgets to eat or drink, or else bolts his food and his drink, especially liquor, in excessive quantities and in a hurried manner; he spends sleepless nights on his couch or else wanders about absorbed in his imaginings and speculations; thus every day brings him nearer to the outbreak of the disease proper. This stage often lasts for as long as several weeks, until the disturbance is evoked by a suitable event, or by the self-stimulus of the excessive tension of the mood and the spirit of the subject.

3. Course of disease. The first stage begins with conspicuous, irrational, bizarre, eccentric speech or action. If he is humored or coaxed, or rebuked or even forcibly restrained, the patient becomes even more excited and gets more worked up so as to be quite beside himself. Total insanity breaks out and is accompanied by the symptoms given above, but this condition of insanity proper is not of long duration, and after a few days the disease assumes its definite, ripened character. In the second stage the patient becomes quieter, but there are no really lucid periods: he begins to reason, to demonstrate, to preach, to criticize the state, the sciences, religion, he tries to improve the entire world. Any persuasion or contradiction excites him and produces a relapse into insanity. But even without outside interference insanity always reappears, at the end of several hours or several days of a demented [deranged] interval, mostly at night, but is now characterized by feverish phantasies rather than by the integral, solid dream of pure insanity. This period of strain is again followed by a period of quiet during which the patient appears to be preoccupied only with himself; but actually this is a state of exhaustion from the effort made by the imagination and by the mind that has wearied itself by the intensive pursuance of wrongly headed trains of thought. Several weeks or even months pass in such alternation of insanity and dementia, changing in front of the sick mind like theatric scenes. In the third stage there gradually disappears the vigorous activity of the imagination, the mind and thus of the disease in general, but the disease itself persists. Its scope only becomes narrower, as it were: there are no more violent attacks; the patient is on the whole calmer; he seems to approach sanity as regards the reappearing mechanism of life, such as eating and sleeping; but he cannot find his way back to right thinking, and just when his speech seems to indicate that he is about to return to sensibility, a relapse occurs. He himself, however, begins to think that he is sane again, and this conviction becomes stronger every day. His behavior towards others is in conformity with this belief, and so he resembles one who, being drunk, thinks he is in perfect command of his senses, to which his speech and actions however give the lie.

4. Termination. After the disease has lasted for two, three, or even four or five months, the patient returns either to full normality due to his soul having tired, as it were, of its morbid activities, or rather because, as in a bodily disease, it has gradually liberated itself by these activities from the materials of the disease and its spurious images and imaginings — which comprises the rare case — or else an idee fixe remains, although the patient recovers the proper use of his senses and his intellect up to a certain point, a certain idee fixe, which accompanies him through the rest of his life, or eventually disappears by sheer coincidence, due to bodily disease, such as a strong intermittent fever. In yet other cases, when the disease has been particularly stubborn, it will result in a permanent general confusion or a complete paralysis of the spirit which scarcely differs from idiocy.

5. Semiotic, diagnostic, and prognostic moments

a. Semiotic moments. In the precursor stage, as well as in the first stage and in a part of the second stage, the signs are the same as those signs of pure insanity (§201) that indicate the dream state, only somewhat suppressed and attenuated, due to the admixed symptoms of dementia. The patient is not quite as lost in his dream life; his entire condition is a less ecstatic, tense, almost feverish one; his appearance is not as fantastic or as ghostly; his glance does not so much wander about, being in complete detachment from the outer world or being fixed onto one point; instead, it penetrates, as it were, the observed object and is more piercing, more boring, and more offensive than that of a man suffering from insanity and the observer can less readily withstand it if he has little spiritual energy. For the rest, the speech and the actions of the patient are the best indications of his condition. Towards the end of the second stage the conspicuous symptoms of the disease disappear; and in the third stage, in which the patient seems to enjoy perfect bodily health, the only remaining symptoms are his look — which is now quiet but is not able to focus on any one object but glances off all objects with equal indifference — and his distorted and confused concepts and judgments, or his constant return to one and the same object.

b. Diagnostic moments. This second species of the disease differs from pure insanity, firstly, in the less intense ecstasy of the imagination, and secondly, in symptoms of affection of the intellect added due to the admixture; it differs from pure dementia in the admixed colors of the dream life; it differs from rage in the absence of an urge of destruction; and it differs from the diseases of the psyche of other orders in the character of constant exaltation which fades only towards the end of the disease, when the disease, if not cured, becomes more like pure or mixed depression.

c. Prognostic moments. All deviations of the psyche that are mixed with derangement of the intellect are less benign than those in which this derangement is absent; for this reason there is less hope of recovery from this second species of insanity than from the first, especially if the disease has lasted for a long time. Furthermore, this species tends to strike at an age when the intellect is in general more active: the years of middle age or older. Women suffer less frequently than men from this kind of insanity and are more easily cured. If the disease has persisted for more than a year, there is little hope of recovery. Otherwise, the prognostic moments given for pure insanity (§201) are valid, especially as concerns the mode of life, environment, treatment of the patient, and incidental happenings in the life of the patient.

§203. Third Form of Insanity:

Insanity with Rage (ecstasis inaniaca)

1. Specific character. The symptoms of pure insanity are associated with actions that are not merely perverted but seek to destroy. The patient not only tears and crushes everything within reach but also inflicts injuries on his own person and, whenever possible, on the persons of others. The character of the disease is thus much altered. The disease takes on an air of violence and fury that is quite unlike the first two forms. But this state is not vacillatory, not ambivalent, but even and constant, and always true to its type — that of insanity — which, due to the characteristics of rage, becomes only intensified and aberrant. And this is what comprises the specificity of the form.

2. Precursors. These may be very short-lived if the patient is shocked out of his senses by some sudden powerful effect and is goaded into violent action; alternatively, the material which forms both ingredients of the disease accumulates slowly over a long time, and the coming outbreak is announced by periodic highly passionate outbursts provoked by the slightest external stimuli, especially after consumption of liquor by those who can no longer do without it and who have acquired a high tension of the vascular system or a depression of the nervous system through habitual surfeit. This reveals itself in the most extreme, most volatile excitability. In this state of extreme tension and irritability, which has already manifested itself in repeated transient outbursts of raging anger, at any slight pretext, the slighter it is the more destructive its results, the excitement soon mounts from irritability and sensitiveness to a powerful aversion and anger which will soon explode into a frightful flame like a spark under the bellows, especially if the slight, irritating external stimulus persists or is periodically renewed. The coming outbreak of insane rage announces itself unmistakably in the attitude of the patient, his movements, facial features, and contortions, the appearance of his face and eyes, his look, voice, and speech. Everything suggests a man seized by the most violent anger, who has forgotten himself and everyone around him, and has rejected all restraint and humane considerations. Who has never seen anything like it?

3. Course of disease. The first stage. The actual insanity appears are the peak of the ecstasy. The patient no longer knows where he is or who he is; he no longer thinks of himself; he has taken leave of his senses; he is a plaything of the wildest dreams which represent only fantastic, terrifying shapes and gory images. The only thing he actually feels is that the sight of flowing blood would quieten him. This is shown by his protruding, bloodshot eyes, by his gaze, which is eagerly seeking an opportunity for destruction, by his livid face, by the tension in all his veins and all his muscles, and by his wild, hoarse, almost choked voice. Fortunately, the duration of such attacks is short, a few hours, twenty-four hours at most, and then the attack is over, and with it the first stage of the disease, and in contrast to other diseases, this is also the acme of the evil, unless the patient is further stimulated during subsequent stages of the disease by extremely violent external stimuli. The second stage takes the following course. The first, strongest tempest has abated. The patient daydreams but his dreams are more quiet, unless he is again stimulated by the great quantities of food for which he experiences a ravenous, animal hunger, or an hour's sleep in which he experiences frightening dreams, or another external stimulus such as a loud noise, bright light, or the sharp expostulations of those around him. Thus, the apparent quietness, the vivid but inactive daydreaming, lasts for only a short time but soon returns. Excitation and relaxation alternate not merely for a few days or a few weeks but, under suitable conditions, for several months. This is the restrained character of the second and longest stage of the disease. The third stage is again shorter and is the decisive one. The dreams of the patient become quieter, his actions less violent, and he may even experience isolated truly quiet periods of perfect lucidity. In this case, recovery will quickly follow. Much progress can be made in a week or fourteen days, for this decisive stage is hardly ever longer, be its outcome as it may. In the absence of such a recovery, if the shocked internal human nature, like the external general nature after a violent storm, is not healingly purified and brought to a new equilibrium, the constant play of imagination, the persistent easily excitable wild mood, or else the dulling of the imagination and energy, will lead to a state in which there is only slight hope of recovery.

4. Termination. The quiet, lucid intervals may become longer until recovery is complete, and body and soul seem to have been born anew, or else the disease terminates in one of the following ways. One: the tendency to violent outbursts disappears altogether, the dream life gives way to dull brooding, the images are extinguished and become colorless imaginings; and the disease terminates in a state of chronic confusion. Two: if the constitution of the patient is stronger, but has nevertheless been disturbed by a wrong way of life, the dreamlike state gradually disappears, and the patient regains his senses, but the resultant condition of the vessel and nerve systems, with or without psychic motives, leads to periodic or irregular recurrence of the morbid tension, when a new outbreak of maniacal insanity recurs once or twice a year, or more often, according to circumstances. Three: patients with such constitutions or with very irritable, weak constitutions, do not experience a recurrency of the disease in this particular form, but in the form of irregular or periodic attacks of epilepsy. In either case the disease will usually persist throughout the life of the patient.

5. Semiotic, diagnostic, and prognostic moments

a. Semiotic moments. The symptoms which precede the outbreak of the disease are its true precursors, as is shown by the fact that the patient is in a state of quite unnatural tension and is completely beside himself. Such a psychic-somatic affection cannot remain without serious consequences. One of the most immediate and natural is mental disturbance brought about by excessive tension. That the disease is in fact insanity accompanied by rage is seen from the symptoms of the first and second stages. Those of insanity are already familiar, while those of rage, with its crass urge for destruction, are unmistakable. If he can destroy nothing else, the patient will tear up his own clothes and his own bed, down to the bedstraw, which he tears up into small fragments. He breaks up and destroys wood panels, brickwork, whatever he is strong enough to destroy; he does not spare his own body, and the life of those approaching him is in danger unless he is bound. In the same manner, the symptoms of the third stage are clear signs of recovery, for quietness and return to rationality, and increasing duration of these periods are clear signs of life returning to equilibrium.

b. Diagnostic moments. The features of the disease which show that it consists of two elements are much too specific for this form to be confused with those already described and those yet to be described. The nature of the exaltation indicates the class of the dream life; the genus, and the admixture of mania define the species. Thus, confusion is scarcely possible.

c. Prognostic moments. The more violent the attack of the disease, the shorter is its possible duration; but a relatively short duration of the attack is no guarantee of its favorable outcome, for the violence of the attack is evidence of the far-going disruption of the entire life. On the other hand, if the attack is milder — if "milder" is the proper way to describe rage attenuated by the animation of insanity (since we have only described the disease in its most violent form) — this is also a had sign, for it proves that the two elements of the disease are more intimately intertwined and very firmly bound to one another. (The author of this book has had occasion to observe periodic attacks of this form of the disease at frequent intervals. The patient does not thirst for blood, but merely has a tendency to break and tear everything, while quarrelling and grumbling; and his imagination, which admires paintings on the walls, fanciful furnishings of the room, etc., is the most conspicuous and most persistent symptom. Nevertheless, the disease lasts for several years, and the patient has seemingly lucid intervals lasting for several months.) Also, two enemies are harder to overcome than one. There is more hope for the strength and mobility of youth than for the inflexibility of a more mature age, and for the weaker excitability of men than for the stronger excitability of women, for the fickleness of the sanguine temperament than for the persistence of the choleric. In general, a disease originating from a spoiled temperament rather than from deep moral corruption can be more easily cured. If there are relapses, either periodically or at irregular intervals, the prognosis is had, as it is in all such cases. The favorable and the unfavorable signs of pure insanity are valid here as well. A particularly welcome sign are hemorrhages, such as hemorrhoidal blood flow and bursting of varicose veins. If, however, this form of the disease results in epilepsy, nothing else but gradual exhaustion and extinction of life may be expected. The final stage is dullness of spirit, wasting away, dropsy, and in most cases, apoplexy.

§204. Fourth Species: Insanity with Dementia and Rage (ecstasis catholicaa)

1. Specific character. This disease is clearly marked by dream life, perversion of the intellect, and violence, but the two last-named qualities are only secondary. The main feature always remains the dream state of insanity. If this state is latent or temporarily retreats, the perversion of understanding and judgment becomes evident; if a powerful external stimulus is active, or if the inner tension is unusually high, rage with its destructive instinct also appears.

* Meaning: kato to olon, that is, affecting and including everything (the soul state). Here and below, the expression is used in this sense only.

2. Precursors. The stage which precedes the outbreak of the disease lasts for a long time. In a life which has been depraved by neglected education, circumstances, and guilts, in which excited sensuality, perverted concepts, and prejudices are prevalent, in which the intellect has been totally neglected or has been strained by brooding or spurious speculations, in which unrestrained arbitrariness rules, in which many embarrassments, restrictions, inhibitions, and dangers have been the lot of the patient, in such a life a moment may come when the measure is full and runs over, and the imagination becomes strained to the limit in trying apparently to effect a full compensation and to transform the evil fate as though by the touch of a magic wand. The well-known precursors of insanity are thereby established.

3. Course of disease. The first stage begins with an attack of insanity, from which the other elements of the disease have not yet separated themselves; this attack lasts only a very short time, about 48 hours, and then the second stage ensues. This stage develops as follows: the dream life is firmly established, the patient already feels at home in his new world, and the creation of his imagination is complete. The intellect reawakens, but its activity is perverted, and the most irrational concepts and statements are pronounced in an apparently quiet and relaxed mood. But only a small stimulus, such as a contradiction, or a negation, is needed for the violence to break forth. The attack of violence soon abates, and the patient again returns to the quiet but confused condition of dementia. This condition is not based on correctly perceived reality but on the dream castle of the imagination. Thus, the main feature of the disease persists during the second stage, which may last for weeks or months. Finally, the pictures of the imagination fade, the perverted activity of the intellect loses its strength, and the violence loses its force. This introduces the third stage. Reality reappears at isolated moments, but the perversion of concepts persists, or else the intellect returns to pursue its proper track but is as yet unable to shake off the dream, or the morbid affection of reason and imagination disappears, but an unnatural excitability of the urges easily degenerates into excessive willfulness, manifested by a tendency to offer insults and physical violence and, from the standpoint of the patient, who is forgetful of his condition, these are fully justified. Thus, the way is paved for the outcome of the disease after the third stage has lasted for some weeks.

4. Manner of termination. Reality may reassume its rights, the intellect may recover, and the patient is again fully conscious and is able and willing to master his own morbid willfulness. In such a case, the disease acts as a storm which clears the atmosphere, a wholesome desire of nature to cure a perversion through another perversion. But if this cure is not successful or is only partial, one of the following occurs: One: the symptoms of perversion of the intellect and of the morbid irritability of willpower disappear, but the dream world remains, in fainter colors and more confused, until it finally disintegrates into general dullness. Two: the perceptions again become normal but the conception does not; some perverse ideas remain and become fixed ideas. The violence disappears completely. Three: the imagination and the intellect have found their way back to normal, but the willpower remains mordibly excitable and serves to feed the fire of complete relapses; for if the tendency to violence has become excited, the imagination reigns supreme, the intellect is soon thrown overboard, and the morbid state becomes habitual.

5. Semiotic, diagnostic, and prognostic moments

a. Semiotic moments. In this form of the disease the signs of insanity, dementia, and rage cannot all be perceived at the same moment of time but only in successive alternation. In the first stage, the signs of insanity are mostly evident: general exaltation, movements, facial expressions, complexion, glance, speech, everything indicates insanity. In the second stage the rising tide has given way to the ebb. The external aspect of the patient, his attitudes, gestures, even the penetrating look in his eyes, or the unsteady, unclear, but not restless, roving of the eyes, but most of all the speech of the patient indicate that the mainstream of his disease has moved from the imagination to the intellect, even though the signs of diseased imagination, in the unnatural perception of objects, have not yet disappeared. But very soon and very suddenly there appear signs of violence. Often, for no apparent reason, the patient suddenly becomes violent, furious, vehement, offensive, and insulting. His eye glitters, his posture and his walk become self-assertive, his facial expressions become menacing, his speech loud, hoarse, and blustering, ideas become confused, perverted images come streaming back; everything announces the confluence of the three elements of the disease. It is only in the third stage, if all goes well, that a return to nature becomes apparent, at first for only a few moments, and later for longer periods of time. The features, the facial expressions, the look in the eyes again become natural, and so do speech, posture, and movements.

But if this does not happen, the facial expression becomes gradually duller and more confused; or else the eyes keep roving or remain fixed on a single point; or the entire attitude is expressive of insecurity and evasion, with a background menace of violence; all these are signs of different residues and modified outcomes of the main form.

b. Diagnostic moments. After the above discussion, it should not be difficult for an attentive observer to distinguish this form of disease from any other, except that the observation must not be restricted to any given moment, but must be repeated at successive intervals. Depending on whether insanity, dementia, or rage happen to have the upper hand at the given moment, the observer is tempted to attribute the disease to this particular form, but only an all-embracing view will lead to a correct diagnosis: it is a group of forms, which are combined together into one form, and the parts are organically interrelated. But in determining the form, the predominant feature must be pointed out; and in this case this is obviously insanity, which is more conspicuous in the first stage, is suppressed at the beginning of the second, only to reappear as a new attack of mania, but it always represents the background of the overall picture of the disease. If this main feature is borne in mind, and if the clearly evident secondary features are observed, it is not difficult to distinguish between this species of insanity and the others, and between it and those of the other genera in this and other orders.

c. Prognostic moments. While a happy outcome of this form of disease is not impossible, the total number of manifestations indicate that the derangement of the soul life is so clear that in most cases there is very little hope. The prognosis is always less hopeful in complex than in simple diseases, due to this very complexity. This is particularly true in the present case, since it is the confusion of the intellect, whose roots in the soul are always deepest, which accompanies the more vivid and more transient manifestations. In addition, a derangement of the psyche which is so general also indicates a somatic derangement which is no less so. An example thereof is the tendency to attacks of mania, which cannot take place in the absence of highly morbid changes in the vessel and nerve systems and the central points of these systems. Accordingly, especially if the disease returns, recovery is unlikely or altogether impossible, since it is evident that the very core of life has been injured. The third stage can consist in confusion or susceptibility to new attacks of mania; thus, the prognosis is that of chronic suffering in each case, and this disease is one of the most ominous and most difficult to cure in the domain of mental disturbances. The case history, and a review of the entire past life of the patient, give the most reliable prognostic signs.

§205. Subspecies, Varieties, and Modifications of Insanity Since the manifestations of disturbed mental life are so numerous, it is almost impossible to define and classify the finest and most individual variations in order to lay down for this theory that character which comprises its most distinct form, its very individuality. No leaf on a tree is exactly like another; the smallest veinlets in the organic venous system cannot be differentiated from one another; and the same applies to the forms of diseases in general and diseases of the psyche in particular. The individual character of the patient and the concurrence of chance circumstances produce unpredictable variations in every form, but if these variations happen to recur several times, they appear to assume forms which are even more definite than those included in the classification. Thus, insanity seems to be different when its object is love than when it is religious imagination. Also, a mild attack of insanity appears to be different from the most violent attack thereof, since the former seems to be closer to depression and the latter to rage. The same is true of all other forms of mental disturbances. This apparent confluence of forms was, in fact, the reason why the real and internally justified differences between the various diseases were so often contested. The mixture of different forms is indeed very widespread, so that it has often happened that a single case has been classified as successive alternation not merely of various species and genera of the same order, but even of all orders, and thus all differences between forms were seemingly abolished. For we all know how often symptoms of insanity, rage, dementia, melancholia, and idiocy all appear in a single anamnesis in successive alternation. Nevertheless, it would be too hasty to consider all these different symptoms as mere accidental manifestations of the same disease: confusion of reason, as many are apt to do. For our part, not only have we never denied the existence of admixtures and complications, transitions and transformations, but on the contrary, we have always considered them as something essential to and specific of the form and have classified those so far described under the genus insanity. But we have- also insisted that the eye of the observer must not remain fixed on the changeable features of the manifestations but must also recognize their fixed ones, which are the foundations of the disease, however variegated its forms may be. We have seen, in fact, that when one fundamental note has once been sounded, it continues to echo through the whole and keep the whole together, and is the distinguishing feature thereof. The pure forms are not often encountered, but they are encountered all the same; binary combinations occur more frequently; the manifold combinations occur most commonly. But the individuality of the complex forms can never be understood unless they are derived from simple forms, and unless these simple forms can again be identified unaffected by foreign ingredients. Such a procedure is valuable for theory and technique alike. Even if this were not so, living nature must always be taken for what it really is, in simple forms and complicated forms alike, and pure colors must not be wiped off just because we can see mixed colors as well. For what is the origin of the latter if not the former? But it is also of interest to observe even the finest shades, for these indicate the existence of various influences, and no influence remains without its effect. Accordingly, the fine shades known as subspecies, varieties, and modifications are of aid in the understanding of the highest individuality of the forms, and we shall terminate the description of each genus by a fleeting glance at the particular features of these varieties, which were in fact observed by nosologists. The real existence of these is confirmed by agreeing reports, even though the names given to them by different observers are different. These remarks apply to the forms of insanity only, but may be considered valid for all other forms as well. These subspecies, varieties, and modifications will not be separated or defined, here or elsewhere, since the material observed is not rich enough for individual studies. We shall content ourselves with submitting a general account for the use of future nosologist compilers, who will enrich and extend it insofar as they are able.

§ 206. Selected Items

1. Eratomania (Sauvages), furor eroticus (Bellin), melancholia erotica (Johnston). These are the names given by different writers to the same disease; what is called by one mania, is called by another melancholia; both are equally wrong if they refer to mere amorous insanity, such as was reported by Schenk (Obs. med. ran, Lib. I, ohs. 5), who describes the case of a merchant who became insane for love. He kept seeing the shape of his beloved in front of his eyes and caressed it as though she were really present. A similar case was observed by Pinel: a young man went insane owing to an unrequited love and believed each woman arriving in the lunatic asylum to be his beloved, whom he called Mary Magdalen. This is a very common manifestation of insanity, which may appear in the pure form or may really border on mania and melancholia. It has been repeatedly observed in monasteries, and particularly in convents. A different form is the amor insanus of ancient and more recent authors, which is not a mental disturbance proper but a passionate love that cannot restrain itself, which, however does not involve complete loss of freedom.

2. Daemonoinania (Sauvages). This is also no mania, but insanity. It is the disease of those of believe they are associating with protecting spirits and angels, the disease of the visionary, which is identical with insania hilaris or melancholia enthusiastica, the frequently described disease of the poet Tasso, who saw his guardian angel come through the window and talked to him for hours on end. It is also the disease of Swedenborg, who says about himself: "The Lord Himself was gracious unto me, He Himself appeared unto me, and let me gaze at the world of spirits and made me associate with spirits and angels." This is generally the disease of enthusiasts and daydreamers at the highest peak of tension; examples are too numerous to be counted, and we shall merely quote the case of one Johann Engelbrecht (see the history of his life, translated by Cambridge) who was driven by the Holy Ghost in His golden carriage into the brilliant, shining light of God's Magnificence, where he saw a choir of archangels, prophets and apostles sing and make music around God's Throne. This disease also frequently appears in convents, which are often visited by saints, by the Holy Virgin, and by Christ Himself. Diabolic manifestations must also be included in this kind of disease; they were given the name of daemonia by Linne. A typical case is that of the painter Spinello, who painted the devil in so frightening a form, that the devil in person appeared in front of him and bitterly reproached him for this representation. We must also include daemonomania sagarum, which was so common in the past, before and after the Reformation.

3. Melancholia metamorphosis (Willis), zoanthropica (Sauvages), with their varieties of lycanthropia and cynanthropia, are mainly manifestations of insanity, but are often combined with melancholia, with folly,* or with rage. Such cases occurred not only in antiquity but also in more recent times. Wierus, Zacutus Lusitan, Schenk, and Bartholin described such cases, especially those of the last kind. A very exact description of the disease will be found in Paulus of Aegina (De re med., Lib. III, cap. 16). Arnold (The Nature of Insanity etc., transl. by V. Ackermann, Part III, pp. 130 ff.) gives a whole list of such metamorphoses, which are quoted, or rather copied, in almost all subsequent books on "derangement of the spirit."

4. Metromania (not in the meaning of "mother mania" but "verse mania," but not in the sense of our time) is not a specific variant of insanity but is very often characteristic of it. Thus, van Swieten (Comment. in Boerh. Aph., Vol. III, p. 550) relates the case of an insane woman who constantly spoke in verse and made up verses very easily, which she could never do when sane and never even attempted to do, for she had earned her living by manual labor from early youth and her intellect was very limited. This kind of insanity is often found in women, and we think we are right in saying that it is a characteristic symptom of mother mania, since it is very closely related to nymphomania and eratomania and is often associated with them.

* [In German: "Wahnwitz."I

We shall content ourselves with this account of varieties and modifications of insanity, and shall merely remark that they are worthy of more faithful observation and description. However, it is seen from the examples given above that such observations were always confined to the most prominent moments, and only such moments were deemed worthy of being represented. Every observer attempted to describe only what was strange, striking, or not yet reported by others, and neglected the attendant circumstances. We shall close this section by remarking that insanity generally bears the imprint of its historical age, or the national character and national civilization. Antiquity had its metamorphoses, the Middle Ages had their demonomanias, while modern times still have their seers of spirits. Also, northern insanity is different from southern.

Second Segment

Forms of the Genus: Dementia (paranoia)*

§207. First Form: Pure Dementia (paranoia simplex)

Specific character. This consists in the loss of freedom of the spirit, excessive tension of the intellect, and perverted concepts and judgments. This pure affection of the intellect can manifest itself in three different ways, depending on its object and the direction taken by the activity of the intellect. Either the intellect, in its overtense and perverted condition, is directed towards the objects and conditions of the sensual outer world, including the patient's own bodily person, and thus appear as folly; or it is directed at the nature and conditions of an intelligible, metaphysical world, when it manifests itself as craziness**; or, finally, it is directed at the nature

* [In German: "Vernlicktheit". The word "paranoia" appears in Latin in the German text and has obviously little in common with paranoia in its present-day meaning.]

** [In German: "Aberwitz."l and conditions of the patient's own personality, in which case the disease manifests itself as foolishness.* Since each of these three manifestations modifies the nature of the disease in a specific manner, and the form, even as a pure form, may assume three different aspects, we have to subdivide even the pure form into three, that is, we have to postulate three species of the pure form; these species thus become the principal forms, so that the complications occurring in this genus become merely subspecies. This is no mere subtlety of reasoning, or a play on words, or some invention of our own; nature itself forces us to represent pure dementia in this manner, and the three different forms of the pure diseased condition of the psyche are so characteristically different that they can be distinguished from one another even by the most inexperienced observer who chooses to use his eyes; for the foolish, the crazed, and the fool cannot be mistaken for one another m their appearance, speech, or affections. Thus, their diseases must be treated separately and completely, and must he so described, including the complications produced by the different subspecies.

§208. First Species of Pure Dementia: Folly (ecnoia)

1. Specific character. Dementia of the intellect as concerns objects and relationships in the external world, including the patient's own body. The patient appears to be sane, except for his understanding and judgment, and even these are often sound except with reference to a single object, but his condition is betrayed by his speech and actions.

2. Precursors. An originally natural tendency to muse, to brood, to study, to invent, to occupy himself with technicalities, with mathematical problems, abstract projects, etc., becomes stimulated and nurtured when it is linked for a longer time to an object that highly fascinates the patient. Everything becomes subordinate to this tendency: business, pleasure, relaxation, and even food, drink and sleep. The patient gradually withdraws from society and retires into himself; he forgets everything except his own efforts. The object preys on his mind day and night, and he is unable to forget it even for a moment. He appears excited or absent-minded or deep in thought, and his tension mounts; finally, he can no longer get any sleep, the tension increases, and the disease breaks out.

* [In German: "Narrheit."]

3. Course of disease. The outbreak of the disease follows several sleepless nights and a state of the highest tension, so that the first stage must be considered to be a continuation of this mood and, depending on the circumstances, this is manifested as a single demented idea to which everything that affects the patient is referred. Or the patient sees all the objects and relationships in the outside world as a chaotic confusion, since he cannot keep his mind on any of them, but is irritated by everything he encounters and passes perverted judgments on everything in a sharp, peremptory, high-pitched voice, or else in a joyful, self-satisfied, and agreeable manner which makes it evident that he thinks that he is completely reasonable. However, he is always unmistakably restless, agitated, overexcited, and tense, as can be seen from his flushed face, the portentous, concentrated, vague look in his eyes, quick gestures, rapid walk, rapid, confused speech, constant return to a single subject, or, on the contrary, roaming attention to several subjects. Like all deviations of the psyche marked by exaltation, this restlessness and mobility in which the body and the spirit are in a state of high tension are acute in the first stage of the disease, which is of short duration. If the patient is not excited or irritated, he does not step out of this circle, but his machine runs down, as it were, until exhausted. If he is brought to a state of higher tension by accident or by wrong treatment, he may easily become raging, but this is not the simple course of the disease. In any case, relaxation must follow, and the second stage of the disease begins after the first has lasted for a few (up to eight or more) days. The patient again begins to eat and sleep and returns to his senses, but he is still demented. His folly becomes a fixed idea or else is replaced by a general loss of reasoning power. Often several fixed ideas alternate, as in the case of the clock-maker treated by Pinel who became demented over his attempts to invent a perpetuum mobile [perpetual motion machine]; he kept working at this idea, and when his fear of the guillotine had brought his disease to a peak, he also became convinced that he had lost his head and received another one in exchange. Both these fixed ideas alternated. Thus, this second stage takes its uniform course, and its duration cannot be predicted. The disease generally becomes chronic; and it is only if the strong constitution of the patient brings about the onset of some violent bodily disease, or a lucky accident occurs which has a beneficial influence on the patient, or if skillful treatment furthers the healing of the disease, that the natural course of the disease, which may take years if undisturbed, can be broken, and the patient may recover. His recovery is more or less difficult and more or less rapid, depending on the circumstances. If none of this happens, there is a slow transition to the third stage, the duration of which varies with the intensity of the disease and the nature of the patient. The disease gradually passes into confusion, stupidity, or idiocy, which is the final result of all excessive tension. No other different termination of the disease exists; unless death of the patient be brought about by consumption, or apoplexy, or some other bodily disease.

4. Semiotic, diagnostic, and prognostic moments. Dementia in the form of folly* cannot be readily recognized in its first stage, in which it is not yet fully developed and in which it could still develop into another kind of disease. It is only when the idee fixe or a perverted view of external objects has taken root that the main symptom of folly also becomes established. Patients suffering from folly are distinguished from other mental patients in that most of their activity is directed externally and to some purpose, briefly, that their activity has a practical tendency. This is true of Pinel's clock-maker; of the merchant who makes his ships sail forth and come into port; of the scientist whose papers are filled with senseless scribblings; of the politician who adjusts the balance of power between states, etc. In any case, a very definite diagnostic feature of the disease is that the speech and actions which express perverted views on external things and on the relations between them, and which are unceasingly repeated, are purposeless or contrary to their declared purpose; and in this manner the disease can be distinguished with perfect certainty not only from the forms of other genera, but also from the other forms of dementia. These symptoms are also prognostic; for, once folly has taken root, there is very little hope. However, if the disease is still in the initial stage, if the patient is a man in his prime (young people and women usually do not suffer from folly, for their disposition and imagination are better developed and more active than the reasoning intellect; there are, however, exceptions to this rule), if the treatment is effective and the circumstances are favorable, all hope may not be lost. But folly which has lasted for a long time, like all soul disturbances of long duration, defies even the best treatment.

We take this opportunity of acclaiming the great gifts and originality of Dr. Alexander Haindorf, the author of the book Versuch einer Pathologie und Therapie der Geistes- und Gemiithskrankheiten (Attempt at a Pathology and Therapy of Diseases of the Mind and the Emotions), Heidelberg, Braun, 1811. The reason he was not mentioned in our critical history of the medicine of the psyche was that we could not be content with merely citing his name, nor could we polemize with his views. The former would have been too little to do him justice, the latter would have been too much for us; for we would have had to refute the entire point of view on which he erected his scientific structure, with which we do not agree at all, even though it originates from one of the modern masters of natural philosophy, J. J. Wagner, whom we unreservedly respect and admire. We think that the views of both teacher and pupil are highly learned but unnatural and, therefore, untrue. It would take no less than a separate volume to justify this statement, so we prefer to remain silent and think that we have nonetheless paid respect to the brilliant author of the Versuch. We have mentioned him here since he also published his own views on dementia, folly, foolishness, and craziness, that do not agree at all with ours, which we attempted to base on natural principles. We would accordingly request the reader, if the question seems important enough, to make his own choice between the views of Dr. Haindorf and our own views; and we hope that the old dictum dixi et salvavi anitnam meant will apply here too.

 

§209. Subspecies of Folly

Folly ceases to be pure dementia if soul activities other than reason [intellect] are also affected. If the disposition is stimulated and the imagination is affected, we have the first subspecies: insane folly (ecnoia ecstatica). The specific character of this form consists in perverted images of things as well as perverted conception of things, these perverted conceptions being related not to the real but to a dream world. This disease is preceded by severe shocks to the disposition, under excessive continued mental strain; as a result, the disposition is violently excited and this excitation is distinctly evident in the first stage, in which the patient is much more violently excited than he would have been during the onset of pure folly. In fact, folly seems to be altogether absent at the beginning of the disease but is diffused in the manifestation of insanity, and only appears as the main component after the first storm has subsided. From then on, however, it becomes the main feature, and insanity only appears at isolated periods. All this applies to the second stage, which may last for several months, whereas the first stage lasts for one or more weeks. Unless both insanity and folly have abated in the third stage, both will be transformed into a general confusion, which will eventually end in idiocy. The signs of the disease are the result of the mixture of both its elements, so that it is possible to distinguish it from all others, and at the same time indicate its mostly unfavorable prognosticon, once the disease has fully developed. The prognosis is favorable only if lucid moments occurred prior to the complete development of the disease. The second subspecies of folly arises when folly is accompanied by rage, which is not infrequently the case. This is the raging folly (ecnoia maniaca), which is a frightful sight, almost the most frightening sight any soul disturbance has to offer. Scarcely anything more terrible can be imagined than a demented patient who is also suffering from rage. The mental life has become totally decomposed into its elements, each element acting as a destructive poison: the elements of soul activity are not bound by a common link of spirit, disposition, or imagination; each separated element destroys itself and its own sphere: the intellect destroys the order and the connection between the ideas of the real world; the will destroys whatever its destructive force can reach and disintegrate. Spiritual and physical degeneration is the sign of this evil, and it is a hellish sight indeed. For this reason there is nothing more frightening than the face and the glittering eyes of a man suffering from raging folly. There is no salvation from this kind of hell unless by a miracle. A man cannot attain these terrible depths of degradation save as a result of the wildest excesses, the greatest vices and crimes. This condition of total mental disintegration strikes men of violent, cruel, choleric temperament and also those whose sanguine temperament has drawn them into the maelstrom of perdition, e.g., into commission of a base crime. Its onset is announced by a state of extreme agitation, which soon turns to a speech characteristic of folly and to manifestations of rage, or else by a gloomy, brooding silence which may last for several days or several weeks on end, and then suddenly bursts like a storm. At first both elements seem to be present together: this is the first stage, of unpredictable duration, which is different for each patient and each set of circumstances. In the second stage folly and rage appear alternately, and this stage may persist for several years; finally, total confusion sets in, when the patient is no longer capable of violent explosions of rage. The symptoms of this disease are evident. Finally, the two forms just described may become combined together in a third subspecies: general folly (ecnoia catholica), in which folly occupies the center of the stage, while insanity and rage rise and fall at each end, like two pails at the ends of a seesaw, so that as insanity (contemplation) mounts, rage (unfree, destructive action) is suppressed, and vice versa. Though very complicated, this disease is not rare; indeed, it is so frequent just because it is complicated, for the frequency of occurrence of a form of disease of the psyche is in inverse relationship to its simplicity, and the pure forms are the most rare. Violent passions, wrongful training of the intellect, and unrestrained desires result in this disease, and their most vivid traces are also its precursors. A violent attack, during which all the elements are still fighting each other, is the first, short stage, which lasts only a few days owing to its very violence. In the second stage there is the alternation described above, which may last for a month or longer. The path of transition to the third stage is paved by the disappearance of insanity or of rage. But folly still persists when the other accompanying element has disappeared, too, and eventually settles into a permanent general confusion, unless lucid or quite lucid moments occur during this stage, and nature, chance, or medical treatment facilitate the extension of these moments to their eventual resulting in complete, lasting return to sanity. The most prominent features of insanity, folly and rage revealed in the eyes of the patient, his facial contortions, and the exceedingly tense condition of his body and soul, are here encountered together or appear in succession; therefore, if the simple features of the elements of the disease are known, the disease itself cannot be mistaken for any other. The prognosis is less hopeful if the disease is deeply rooted and of long duration.

§210. Second Principal Form of Dementia:

Craziness (paraphrosyne)

1. Specific character. Loss of freedom of the spirit accompanied by over-tension and perversion of conceptions and judgments with reference to the metaphysical world and everything therein.

2. Precursors. Religious raving and fanaticism, brooding and speculating on the abyss of human knowledge, misguided — even impure — passionate reading of the Bible, especially the tireless, persistent study of the Apocalypse carried on day and night, also misdirected research into the deepest mysteries of nature, study of the Kabbalah, etc. The more engrossed a person becomes in these studies, the more likely he is to become crazy. Such efforts result in loss of appetite, in lack of sleep, and in exhaustion; but the tension increases and is reflected by the almost beatific expression of the face, the radiance in the eyes, the convulsively rapturous smile, "as though of one possessed." But very soon the patient goes out of his mind altogether, and the disease breaks out.

3. Course of disease. The patient suddenly claims to have broken the seal of all the mysteries he sought to fathom: he knows the causes, the ends, and the middle of all things; nothing is a mystery to him any longer; he understands the Apocalypse, he has penetrated the mysteries of nature, he possesses supernatural forces; he is himself the prophet, the apostle, the messenger of the Highest. Thus, Arnold (after Granger's Biogr. Hist. of Engl., IV, p. 208) tells of one John Kelsey who traveled to Constantinople in order to convert the ruler of that city, and in fact preached at street corners, but unfortunately only in his mother tongue, which was English. Euphoria constitutes the first stage of the disease; it includes intermittent periods of tiredness and may last for a few days or a few weeks, after which a definite idea usually becomes fixed and forms the nucleus of the second stage, which may last for months or even years, unless shortened by favorable circumstances or interrupted by unfavorable incidents, when the disease changes direction and acquires a different character. If the fire has burnt itself out without the patient having recovered, a caput mortuum, as it were, of the disease remains behind: a fragmentary clinging to misconceived supernatural things, illogically conceived; the patient remains happy in his madness; at the same time, he returns to relative sanity and prudence; he remains good-natured and hard-working, except that his absurd transcendent notions persist, and that he must not be reminded of his confused rhapsodies on metaphysical things. Thus, for example, the hospital and asylum at Sonnenstein near Dresden, which in 1812 reported many cases of the forms of disease already described and yet to be described in this hook (as did the asylum at Waldheim at the same period of time), also testified to an extraordinary case of this kind, where the patient did his day's work, including artistic handicraft, played a good game of checkers, and participated in friendly conversations, but one had to be wary of raising the subject of the elements of all things or related subjects in his presence. Craziness at its peak, when it has fully flowered, characteristically becomes contagious. Arnold cites many such cases (Section HI. p. 231 ff.). Thus, a certain Coppinger, who lived at the time of Queen Elizabeth, believed himself to be the harbinger of the salvation, a certain Arthington believed himself to be the prophet of the Last Judgment, and a certain Hacket thought himself the King of Europe. When Hacket, believed by Coppinger to be the holiest man of all next to Christ, had been drawn and quartered, Coppinger's rage became total and he died of starvation; only Arthington was cured. Thomas Wenner, who expected the Second Coming to occur at any moment, persuaded a large crowd to assemble in the street and to proclaim Jesus Christ as the only king, since all human reign, including that of the usurpers Cromwell and Charles II, had now to come to an end. Similar expectations were entertained by the preacher John Mason, and large crowds, infected by his eloquence, celebrated the Coming of Christ with singing, fiddling, dancing, wildly enthusiastic commotion, and much noise. A whole family by the name of Ducartres believed that they alone on earth confessed to the true God and received instructions from Him by means of inspiration, omens, and miracles from heaven; as in Noah's time, mankind was doomed, and they alone would be saved in order to establish the Throne of God on earth.*

4. Semiotic, diasgnostic, and prognostic moments. The symptoms of craziness unmistakably manifest themselves in the look and the eyes of the patient. The gaze is intense and penetrating, with a spiritual and radiant expression. The eyes are bright and shining, and are usually raised, as is the whole head. The features and facial expressions and the movements of the body indicate penetration into the deepest mysteries. No mental patient moves about with as much dignity as a victim of craziness. His speech is measured, mysterious, full of literary expressions and allusions, all of them senseless. He likes writing or painting strange figures on paper and on walls, is talkative, and is inclined to share his revelations with everybody. This is the difference between a victim of craziness and a victim of folly or foolishness.

* Such occurrences are not rare in our own days either. They are manifestations of craziness, even though they are not usually held to be such. Exempla suet odiosa. Wherever the reason 1"Witz"] of man oversteps its natural limits, there is at least a chance that craziness rAberwitz"i will ensue ("Aberwitz" = "Uberwitz" = lit. over-reason]).

The crazy man retains a natural perception of the objects around him, unlike a victim of insanity, and his demeanor is peaceful, unlike that of a victim of rage. Since he displays signs of exaltation, the disease cannot possibly be classified under the order depression and cannot be mistaken for any mixed form. Craziness is the fruit of the most intense mental tension and bodily disintegration, and can rarely, if ever, be cured, especially if it has lasted for a long time and has become deeply rooted.

§211. Subspecies of Craziness

Craziness at its peak intensity readily combines on the one hand with insanity, when it manifests itself as insane craziness (paraphrosyne ecstatica), and on the other with rage, when it appears as raging craziness (p. maniaca). A case of the former kind was described by Tissot (v.d. Gesundsh. d. Gel., § 14) [On the Health of the Desires(? )]: a woman, who lived among the Moravian Brethren, kept seeing the Savior in person, and refused to speak except to say the words "my sweet lamb." She wasted away and died after six months. Such cases are also cited by Engelbrecht (see Arnold, Section III, pp. 235 ff.) and Swedenborg,* who have already been mentioned. Several cases of the latter kind were described by Zimmermann (Uber die Einsamkeit) [On Loneliness]. The story of the Anabaptists of Munster is rich in incidents of this kind, including one in which some thirty patients made a quixotic excursion against the besieging army in order to destroy it, a fate which subsequently became their own.** The occurrences, manners of termination and symptoms of these two forms do not require any further description.

* A mood very closely related to this disease is probably at the source of Jung-Stilling's Science of the Spirits.

** Heid Gichtel, who was described in Kanne's Leben and aus deco Leben etc. (Life and from Life, etc.J, can very well be included among these cases, namely at moments when he was overcome by the urge of self-destruction. Incidentally, this author gave us several case histories in that book without intending to do so and without knowing that he had done so.

§212. Third Principal Form of Dementia: Foolishness (moria*)

1. Specific character. Unfree exaltation of the spirit, accompanied by perverted notions about the patient's own person, to which a foreign identity, mostly that of a high personality, is attributed. The most prominent symptom of foolishness is the doubly ridiculous internal contradiction and external demeanor.

2. Precursors. Conceited, vain, proud persons, who give free rein to these tendencies and passions, acquire a very high opinion of their own worth, their qualities, and the dignity of their own person, and express these inner feelings in their entire demeanor. If, owing to external circumstances and events, their individuality is unduly suppressed, or, on the contrary is unduly elevated, changes take place in their nature which are expressed by conspicuous manifestations, and are the precursors of complete foolishness. The patients tend to excess in all things in which they presume or believe they can distinguish themselves. Eccentric clothing, surroundings, pleasures, disordered living, squandering of money, giving away precious objects (or those considered precious) as gifts, as though they were baubles of little value, all this indicates excesses, over-tension, and a tendency to foolishness, which very soon breaks out in all its strength.

3. Course of disease. The attack begins with unrestrained merriment, talkativeness, agitation, perverted occupations, or some ridiculous, nonsensical practical joke. At this stage the patient is still sufficiently conscious of his acts to believe that these doings will gain general approval and draw attention. He then soon puts forward claims about his personality, his merits, and his dignity, and informs the world at large of what and who he thinks he is. In this way emperors, kings, cardinals, generals, statesmen, or millionaires are created — in short, whatever the vain, proud, foolish heart desires; even if it is to be God Himself of a fourth person in the Holy Trinity. In the last-mentioned case of foolishness another ingredient is also present; whereof more later. The demeanor of the patient is suited to his imaginary identity. The look in his eyes, his facial expression, posture, gestures, speech, clothes, accessories, etc., all have about them something theatrical, and are intended to create an impression. The patient plays the assumed identity as though he were playing a part. This is accompanied by the highest degree of complacency. Thus the disease starts, and continues for one or more weeks, and then it enters its second stage, which is merely a continuation of the first. In this stage the patient retains his own identity, or leaves it for the sake of another, similar or related one, or else if he was still undecided in the first stage and spoke and acted as several different persons (which is not infrequent) he now decides on the part he wants to play. Or, on the contrary, he may now be everybody, whereas previously he was only some definite person. As a rule, however, this tendency to change is an indication of the decline of the disease and shows that the patient is no longer able to retain any definite form of foolishness. This condition is nearer the state of confusion, to which foolishness is usually added, and thus the third stage starts. The author of this book had occasion to observe a patient whose disease had lasted for several years and who would answer questions on his identity and position in life in a different manner almost every minute. We must add that foolishness is often not a primary disease, and its incipience is not predetermined, but is derived from previously existing melancholia, as was also noted by others, for example, Erhard, Reil. This manifestation, like many others, is a mixed case belonging to the forms already discussed, and will be discussed further in Chapter Four. In any case, foolishness, be it primary or secondary, has usually only one outcome, namely, general confusion, stupidity, and finally idiocy; cases in which it can be cured are few and far between.

The meanings of the terms moria, ecstasis, and paraphrosyne employed in this book are obviously not those used by nosologists. For example, Linne uses the word 1710ria for idiocy, Chiarugi uses the word ecstasis for melancholia attonita, while most nosologists use the term paraphrosyne to denote what we have named insanity. Nevertheless, we consider our own usage to be suitable to the subject matter, and we believe we have defined the terms used in this science of forms with sufficient clarity.

4. Semiotic, diagnostic, and prognostic moments. The cases of foolishness which have just been described are actually so many symptoms thereof. No mental patient laughs as much or is as jovial as one who is suffering from foolishness; no one is as careful of his environment, his clothes, his accessories, or of the arrangement, or rather the decorations, of his room. He has as many medals, stars, crowns, miters, scepters, and generals' batons as he needs and more. His room is a palace, and his kingdom is as limitless as his wishes. Many examples are given by Arnold and his followers. One is that of a Russian merchant by the name of Pankiwiez (Bonnet, Med. septentr.) who was King of Poland, Emperor of Moscow, Grand Duke of Lithuania, Russia, Prussia, Masuria, etc. These are the unmistakable signs of foolishness, by which it can he distinguished from any other disease of the psyche. It could possibly be mistaken for insanity, since those suffering from either disease dress extravagantly; the insane also adorn themselves, and decorate their surroundings. But this is not the gay adornment or the motley garments of the foolish; these are adornments and clothes which move us to tears and not to laughter: they are souvenirs of a lost love; they are the marks of death of the most beautiful sensations of the human heart. Let the reader think of Yorik's Maria or Shakespeare's Ophelia, whose nature was so beautifully described by Goethe (Wilhelm Meister's Lehrjahre,Vol. Ill). We have already described the usual outcome of foolishness, which is gradually increasing apathy; but a transition to rage is also possible. Such rage is usually periodic, and is preceded by periodically increasing agitation, hasty movements, irritability, and the usual signs of head congestion; or else the patient may become melancholic, but this is rare, unless melancholia was the patient's original condition. If this occurs, the jovial nature is gradually lost, the patient becomes quiet and withdrawn and gradually declines, even though he appeared strong enough before. This outcome leads to progressive wasting away.

§213. Subspecies of Foolishness

It has just been said that foolishness may pass into rage; but it may also combine with rage from its very inception; and we thus have raging foolishness (moria maniaca). The patient is no longer good-tempered, but readily becomes excited or violent, and his actions are those of one suffering from rage. He no longer decorates or adorns himself, but destroys things, and at the same time constructs distorted images in a derisive, mocking manner. A patient suffering from raging foolishness mocks at everything, abuses everything, casts everything off. Nothing is good enough for him but he himself. He attacks everything except himself. For he is sufficient unto himself and expresses this in words, mien and deeds. A patient suffering from raging foolishness is sensitive to insults, and is vindictive and resentful. Even though his freedom is lost, he can very well disguise his feelings and is dangerous. He is both sick and malicious. The disease may be mild at its inception, but nevertheless contains a germ of violence; rage soon appears and does not disappear except in cases of complete recovery, which can only happen as a result of major internal upheavals. On the other hand, foolishness may also combine with insanity, yielding insane foolishness (moria ecstatica). Indeed, foolishness very often takes this course, and this form occurs more frequently than the pure form. Here it is not merely the patient's conception of his person that is pervert, and his speech and actions are not merely a consistent chain originating from the pervert basic conception and related to it, but the outline of his conception becomes filled with living vistas, and the patient has no need to think of a scene for his disease, for he can see it in front of his eyes. Since this form of the disease is also more vivid and fresher than the former, there is also a stronger reaction of the vital force, and thus also a better hope of recovery than in the former case. Lucid moments return more easily, and once this has happened, the patient desires to bring them back even after they have become lost. Moreover, in this form of the disease the patient is as happy as any victim of foolishness can possible be. Accordingly, many of those who have awakened from this pleasant dream do not find that they have gained anything by their improved condition, but are ready to exclaim with Horace:

"poll me occidistis, amid, non sanastisz"

§ 214. Fourth Principal Form:

General Dementia (paranoia catholica)

1. Specific character. Loss of freedom of the spirit, accompanied by exaltation and fusion of the main single forms of dementia, so that traces of folly, craziness, and foolishness are found successively in the same individual. But since, as in other cases, one of the forms predominates over the others, the disease seldom appears in an indefinite, changeable aspect, but one or other of these elements becomes the main one.

2. Precursors. Vain, eccentric persons, who are inclined to brood and who reach for the greatest heights and the lowest depths, may be brought by their perverted mode of life and their vain efforts to a very tense condition, and then, for some definite reason or for no reason at all, they gradually arrive at a confusion of thoughts. The onset of this state is characterized by agitation and perversion of the entire mode of behavior, which carries an unmistakable imprint of its elements.

3. Course and termination of the disease. The first stage is more acute and more violent, as is usually the case with such outbreaks, and closely borders on rage, since general dementia can only be the result of the utmost tension, which manifests itself as violent movement: violent speech, bluster, and general interference with others. In the second stage the isolated elements of the disease appear in more distinct succession, and can be recognized by the features described above. The third stage represents a transition either to real rage or to a general confusion ending in idiocy.

4. Semiotic, diagnostic and prognostic moments. The signs of the individual forms of dementia appear in combination, at least sometime during the course of the disease, if not at any particular moment. Nevertheless, the look in the eyes of the individual affected by folly, craziness, and foolishness, as well as his facial expressions, attitudes, speech, and actions, are somewhat modified by the characteristic traits of each form, so that the detection of single, separate traits is more exacting and requires more skill than in any other form of disease of the psyche. It is this variety of features which distinguishes general dementia from its simpler forms. Its other features, namely, the sum total of its manifestations which affect the sphere of concepts and judgments and its expression in words and deeds, the mode of affection of disposition and willpower, and its general quality of exaltation, serve to distinguish it from the forms belonging to other orders. The prognosis of the later stages is determined by the course of the first stage, while the prognosis of the outcome depends on the course taken by the third stage.

Third Segment

Forms of the Order Rage (mania)

§215. First Species: Pure Rage (mania simplex)

1. Specific character. Loss of freedom, with a violent destructive instinct. The patient is conscious of himself, and does not act while being guided by perverted notions, passionate nature, or excessive tension of the imagination, but simply out of a blind desire to destroy what he is unable to overcome. Pinel must be credited with being the first to have reported this pure form as such; he was followed by others, including Reil.

2. Precursors. These will be described according to Pinel. Neglected upbringing, wrong upbringing, weakness and indulgent attitude of the parents, together with a perverse, unyielding character of the child, goad him into rage, which is unleashed by any resistance to his own supreme will, so that he destroys everything weaker than himself, for example, he immediately kills all animals who refuse to obey him. These outbursts gradually develop into true rage, the onset of which is manifested by a burning sensation in the intestines, intense thirst, and severe constipation. The burning spreads to the chest, the neck, and the face, which becomes markedly red. After the burning sensation and the redness have reached the vicinity of the temples, they are intensified, and the arteries in this part of the body pulse more strongly and more rapidly, as though about to burst. Thereafter the ailment passes into the head.

3. Course of disease. Now follows the attack of mania proper. The patient becomes t he prey of a bloodthirsty, irresistible impulse. If he can get hold of a knife, he is likely to murder the first person he sees, without sparing friends, relatives or even his own wife and children. This notwithstanding, he is not out of his senses either before of during the attack; he gives sensible answers to questions which are put to him, his thoughts are orderly, and he shows no trace of insanity or dementia. He may even warn those around him to beware, so that they can move out of his reach. But not every patient is so considerate. Thus according to Reil, a peasant had to be locked up in a lunatic asylum because of his tendency to throw stones at all passers-by. Once in the asylum, he proved to be so well behaved, so free of any trace of dementia, insanity, or rage, and was so industrious and hard-working, that he was eventually discharged. On the evening of his return home, after he had taken leave of the neighbors who had come to his house to welcome him • back, he locked himself up with his wife and children and murdered them all. An attack of this kind is usually the final stage: the patient regains his senses and experiences bitter remorse for what he has done. For this reason the disease is apt to give way to melancholia, which usually ends in suicide or another murder, most likely that of a child, for, as proved by criminal records, the patient hopes that this — being the surest way to execution — will relieve him of his suffering. The above description also indicates the semiotic, diagnostic, and prognostic moments. Pure mania is periodic, and for this reason is a refractory disease.

§216. Second Species: Insane Rage (mania ecstatica)

1. Specific character. The rage is accompanied by manifestations of insanity. The patients imagine the existence of numerous objects, and neither see nor hear anything around them; or else, like someone enchanted, they see objects with imaginary colors and shapes (Pinel, p. 159). Thus, one such patient thought an assembly of men was a legion of devils and tried to break out of his chamber in order to kill them. Another one tore his clothing and bedstraw into small pieces, as he thought they were a cluster of intertwined vipers.

2. Course of disease. The disease begins with an agitated, unrestrained mobility, with a rapid sequence of images not originating from any sensual perception, in which each successive image destroys the preceding one and is more fantastic than it. This is accompanied by violent emotional upheavals which have not been provoked by outside objects: joy, sorrow, anger, the last feeling soon becoming permanent and determining the actions of the patient. Once awakened, the excitability soon grows and turns into blind rage which persists until it has spent itself. However, the objects of this rage are always the images produced by the insane mind, and thus there is a difference between this kind of rage and its related species. Either the disease ends with this one attack, for its very violence prevents it from persisting, or if its roots are too deep for it to spend itself, it becomes periodic, or recurs at regular or irregular intervals. Recovery can be hoped for in the first case only; in the last the evil persists until the forces are exhausted, and the disease usually ends in general confusion and dullness.

3. Semiotic moments. The elements of this form of rage easily show it for what it is; for the accompanying insanity imparts to it its own color. The disease appears to be almost romantic: the patient rages, but only against his own imaginings, as if in delirium; and his condition is evident from the look in his eyes, his speech, and his movements. The wild, glittering eyes appear to be searching for something or to stare at something which is not there; the speech borders on theatrical, pathetic rage, somewhat attenuated by the participation of the imagination. The disease is thus easily recognized, and can readily be distinguished from other forms. For the prognosis see paragraph 2 above.

§217. Third Form: Rage Accompanied by Folly

(mania ecnoa)

1. Specific character. The patient rages, but does so with reason; only it is a perverted reason; senseless arguing is the characteristic feature of this form of disease. There are, however, exceptions, for many a patient reveals great acuteness, even humor, but this humor combined with his actions, becomes folly. An example is the patient who delighted in breaking the window pane of his room into small pieces and throwing the fragments into his neighbor's backyard. When he was asked not to break the window, he answered that he was only throwing the glass fragments out. Individuals suffering from this kind of mania are usually very sensitive, are easily offended, and lose their temper at the slightest provocation.

2. Course and termination. This evil most often affects individuals of choleric temperament combined with a sharp intellect, who are not masters of their temperament, and who despite all their education have never learned to restrain their wild impulses, and suddenly fall prey to attacks of temper or rage as a reaction against an insult or a bad injury which cannot be immediately avenged or expunged. They initially release their frenzy in speech, and still reason even when they act in the wildest manner. This behavior lasts throughout the first stage, which, incidentally, bears the greatest resemblance to pure rage. In the second stage the patient is generally more irritable and quarrelsome; the original cause of the irritation seems to have been forgotten, and the rage is mostly displayed as agitated movements, while the folly keeps appearing as its biting, arrogant, mocking, disdainful self. Thus, the disease passes to its third stage, when the storm gradually abates and the senses return. The Calvary of the patient thus lasts three, four, or five weeks, after which he is cured for ever; or else the attack is temporarily over, but keeps recurring in response to new stimuli, and eventually becomes periodic. Or, if the malady is too deeply rooted, and the injury inflicted too severe, the patient does not recover his right senses at all, and the disease becomes chronic in an attenuated form. Such patients are very numerous and many of them have been described by Pinel. Arnold also described such cases, for example (Section III, p. 130) several examples of true lycanthropy (from Wierus, De praestig. daem.), which cannot be classified as either insanity or melancholia, but only as that form of rage which we are discussing. First case: at certain seasons of the year a man thought that he was a rapacious wolf and roamed through forests and caves in pursuit of his victims, mostly children. Second case: a day laborer at Pavia thought he was a wolf, and attacked and killed people in the fields. He was finally captured after much difficulty. He firmly believed and proclaimed he was a wolf, except that "his fur was turned outside in." Here is a characteristic sign of rage combined with folly!

3. Semiotic, diagnostic, and prognostic moments. In its initial stage the disease differs from its later stages in that the excitation which first occurs contains elements of both folly and rage and externally resembles the delirium in high fever in its vividness. This differs from the later picture inasmuch as anger differs from irritation, so that the initial symptoms are those of wildness and the later ones more those of irritation. However, traces of the disturbed reason keep breaking through. This is the difference between this form and that of folly accompanied by rage, where the elements are in reverse proportion and the dementia of the intellect is the main feature of the disease. These characteristic traits make it easy to distinguish rage accompanied by folly from the other forms of rage, and from other diseased conditions of the psyche. Lucid moments, if observed during the early stages of the disease, say after the first 8 or 14 days, are a good sign; but if there are no lucid moments and the disease persists, there is little hope. If after an indeterminate interval the disease returns, we have a periodic type of the disease, which continues to develop. However, I myself have seen a case in which the disease kept recurring, almost always at the same season, but which nevertheless ended in complete recovery.

§218. Fourth Form: Common Rage (mania catholica)

1. Specific character. Persistent rage and audacity with almost insurmountable strength, every sign of a highly passionate, excited imagination, and at the same time total confusion of the intellect. Since this form is also the most fully developed, the most complete, and the most common one, we shall describe it in more detail.

2. Precursors. In persons who have a strong, stable constitution and a vigorous temperament but whose moral life has gone astray, perverted thinking, feeling, and action finally exact their toll. Hell opens its gates, and the heartbreaking feelings, the glowing, black images, or, rather, distorted masks it evokes, race in front of the excited imagination; the urge of destruction is the only motive power of such souls, which are sick to their very roots. When this urge stirs, the disease sets in with restlessness and continuous insomnia.

3. Course of disease. (This description is partly taken from the excellent description by Chiarugi.) First stage: intractable, quarrelsome, insolent, brazen demeanor; wild, menacing appearance. Natural evacuations are arrested; the skin becomes flaky, the forehead wrinkled, the eyebrows rise, the hair appears to stand on end, and the patient becomes short of breath. The face begins to glow, the eyes appear to emit sparks, rove about, and cannot rest on a single point; the eyelids open and shut periodically, and the eyeballs protrude from their sockets. The patient can go for long periods without food and is insensitive to cold. If he can sleep at all, his sleep in short, restless, and light. Second stage: rage, boldness, and unreason develop to their fullest extent. The patient screams, rants, rages, and offers insults and bodily injuries to his dearest friends or relatives whom he now regards as enemies. He tears up his clothes and destroys or plays havoc with everything that comes to hand. A characteristic feature of the disease is the desire to walk about stark naked. Whoever disturbs the patient is insulted or struck. This is accompanied by extraordinary, confused imaginings, and sweeping, nonsensical statements. The patient may become quite still or may mumble as though he were entirely alone, or may speak and gesticulate when alone, as though he were in company. If, for the sake of their own safety and the safety of others, such patients are fettered while at the height of their attack, nothing is more malevolent than the satanic grimaces on their face. After they have screamed themselves hoarse, they refuse all food, but take drink. After a few days their appetite returns and becomes like that of a ravenous animal, and they greedily devour everything, including, as has been repeatedly observed, their own feces, which is excreted in abundance, black and stinking, and they may dirty their clothes and their room with it. Despite the physical and mental strain, the strength of the patient seems to increase every day. He is able to break the strongest bonds, including chains; his limbs become remarkably elastic and agile and can execute movements which are contrary to nature. The author of this book saw a woman who was put in a straitjacket and strapped to her bed as though she were a baby, and who nevertheless managed to slip out of these double bonds with the greatest dexterity. These patients, though foolhardy and daring, are generally, but not always, intimidated by a strong, menacing voice, by the sight of a stick, and by rigid, though harmless fettering. Once their rage has spent itself, they become quiet and gloomy, and seem to think or brood over something, but may have another attack at any moment. Finally, the third stage sets in. The violent outbursts cease, and are followed by exhaustion and uneasy sleep which is disturbed by frightful nightmares. The pulse becomes weaker, the entire body becomes dirty-looking, the face becomes leaden and drawn. The patient maintains a stubborn silence, or else sings and laughs in a most peculiar manner, or keeps up an unceasing stream of talk. These uncertain pauses, which may be said to have something of idiocy in them, are frequently interrupted by attacks typical of the first stage, but these are short-lived. The memory of the patient is retained at all stages of the disease (a patient who recovered described to the author of this book all the scenes of his frenzied dreams and confusions). At the peak of the disease, all the senses acquire a greater fineness and sharpness. It has also been repeatedly noted that such raging patients are never infected by epidemic diseases, and seldom by an infectious disease; nay, according to the observations of Mead and others, consumption, dropsy, and other chronic diseases disappear with the outbreak of mania. Unless the patient is freed from his evil by recurring attacks of a physical disease, for example, a series of fever paroxysms, one of the following will happen. His forces may become exhausted to the point of complete idiocy; or else idiocy becomes an intermediate condition, which is periodically interrupted by attacks of mania, resembling the eruptions of a long quiescent volcano; or else the patient sinks into melancholia or general confusion, which is interruped by attacks of mania; or the mania becomes chronic and never leaves the patient, but his senses and reason seem to be fully reestablished. Twenty-five years ago, the author had occasion to see a woman pounding her chains against a stone floor, on which she sat in a state of the greatest neglect, day and night, year in, year out.

§ 219. Semiotic, diagnostic, and prognostic moments. The frenzied behavior which persists throughout the disease, or which keeps breaking out again and again, is an indication of the genus of the disease, while its apparent features are signs of both insanity and dementia, the components of this particular form. While such raging patients may occasionally behave as though suffering from foolishness, the disease cannot be classified as foolishness, but in accordance with the form which persists and is its main feature. Even if in the course of the third stage such patients appear to be sunk in idiocy or melancholia for long periods of time, we cannot presume that a change in the nature of the disease has occurred, for the mania may break forth anew at any moment, and thus reestablish the original character of the disease. It is only when a condition of idiocy or melancholia becomes habitual, and there is no return of mania, that we can speak of such a change. If one of these cases in fact occurs, that is, if the mania becomes periodic or passes completely into idiocy or melancholia, we may be sure that the disease is incurable. Nevertheless, it was noted by Pinel and others that the principal attack of the disease followed by recovery may take place even after several years, after the disease has become deeply rooted. In general, we can state that this form of mania, even if its course is regular, is often interrupted during its second or third stage by a principal attack followed by recovery, much like recurrent fever. The lucid moments which sooner or later always appear in this disease are its typical feature, but no more determine its course than an intermission between successive attacks of a recurrent fever.

§220. Subspecies, varieties, and modifications of rage

Not all the forms which are listed by various writers under mania do in fact belong to this genus, as already pointed out with reference to daemonomania and erotomania [erotomania], since these forms do not bear the character of rage, but rather of insanity. Even melancholia itself, of which we shall very soon speak, has been wrongfully classified by some under mania. Not even ranging melancholia (mania a pathemate, Sauv.; melancholia ferina, Mercurial.) is a variety thereof, but will be assigned its proper place later in the book. Nor are the following varieties, which were described by different writers as:

1. mania cum hallucinatione melancholica;

2. lycanthropia et cynanthropia;

3. mania cum rise, cum studio, cum tristitia

true varieties: they are mixed forms. The distinctions made by the nosologists between the different kinds of mania according to the very numerous factors affecting them, finally, do not give rise to subspecies, etc., but to the forms themselves; otherwise, we should consider Chiarugi's mania mentalis, m. reactivae, m. plethoricae, m. immediatae, and m. consensualis, and other nosologists' and practitioners' mania ab animi contentione, a quartana, a venera, a febre autumnali, a frigore, a mercurialibus; a retentis menstruis, or m. puerpericae, lacteae, metastaticae, temulentae, etc., as species or subspecies, too. For it is only the persistent symptoms that can determine genera, species, and subspecies. Thus, only the following manifestations, which substantially affect the form of the disease, can be considered as belonging to this group.

I. Mania continua acuta. This disease is full development of rage without interruption, of short duration, in strong subjects. The disease spends itself, which is conducive to recovery, but we must not presume that it is similar to raging in fever, or to attacks of rage produced by ingestion of poisons or occurring after a strong delirium, etc., as none of these is a form of the disease proper.

2. Mania continua chronica. This may also be called frenzy*; the patient executes the same noise-producing motion, such as hammering, for years on end. This is no original form, but is the result of true mania, and is incurable.

3. Mania periodica. This form of the disease often appears if there is heriditary predisposition. The periods are largely determined by menstruation, a tendency to hemorrhoids, change of season, and changes of the moon. Since the disease is periodic, it is always difficult to cure, or may be altogether incurable.

4. Metromania (not furor poeticus but furor uterinus); mother mania; also nymphomania, which is an almost raging libidinousness in women and which may become rage (Vogel, Nosol.). The disease has many stages, or degrees, of which the highest is rage. (See a very detailed and exact description of the disease by Bienville: On Nymphomania. Translated from the French, Vienna, 1782. The fourth and fifth chapters describe cases and symptoms.)

5. Satyriasis, which is the same disease affecting men (Vogel, Nosol.). Both these forms have often been attributed to purely bodily causes, but if intensified to actual rage, they are always the result of a corrupt life, even though the morbid irritation of the sex organs is also a determining cause. In monasteries and convents there are numerous examples of both forms. The disease of the women often becomes epidemic (melancholia milesiaca, Sauvages). But this is definitely not melancholia in which indiscriminate destructive impulse predominates!

* [In German: "Tobsuclit."]

6. Melancholia saltans (Sauvage). This is not melancholia either, but a savage impulse to dance and jump. Schenk (obs. med. rar. Lib. I, ohs. 8) maintains that this form assumes epidemic proportions, both in Germany and elsewhere. It attacks people in all positions in life, but mostly sedentary artisans, and members of the lower classes. Cobblers, tailors, peasants, etc., throw off their clothes and dance without rest until they die of exhaustion, or until they are forcibly restrained. Some of them find their death by a- fall on the rocks, while others are known to throw themselves into the Rhine or other rivers.

Chapter Three

NOSOGRAPHY OF THE SPECIES OR FORMS OF GENERA OF THE SECOND ORDER

First Segment

Forms of the Genus: Melancholia (§ 194)

§221. First Species: Pure Melancholia (melancholia simplex)

1. Specific character. Paralysis of the disposition, that is, loss of freedom of the disposition accompanied by depression, withdrawal into oneself, and brooding over some loss, death, pain, or despair. Restless, anxious, rapid movements, or a fixed stare. The patient is insensitive to everything except the interests of the fettered disposition; he sighs, weeps, and laments.

2. Precursors. If the temperament of a person is melancholic, from which the name of the disease is taken, or if it is sanguine or phlegmatic, joy is missing from the former state and excitement from the latter; then in general, if there is no resistance in the disposition, or if there is depression due to a serious loss or the fear of a loss, with the resultant grief, the person gradually becomes quiet, withdrawn, secretive. He loses appetite and sleep, loses weight, becomes shy and fearful or suspicious, withdraws from the company of his friends and acquaintances, is reluctant to go about his usual business, and gradually sinks deeper into his gloomy broodings; and thus the disease overtakes him.

3. Course of disease. The first stage may be different for different individuals. It may begin with a kind of dumbness or rigidity. Other patients appear to be developing mania, others again insanity, yet others foolishness. This is because after freedom has been completely lost, some are vehement, quarrelsome, and ever ready to fight; others are lost in daydreams; still others are very merry and make ridiculous gestures, etc. But soon the true aspect of melancholia becomes apparent: the savagery, the dreams, the laughter disappear to be succeeded by depression, withdrawal into oneself, sadness, and weeping. The patient may sit in rigid silence, or may mutter to himself, utter deep sighs, weep, wring his hands, while utterly ignoring everything around him; he can hear no voices, not even those of his best friends, so much is he lost in brooding over the object of his suffering. This stage may last indefinitely, or for a week or two, or even for more than a month. Finally the fit, which has thus attacked the disposition, seems to have passed, the patient appears to be on his way to recovery, and the second stage begins. The patient again becomes partially receptive to what is going on around him; he answers questions which are put to him, but his answers tend to be brief or monosyllabic; he takes some food and seems to be generally more at peace, except for restless nights, which he spends tossing about in his bed. What ails him now becomes clearer, for he now loudly bewails the object of his loss or his sorrow; but this object soon becomes the only point around which all his thoughts and his speech revolve.

This may be the appropriate place to correct the current conception of idee fixe. For it is indeed a so-called idee fixe which burdens the soul of the patient. Thus, the author has under his daily observations a woman who keeps lamenting the misfortunes of her husband and children, sighs and weeps, and considers herself to be the most unfortunate person on earth, for whom no help is possible. In fact, her husband and children fare very well indeed, especially since they have been liberated from the presence of this nag, who never left them a quiet moment. Now it is obviously nonsensical to keep brooding on the imaginary misfortunes of others; but the question is if the true origin of fixed ideas is indeed the intellect, as many are wont to believe. We say: no! In our view this is the false idea which humanity has held for several hundreds of years, and which it still holds, namely, that the origin of the false notions of patients suffering from melancholia, which are just that and nothing more, is being erroneously attributed to the intellect. Here the intellect is not at fault; it has not strayed or lost itself in meditations or speculations. It is the disposition* which is seized by some depressing passion, and then has to follow it, and since this passion then becomes the dominating element, the intellect is forced by the disposition to retain certain ideas and concepts. It is not these ideas or concepts which determine the nature and the form of the disease; the presence of an idee fixe does not mean that the disease is an affectation of the intellect; the intellect is a mere servant of the sick disposition, and for this reason any definition of melancholia which states that its nature lies in the idee fixe is altogether erroneous. The idee fixe may or may not be present, or at least may not be apparent, but melancholia still remains what it is: depression of the disposition, withdrawal into oneself, detachment from the external world, without interest in anything better than this world. For this last would be the most perfect state, whereas melancholia is the most miserable one. But let us return to the description of the disease. We have said that in the second stage the receptivity to external effects becomes partly restored. This means that the senses become reawakened and the reason is again active, but the disposition remains fettered; and the loss of freedom remains as before, for the life of the patient revolves around the one object which has enslaved the disposition, so that this object is an idee fixe of the patient, who keeps thinking about it and is drawn to it as though by the force of gravity. The patient may remain in this condition for years, unless a favorable revolution takes place in the bodily organism, or another favorable incident occurs, or else the fetters are broken by true medical art and the disposition regains its freedom. If none of this happens, the patient who can carry the burden of his own condition no longer sinks into foolishness, which eventually becomes silliness; or the pressure in his inner soul makes him sink into dullness and idiocy; or else he may waste away. Thus pure melancholia progresses and ends.

4. Semiotic, diagnostic, and prognostic moments

a. Semiotic moments. The typical signs of melancholia become evident only after the disease has properly developed, but then they become prominent. The disease is clearly identifiable by the look and eyes, facial expression, posture and movements. The look in the eyes is dull and distracted; it is not fixed on anything external, indeed, tries to avoid resting on strange objects. The eyes are sunk, and stare ahead or at the floor. The face is pale or gray, the skin faded, the cheeks hollow, the features deeply furrowed by sorrow; the head is sunk forward or inclined to the side, the chest is hollow; the breathing is heavy, the heartbeat and pulse are faint and slow. The patient often wrings his hands; he may stand still as if petrified, or may walk restlessly to and fro. (The author of this book had the opportunity of observing such a case of melancholia: a woman who believed she was unworthy of daylight kept tripping with closed eyes to and fro in a narrow circle.) The patient may be perfectly silent, or he may speak, with much sighing and lamentation, of the matter which oppresses him — his "heartbreak" as the English call it — being, for example, that God has forsaken him. He spends sleepless nights, tossing about on his bed, and the next day it is the same with him as on the previous one.

* Or is this expression too provincial, too vague, too abstract, or even too unnatural and artificial to be still synonymous with the picturesque word "heart"? Should we then cease placing sorrow and grief, joy and hope, in the disposition? Wherever else should we place them?

b. Diagnostic moments. The character of depression, which is displayed by this form of the disease in all its stages, distinguishes it from all forms in the order of exaltation, while the simplicity of its symptoms distinguishes it from all complicated forms.

c. Prognostic moments. As the disease becomes more prolonged, the conviction of misfortune becomes more deeply rooted in the disposition, the condition of the patient approaches more closely to foolishness, stupidity, or idiocy, and there is less hope of recovery. But if the behavior of the patient becomes quieter, and he eats and sleeps more, or gains weight, the outlook is more hopeful. Even the ancients knew that a return of previously suppressed hemorrhages or of periodic fever is a good sign.

§ 222. Second Form: Melancholia with Idiocy (melancholia anoa)

1. Specific character. The signs of melancholia are general and permanent dullness, depression, deep thinking, and brooding.

2. Precursors. Naturally fearful persons, persons who are timid, weak, easily shocked, easily depressed, and unable to stand on their own feet, with education or intellectual activity, and who have been constrained by unfortunate circumstances, may fall prey to a paralysis of the disposition (of the senses but not of the sense organs) and of the intellect if exposed to a strong sudden pressure, or to a pressure which is milder but more persistent. This condition is preceded by general restlessness and anxiety, weeping, trembling, uneasiness, and total absence of mind.

3. Course and termination. The outbreak of the disease which follows the suffering just described seems to evoke some kind of reaction in the first stage. The patient churlishly pushes away everything that comes near him, and may strike those wishing to help him. His face becomes flushed and there is a strange glitter in his eyes, as though an attack of mania were impending. Or else he may become talkative, laugh, sing, and talk nonsense, as though he were about to become demented. But soon the excited irritability of his weak nature becomes exhausted, the patient returns to dull brooding, which is the more intense the more excited he initially was, and after a week or two the disease passes into its second stage. The main character of the disease becomes established: the patient becomes more and more withdrawn, more and more indifferent, more and more insensitive. Nothing excites or affects him any more; he complains no longer, but keeps senselessly staring ahead, and is unwilling to be active in any way at all. He prefers to sit or lie, and spends his days in a kind of catalepsy. In the third stage, which may arrive within four, five, or six months, he recovers some kind of automatic life; he walks about again, and can be made to do certain mechanical jobs, but he does everything half-heartedly, spoils more work than he can complete, soon gives up, and remains sitting in a kind of infantile idiocy. In this way he spends the remaining days of his life, which has exhausted its motive force.

4. Semiotic, diagnostic, and prognostic moments. When melancholia is manifested by brooding and staring ahead at a fixed point, the element of idiocy in the disease is expressed by the dull physiognomy and by the weak, infantile nature. These two traits distinguish this form from all others, and it is exactly owing to this union between the depression of the disposition and the depression of the intellect that the prognosis is bad.

§223. Third Form: Melancholia with Apathy (melancholia aboyle)

1. Specific character. The symptoms of melancholia are accompanied by a total paralysis of willpower. The patient keeps his reasoning powers as far as this is possible with his oppressed disposition, but he is unable to make a decision and carry it out. For this reason he seems numb and immobile, while remaining reasonable.

2. Course of disease. The disease has no precursors, for it breaks out suddenly, after some occurrence which has deeply affected the receptive disposition, and to which no resistance is offered, since the patient did not acquire inner resistance at any previous time in his life. Persons who care for nothing but external things, and are fully immersed in them, may be so moved by a misfortune or by a terrible happening that their disposition and willpower become numb. This is the beginning and also the actual nature of this disease. What has been described by different writers as melancholia attonita is its first stage. The patient behaves as if thunderstruck; he cannot grasp this monstrous force which has just shaken his disposition; he cannot stir or move. He remains in this condition for several days, unless some powerful remedy brings him back to sanity. An example is a young man who became victim of melancholia attonita on hearing that his beloved wanted to marry someone else, but came out of his numbness on being assured that she had changed her mind. If no such help comes, the patient slowly comes back to his senses and is aware of what has happened, but his disposition remains fettered to his misfortune, and his paralyzed willpower prevents him from taking any action. The usual motives of daily human occupations: desires, reasoned objectives, needs, nothing is able to move him, or to make him as much as lift a finger. This is the second stage, which may last for years. Eventually, he becomes dull and imbecilic. Pinel, Arnold, Chiarugi, and others related cases in which the disease passed directly from the first stage to the stage of idiocy.

3. Semiotic, diagnostic, and prognostic moments. The signs of the first stage of the disease, after it has developed to its full strength, are always the same: the patient remains sitting, standing, or lying just as the disease attacked him, motionless as a statue, with his eyes rigidly fixed on one point. He cannot see or hear; he does not resist anything that may be done for him, for his capacity to react is extinguished. In the second stage there are signs of melancholia, evidenced as a dulling of the disposition, accompanied by paralysis of willpower, even though the patient is again conscious and can move.

Signs of general apathy indicate the final stage. In the first stage this form is distinguished by its typical features, in the second by the apparent reasonableness of the patient combined with lack of all feeling or activity; the signs of the third stage are the same as those of the outcomes of many other forms. Unless full vital activity returns in the very first stage, the prognosis is always bad.

§224. Fourth Form: General Melancholia (melancholia catholica)

If a permanent paralysis of the senses and of the intellect is associated with the form just described, we have the form of general melancholia which is rare, and seldom lasts for very long. It very soon ends in complete idiocy, or in death by apoplexy. §225. Subspecies, variations, and modifications of melancholia

It may be surprising that a tendency to suicide is not found among the symptoms of melancholia in its main forms, since nothing is more typical of melancholic persons than a tendency to self-destruction. But just because it is typical, it is not an impulse of affected disposition, but belongs to the capacity for action, that is, to willpower. Wherever this tendency is present, the disease is part of the third order, under which it will duly be described as melancholia taedium vitae or melancholia anglica. Thus, it cannot be included in the group now being discussed. This group includes only:

1. Homesickness (nostalgia). Its entire character is that of pure melancholia, except that it is modified by a definite object.

2. Religious melancholia (m. religiosa; Sauvages, spec. 3; also known as m. superstitiosa or aesperatio aeternae salutis, Willis). This form is also determined by its object, and does not differ from pure melancholia in any other respect, unless accompanied by a tendency to suicide or murder, in which case it properly belongs to the third order.

Second Segment

Forms of the Second Genus: Idiocy (anoia)

§226. First Form: Pure Idiocy (anoia simplex)

Specific character. The senses, especially the higher senses, cannot comprehend or grasp, and the intellect cannot collect any ideas from the sensations. The spirit is quite empty and is merely vegetating. The animal feelings and instincts, such as hunger or the sexual instinct, are, however, stronger, and the patient can easily be excited into anger, which may become rage. This is cretinism, which is congenital. This cretinism, like any innate idiocy, is caused by imperfect, immature development of the brain, evident as imperfect skull formation. It cannot be the subject of our considerations, since we are dealing with disturbances of soul life, and not with soul lives which have never begun to exist. The individual must possess the preliminary qualities which make him human, that is, consciousness and capacity for freedom, before a disturbance of these higher conditions of life can become possible.

§227. Second Form: Idiocy with Melancholia (anoia melancholica)

1. Specific character. Weakness of power of recognition, inability to retain ideas or make judgments. Nevertheless, the patient is aware of his own condition and bemoans, with much sighing and complaining, his said lot, the reason for which he does not know, since he does not understand himself. This is accompanied by ceaseless though purposeless activity, in order to prove that there is at least the willingness on his part to be active.

2. Precursors, course, and termination. When the intellectual powers are limited by nature and the efforts toward spiritual activity, especially of the memory, are forced from the outside or by the patient himself, total dullness ensues. The patient can no longer concentrate, forgets what he himself or someone else has said a moment ago, cannot understand the simplest ideas, and finally loses all intellectual freedom. But the feeling of discomfort produced by this condition and of being despised and rejected makes the patient sad and depressed; he becomes shy of people, withdraws into his own loneliness, in which he occupies himself with his own person, and finally becomes like a child, who now laughs, now weeps, and spends his life in childish games. Such persons may live to a very old age. Haindorf saw one of these unfortunates in the asylum at Wiirzburg. This man was born mentally retarded, but was forced by his narrow-minded parents to study theology, even though obviously incapable of fulfilling any clerical duties. As a result of the reproaches of his parents and out of grief over his own inability, he became victim to melancholic idiocy, and at the age of 78 years still inhabited the asylum where he had been for over 40 years.

3. Semiotic, diagnostic, and prognostic moments. The weakmindedness, the simplicity, the dullness of such patients is clearly evident in their looks, their features, and the expression on their faces, their posture, movements, and speech. The look is lusterless, dumb, and dull, the features slack, the facial expression blank, childishly silly, often tearful, the appearance neglected, the movements awkward and purposeless, the speech childish, without any sense or meaning. In the initial stage gloom and depression are evident in the facial expression, in the lamentations, sighing, and weeping, and the entire frightened attitude of the patient; but these admixtures of melancholia disappear in the course of time. This association of melancholia with idiocy in the first and second stage of the disease, before the former is lost in the latter, constitutes the difference between this and all other forms of idiocy, and also between it and all other diseases of the psyche. Prognosis can only be favorable before the disease has fully developed. The author was able to save a victim of this disease, a young man with a naturally limited intellect who had become weakened by onanism and by futile intellectual efforts, whom his parents had destined for the ministry. After the young man had already sunk into the blackest depression and total weakmindedness over the failure of his efforts, the author succeeded in diverting him from his mistaken profession and in directing him on a path more suited to his condition. Recovery was complete.

§228. Third Form: Idiocy with Apathy (anoia aboyle)

1. Specific character. Weakness of senses and of the mind combined with inability to act. Owing to the absence of willpower, the patient does not move or speak, his mouth hangs open, and his eyes stare blankly. Unless he is forced to work, the patient will remain in a lying position at the same spot the whole day long.

2. Precursors, course, and termination. Although it is a separate form, which differs from all other forms, this is usually no primary complaint but a disease which has arisen as a result of earlier soul disturbances of another kind. Even though it may occur in a milder form among common people of the roughest kind, living almost on an animal level, people whose soul has been neglected through lack of any education, it is encountered in its full development only as caput mortuum of previous soul disturbances, mainly chronic frenzy, especially if the treatment for the frenzy was harsh and tyrannical. Lunatic asylums are full of patients suffering from this disease. We have said that its precursors are chronic, periodic mania, stubborn insanity, and dementia. A transition from these forms into idiocy with apathy is to be expected if the patient gradually becomes more quiet and relaxed. At first there is still some mobility, and the previous morbid activities of the psyche are replaced by general confusion, which in turn becomes complete idiocy, while the mobility is transformed to pure idleness, as described above. The patient may live on in this condition for many years until the organs of vegetative life are also used up, when he usually dies of consumption or apoplexy. The symptoms of the disease have been adequately described in the section on its specific character, and no prognosis is necessary.

§229. Fourth Form: General Idiocy (anoia catholica)

1. Specific character. Loss of freedom of the entire life of the psyche because of low vitality; dullness of the senses and understanding, loss of memory and of imagination, or weakness of both, at an infantile level; lack of receptivity to anything affecting the heart; inability to act.

2. Precursors, course, and termination. Either the disease arises suddenly, through great shock, as related by Pinel in the case already cited, where a man man became completely idiotic at the sight of the sudden death of his brother, while the third brother also fell prey to complete idiocy on seeing what had happened to the second brother; in such cases there are no precursors. Or else, the disease follows other highly debilitating diseases, medical administration of large amounts of mercury, or may be the final result of masturbation, etc. In such cases the precursors include weakening of the memory and power of judgment, weakness of the sense organs, inability to grasp several successive ideas, vertigo, fainting fits, fanciful thinking, attacks of epilepsy, and partial paralysis. Or else, the disease may be the result and the symptom of senility (amentia senilis in its highest degree), in which case the precursors are increasing dullness of the senses and the understanding. Such amentia senilis, unless it appears at a very old age and thus is no disease at all but a natural result of a long life, must also be considered to be the consequence of an unnatural mode of life. In all these cases increasing weakness is accompanied by an increasing intensity of the general idiocy, and the disease can only end in wasting away and death.

3. Semiotic, diagnostic, and prognostic moments. A dumb, blank, exhausted look, pale complexion, flabby features, expression of complete soullessness on the face, slack posture, idleness, obvious lack of any feelings, all these point to complete idiocy. In this way idiocy can be easily distinguished from the other species and forms of disease of the psyche. If the disease was caused by fright, the prognosis is favorable only if effective help is administered in good time; if the disease follows other diseases or excesses, the prognosis is favorable only if the constitution of the patient is strong, his living conditions are good, and the help given is beneficial. Finally, old age is itself an incurable disease.

§230. Subspecies, etc. of Idiocy

Idiocy has been subdivided into several grades for the purposes of forensic medicine. The description of these fine differences must be credited, in the first place, to Hoffbauer (Die Psychologie in ihrer Anwendung auf die Rechtspflege, etc. [Applications of Psychology in Law, etc.], Halle, 1808). However, these grades do not constitute individual forms, which might be regarded as subspecies; neither are stupidity, silliness, naiveté* to be counted as subspecies, etc., of idiocy, unless accompanied by a true loss of freedom. We shall accordingly content ourselves with reliable determinations and symptoms of the main forms, and leave this category unlisted.

Third Segment

Forms of the Third Genus: Apathy (abovlia)

§231. First Form: Pure Apathy (abulia simplex).

1. Specific character. The patient retains his sensations and his consciousness; understanding and intellect are neither unnaturally excited nor depressed or dulled, but the patient is completely idle due to his lack of will. The will of the patient is fettered; the patient has lost his freedom of will.

2. Precursors, course, and determination. Excesses and the results thereof and bad luck which oppresses the disposition produce a melancholy mood, which is not intense enough to become true, deep melancholia, but may last for several weeks or months, and after it has eventually disappeared it leaves a condition described above as "residue." The patient cannot be brought to any kind of activity; he is perfectly happy to stay in bed the whole day, does not move and does not speak, even though he is in full possession of his senses. Coaxing, begging, threatening are of no avail; the patient has lost his willpower. He may remain in this condition for days, weeks, or months, a burden to others and to himself. He would probably kill himself if he could only make a decision to this effect. Eventually even the mechanism of the vegetable life fails; cachexia with its inevitable results develops, and the patient wastes away and dies, the last period of his life being spent in general dullness. It is only rarely that the condition of apathy, once it has become habitual to the patient and has destroyed his vital forces, can give way to vital activity; the utmost that can be expected is for the patient to again execute automatic motions. He does not want to do what is required of him, but neither does he resist; he can be bent like a piece of lead.

3. Semiotic, diagnostic, and prognostic moments. The general aspect, posture, and movements of the patient are the indications of his condition. His eyes are lifeless, his face expressionless and blank, for all inactivity makes for dullness. His deportment is slack and negligent, his movements slow and hesitant. It often seems as though he does not know whether to walk or stand still. His entire being bears the imprint of hesitation, or rather of his inability to make a decision. In this characteristic trait lies the difference between this form of loss of freedom and all other forms which do not show these symptoms: for if the patient but willed, or were able to will, he would be sane. A return of a more happy and lively expression in the look and the face is a good sign, but one which is met with only infrequently. If this occurs after the disease has lasted for a short time, a return to complete life may be hoped for. Dullness and cachexia indicate the worst possible outcome.

* [In German: "Duminheit, Albernheit, Einfalt."]

§232. Second Form: Apathy with Depression (abulia melancholica)

Specific character; course of disease; symptoms. The most conspicuous feature of this form is, as before, apathy with all its symptoms; but it is associated with depression, sadness, sighing, and weeping. This form is manifested by persons of a delicate, sensitive disposition, without powers of resistance, after the storms of life have thrown them to the ground and paralyzed their forces. Apathy is the first symptom to become evident, and it is mainly the consciousness of his inability to act that depresses the patient. The depression gradually gains the upper hand and the patient sinks into complete melancholia, in which despair frequently takes the place of willpower and drives the patient to suicide. If he does not commit suicide the patient gradually wastes away. His looks, facial expression and movements betray weakness and sorrow. His entire demeanor indicates mental exhaustion, but as in the first form, this never occurs without some fault of the patient committed in the past. This form is distinguished from pure apathy by the presence of traits of melancholia, and is distinguished from pure melancholia by the absence of a complete withdrawal of the patient into himself, since the pain over his inability to act maintains his disposition in constant stimulation. Unless very favorable incidents occur before the disease can take strong roots, the prognosis is bad. But if the depression gradually disappears, and the features of the patient are seen to brighten, we may hope for a renewal of the vital forces and the joie de vivre; if depression seems to gain the upper hand, the opposite is to be expected. Finally, the patient's condition becomes what Auenbrugger named "quiet fury" (cf. Auenbrugger, Uber die stille Wuth [On the Quiet Rage], Dessau, 1783; third and fourth case history), where the patient exclaims: "I am lost, nothing can help me any more," and gives himself up to despair.

§233. Third Form: Apathy with Idiocy (abulia mum)

If paralysis has affected not only the willpower but also the spirit, we have apathy with idiocy, but the last must not be the main state, for such a form would belong to the second genus. The disease is the result of the spilling of semen. The patient is no longer able to think, and his senses are bound by the compulsion of external objects and their stimulating effect on masturbation, to which the patient surrenders himself without offering any resistance. He is totally indifferent to all other matters.

§ 234. Fourth Form: Apathy with General Depression of the Psyche (abulia catholica)

The form in its pure state can be observed only in the so-called melancholia attonita, which is a disease in its own right. The inability to show any mental reaction is its basis.

Chapter Four

NOSOGRAPHY OF FORMS OF THE THIRD ORDER

§ 235. Introductory Observation

If we may consider man, that is, his soul, as a small world, we may also call his thoughts, sensations, and desires the inhabitants of this small world, and just as in the world at large, these may be well-shaped or misshapen. It has been seen that observation has so far rather inadequately surveyed the realm of these spiritual monstrosities and separated all the individual monstrosities. It is the large masses, the compiled complex groups of morbid manifestations of the psyche, which have attracted the main attention and guided the hand of the painter. We, too, shall proceed to deal with these groups, since they admittedly occur most frequently, but at the same time shall stress that they cannot be properly understood or appreciated unless the eye has previously become accustomed to the simple forms, which do in fact appear alone without any admixtures, but not as frequently, since they most often appear as constitutent traits of a larger picture. Certain physiologists consider that the entire organism consists of individual vital faculties; in the same way we might say that the complex forms of diseases of the psyche are composed of many simple forms, each of which has its own shape and its own existence, but happens to be subordinate to a greater whole in any particular patient. The forms so far discussed are of this last kind. Their individuality is lost, and they merely represent groups of symptoms in a series of forms of diseases of the psyche, which must now be presented as belonging to the third order. As the simpler forms lose their individual character in the very complex forms, many observers doubt the existence of complex manifestations, and some believe that the nature of all mental disturbances is contained in one single principal form. The temptation to agree with this view is great, especially if, as not infrequently happens, one single disease is seen to run through almost the entire gamut of all forms and shades of psychic deviations. For example, the author observed a case which began with dementia, which was half folly and half craziness, reached its peak as rage, returned to its previous degree of intensity, and then descended first to melancholia and then to idiocy, from which the totally exhausted patient made a permanent recovery and fully returned to his senses after a few days, after the entire disease had lasted for five weeks. A superficial, untrained observer would not have been able to recognize his point of reference or find the main feature of the disease which gave it its specific character, so that everything else was only secondary. An accurate, prolonged observation of this case according to the concourse of all the circumstances showed that the disease was a complicated case of dementia, which, owing to irritation, had increased in intensity first to symptomatic insanity and even to rage, and then after the forces had become exhausted, sank back to symptomatic melancholia and idiocy. However, both in the exaltation and in the depression stages, the main feature of the disease, dementia, kept breaking through, and manifested itself even in the last stage, when the patient was convalescent, as fixed ideas from which the patient could not liberate himself until his mental forces returned with his regained physical health. If the patient had not been initially violently and persistently stimulated, mania would not have arisen; and had he not been forced to remain for a long time in this condition of excessive tension, the unimportant symptoms of melancholia and idiocy, which were simply the result of exhaustion, would not have appeared. Thus, the course of the disease was disturbed, and its course deviated from its natural one. This is often the case in somatic complaints, which are frequently complicated, or rather confused, by the applied treatment. While the disease just described did in fact pass through an entire gamut of manifestations, it was anything but amorphous, and on the contrary, retained its nature, dementia, with mere symptomatic additions and admixtures. Such is very often the case, and there are many possibilities of considerable variations. Hence the many complications, which may look like hopeless confusion to someone who fails to see the main theme and the main design; but the interpretation will be easy to the observer who has studied the simple forms, or better, has observed them for himself. It is the conviction of this author that even though the different possible cases are exceedingly numerous, any physician who has the opportunity of frequently observing mental patients must ncessarily encounter one or more simple cases. Thus, if we could collect all these observations, there should remain no cases which have never been definitely observed. But just because it is scarcely possible to foresee each one of the large number of possible complications, the list which we shall give can only include the main cases and those most frequently observed. All that is needed is to outline their main features, since these have been described in detail above in the discussion on the simple forms, and will merely be summed up here. In any case, as has already been said, most complicated forms constitute unpredictable individual cases.

First Segment

Forms of the First Genus of the 'Third Order:

Mixed Disturbances of the Disposition (animi" aorbi complicati)

§236. First Form: Quiet Insanity (ecstasis melancholica)

1. Specific character. A fusion of insanity with melancholia, so that the former is not as violent, while the latter is not as lifeless. Joy and sorrow alternate, and the course of the disease moves between exaltation and depression within the limits of the feelings and the imagination.

2. Precursors, course, and termination. Young persons with a sensitive disposition and a vivid but not a wild imagination may show a tendency to be absent-minded, depressed, and withdrawn, and to complain and weep quietly all day and night, if their dearest worldly wishes are frustrated. Finally, the brooding imagination, which has been exclusively concentrated on the object of its heart's desire, becomes confused, the patient surrenders to his heartbreak, and the disease breaks out. The real world disappears, the world of wishes appears to the sorrowing soul as a lovely dream, and momentarily eases its condition, until the burden of the pain again pulls the disposition down from this happy sphere. Now there is a change of scene. The patient again becomes a picture of dumb pain, and again sinks into the abyss of his misfortunes, until a ray of the consoling imagination again disperses the darkness in the disposition, and the balm of insanity replaces the burdensome depression. Thus does his disease play cat-and-mouse with him, until melancholia finally wins and becomes the permanent condition. If the inner suffering also destroys the bodily constitution of the patient, this must be considered as a desirable outcome, for unless help comes immediately after the outbreak of the disease, there is little hope of cure.

* The author of this book distinguishes animus from anima in the same manner as one distinguishes between the part and the whole: animus is the disposition, the heart (capacity for desire), while anima is the soul, generally speaking, one aspect of which is the disposition. The entire soul includes the disposition, the spirit, and the will; in other words, animus, mere, veluntas. See my dissertation: De voluntate mediri etc.

3. Semiotic, diagnostic, and prognostic moments. The entire appearance of the patient gives a true picture of his disease. The patient has a broken look in his burning eyes; his face betrays an unnatural tension which is at once happy and painful; his hollow cheeks are alternately flushed or pale; his body is emaciated and bent; his hair is matted or adorned in the most eccentric manner; his clothing is neglected or else just as eccentric. The patient roams in deserted places, preferably through fields and forests, or on lonely mountain slopes where he can sigh and weep to his heart's content, or else he dreamily weaves garlands out of faded flowers and sings confused songs with a heartbreaking voice. He scarcely eats or sleeps, and does not listen to the consolations of his near and dear ones whom he does not recognize any more. Finally, he just sits still, withdrawn into himself, the pictures of his imagination having faded out of sight. The disease differs from pure insanity in its lack of exuberant vitality and in the sorrow which envelops the patient's entire life, and from pure melancholia in the interplay of softly dreaming insanity. Unless lucid intervals occur at an early stage of the disease and become increasingly frequent, there is little hope of a favorable outcome.

§237. Second Form: Melancholia with Foolishness (melancholia moria)

1. Specific character. Deep, somber, withdrawal into oneself, and brooding, or alternately unrestrained merriment and foolish behavior.

2. Precursors, course, and termination. Persons with a lively temperament who have been shocked by a great misfortune with which they are incapable of coping, experience an upheaval of their entire nature, active restlessness, confusion of ideas, instability of movements, and perverse activity; all these introduce the disease. The liveliness and the confusion soon give way to the darkest melancholia, which incapacitates the patient not merely for days, but for weeks and often for months, unless it is interrupted. Near the end the severely oppressed disposition attempts to catch its breath by trying to recall pleasant memories or by a forced gaiety; the patient is seized by a feverish merriment and he works himself up into a condition of imaginary happiness to escape the torments of depression. He becomes a fool, feeling now happy being a king or an emperor or a millionnaire, or the most handsome man on earth, or even the ruler of the cosmos; this happiness lasts as long as this condition persists, which may be several days, weeks, or months. Thereafter, his soul sinks back into its dark abyss, and the former condition returns, until it is supplanted by repeated tension when new forces have been gathered. Finally, one of these two conditions becomes permanent, and the patient remains a jolly fool until his forces are finally exhausted and stupidity takes over; or else it is melancholia which is victorious, and the last days of the patient are spent in dull confusion.

3. Semiotic, diagnostic, and prognostic moments. The signs of both melancholia and foolishness are well known, and they are manifested in the patient alternately, so that the disease cannot be mistaken for any other and can be readily distinguished from other forms; however, the diagnosis must not be based on the condition of the patient at any given moment, but the entire development of the disease must be watched. While both melancholia and foolishness, when occurring separately, are conditions of loss of freedom which are very difficult to cure, the cure is more difficult still if both occur in combination. Melancholic foolishness is seldom cured, unless some happy incident occurs at the beginning of the disease.

§238. Third Form: Quiet Fury (after Auenbrugger) (melancholia furens; Nosologists' mania melancholica)

1. Specific character. Reserved, somber, withdrawn nature, avoidance of social life; anxiety, despair of one's own abilities and outside assistance; contemplation of suicide, and if suicide is prevented, a most violent outburst of fury and frenzied rage.

2. Precursors, course, and termination (after Auenbrugger). Deeply humiliated pride and ambition, longing for lost, irreplaceable things, torments of jealousy, a major financial loss incurred by a miser, anxious, oppressive, inconsolable despondency, despairing imaginings of coming want, poverty, shame, remorse of a guilty conscience, all these can contribute to this mood. The attack is preceded by sudden absent-mindedness, brooding, confusion, restlessness, fear, and shyness of human contacts. The anxiety and depression mount from hour to hour; no consolation, no coaxing is of any use, the patient is dumb and deaf to all entreaties, nay, he displays aversion and vicious dislike towards all well-wishers. He seems to have lost the gift of speech, or else keeps saying: "it is all up with me, nobody can help me any longer." The patient beholds those around him with suspicion and is full of anger, and tries to deceive them with pretended calm until he has the opportunity of taking his own life. If his attempt at suicide is prevented, he offers the strongest resistance, tries to escape, rages and curses unceasingly for several days and nights, until relaxation sets in; whereupon he returns to his senses, or else the fuming sets in again. This first stage, during which the storm gathers, may last for several weeks or months, whereas according to Auenbrugger, the second and third stage never last for more than nine days. This author gives four possible outcomes of quiet fury: the patient may commit suicide during these nine days, or he may recover during this period of time, or the disease may pass into harmless, sad folly, or else into incurable stupidity and senselessness. This physician blames himself for having brought this about in one case by making the patient drink excessive amounts of poppyseed juice. Even if the disease is cured, relapses may occur. The signs of the disease and differences from other forms follow from the moments just described. The prognosis is favorable only if after an attack the patient not only becomes perfectly calm again, and again shows a willingness to live, but also if his external circumstances take a turn for the better. If this is not the case, a relapse will occur sooner or later, as demonstrated in cases recorded by Auenbrugger.*

§239. Fourth Form: Melancholia with Dementia, Insanity, and Rage (melancholia mixta catholica)

1. Specific character. The main feature of the disease is melancholia, but extremely variegated, multicolored symptoms appear alternately as admixtures. Moments of pure dementia with preoccupation, with peryerted and contradictory concepts; moments of total dream life, in which all other symptoms disappear; moments of the most terrible rages; then again quiet withdrawal into oneself, and manifestations of pure melancholia. Thus, there is a changing picture of different kinds of attacks and periods with occasional lucid intervals, especially in the later stages.

* The author of this textbook would willingly have foregone describing his own cases had he been able to find a sufficient number of monographs as good as that of Auenbrugger which, though often incomplete, yet affords an adequate insight into the disease. This form was surely diagnosed by Chiarugi too, but he did not record it in a monograph.

2. Precursors, course, and termination. If an energetic person leads a perverted, fantastic, corrupt, or criminal life, the foundation of suspicion, brutality, a perverted view of things, and unrestrained impulsies and desires has already been laid. If there is a sudden, unexpected obstacle in the way of such activities, the disposition of the soul then acquires all the ingredients of future symptoms, and the soul becomes tense, overtense, partly depressed, and partly excited. The persistent pressure accompanied by melancholia eventually gains sway and all other manifestations become suppressed, and appear successively from time to time. A long period of gloomy brooding is followed by an unnatural excitement. We observe sharp, penetrating, eccentric judgments, and vivid imaginings. The patient does not eat, drink, or sleep, becomes more and more tense, and eventually breaks out in eccentric behavior which may turn to fury. After the rage has spent itself, melancholia returns, until a general relaxation results either in recovery or in permanent confusion, or else the recovery, which may last for as long as one year, proves to be only temporary and the disease breaks out again, usually with tragic results. The author of this book himself observed a patient, whom he had apparently cured, fall prey to a relapse in a far away place one year later and commit suicide. In this form the disposition is disturbed by a mixture of melancholia, folly, insanity, and rage, and these signs are unambiguous and cannot be mistaken for any other form. The complication of this large variety of symptoms in itself leads to the worst possible prognosis.

§240. Subspecies, Varieties, and Modifications of the Genus of Mixed Disturbances of the Disposition

The writers of ancient and recent times described the different traits in this group of diseases fairly accurately. We ourselves have often mentioned different forms representing a mixed character originating from more than one order. These are probably most conveniently described in the present group of this genus, and for all practical purposes we need only list them to give their accurate description. The list includes the following forms which in their most developed embodiment appear to fit in here, even though lower

degrees and mixtures of these forms have been described elsewhere in this mok:

1. Melancholia metamorphosis, with the following modifications:

a. lycanthropia;

b. cynanthropia;

c. hippanthropia;

d. boanthropia.

All these include different grades and modifications of melancholia, dementia, insanity, and rage.

2. Daemonomania at its most intense, according to the biblical descriptions of the so-called possessed.

3. Melancholia errabunda or silvestris also belongs to this group and nay be identical with the form just mentioned. This is because patients who roam solitary, deserted places, graves, forests, etc., are not merely frightened, but also wild and raging.

4. Melancholia misanthropica seu antipathica. This includes the latent or manifest urge to murder, displayed by truly melancholic patients who cannot rest until they have seen the blood of a man, preferably that of their dearest friend or relative, and in particular that of a child. This thirst for blood and for the death of other people goes so far that the patient is repelled by the mere sight of a life other than his own.

5. Melancholia taedium vitae or anglica differs from quiet fury inasmuch as the destructive instinct, which is the surest sign of rage, persists, while the patient completely retains his senses and is perfectly calm.

Second Segment

Forms of Mixed Disturbances of the Mind (morbi mentis mixti) (Genus: Confusion)

§241. First Form: Silliness (paranoia anoa) (fatuitas, Vogel; morosis, Borsieri; amentia, Sauvages)

1. Specific character. A mixture of foolishness and idiocy. The patient plays practical jokes which, however, do not betray the consistency of a fool but the inconsistency of a child; he has perverted ideas but does not persist in them, and cannot concentrate on any external object, even a material one, but wanders from one to another. Pinel gave a very faithful description of silliness (Article XIX).

2. Precursors, course, termination, and symptoms. Silliness is a definite form of disease, but it is rarely a primary one. If a tendency to insanity or dementia is present, but the mental energy is insufficient for the disease to develop its characteristic form, the disease may appear as violent emotional upheavals which follow excessive mental efforts. The disease is mostly the residue of foolishness or melancholia, which are incapable of developing as such. It attacks older people rather than young, and women rather than men. It begins, continues, and ends in childish pranks and may last for years. The author of this book saw in the lunatic asylum at Waldheim a group of old women who spent their leisure time on the playing field, teasing one another like children. Thus, for example, one of them would hide herself from the others in a sentry box, as a child would do. Another woman would come knocking on the back wall of the box, whereupon the first woman would run out and chase the other around the box, with much screaming and laughter. Other women joined them and danced, sang, laughed, etc., like children, while another woman walked about gravely with a caterpillar on her hand, which she was very pleased to own, since she considered it to be the King of Sweden. Yet another one staggered on heavily under the burden of motley rags which she had sown onto her frock in a layer several inches thick. Silliness can only end in dullness or idiocy. Its features are the same from beginning to end: a childishly happy expression on the face of the patient; but when the patient is irritated, he may have a passing attack of anger or even transient fury which resembles those to which foolish or idiotic patients are subject. In none of these cases is a favorable prognosis possible.

§242. Second Form: Confusion in the Narrow Sense of the Word (paranoia anomala)

1. Specific character. Mixture of folly and idiocy. General confusion of concepts and of imagination. Rapid sequence of mental images without any connection, romantic combinations which disappear as soon as conceived.

2. Precursors, course, termination, and symptoms. If the morbid incidents are not only symptomatic, as is often the case before the outbreak of insanity, folly, melancholia, or rage but constitute a separate phenomenon, then this form of the disease is never primary but is always a residue or, rather, a transformation of other forms from which the patient suffered in the past, for example, those just listed; and these are therefore to be considered as precursors of confusion in the narrow sense of the word. The patient is apparently in good bodily health; lie eats,drinks, sleeps, and wakes as usual and can be made to do various mechanical jobs, such as those of a handyman, carrying and sawing of wood, etc., but his entire demeanor betrays his inner disturbance. He appears pale and drawn, the look in his eyes is blank, staring, dumb, and spiritless, while his face, though the skin and the facial muscles are slack, has something tense in it, which betrays inner preoccupation. The patient always seems to be thinking about something other than what he is looking at, that is, he seems to be always musing, and to be absent-minded. In fact, he thinks of nothing at all, his thoughts are fragmented, and the wisps of thought appear when he addresses passers-by, which he very much likes to do, seeking in a confused manner, to communicate. He is not in the slightest degree menacing or unrestrained. Lunatic asylums are full of such patients, and the author of this book can daily observe a few of them in whom the disease manifests itself very typically. Once this form has developed, it persists unchanged for many years. There are no lucid intervals any more than in stupidity; and it is only shortly before his death that such a patient may suddenly regain the light of reason and leave the world as a human being, after having lived as an automaton for perhaps one-half of his appointed span. The final stage is usually idiocy, and the patient wastes away, unless he dies of apoplexy — a manner of termination which, too, has been observed by the author.* This form differs sharply from silliness in that there is not the slightest trace of a foolishly merry, childishly mobile demeanor. The patient walks about quietly, and also likes to remain standing on one spot for hours on end, aimlessly staring ahead.

§243. Third Form: Confusion with Frenzy** (paranoia anomala maniaca)

This is also a residue of an earlier disease, namely, of foolish rage, but it is an independent form. Folly has dissolved into confusion, and rage into frenzy. The disease is incurable, and terminates with idiocy and wasting away, or with apoplexy.

* Dissection of the cadaver revealed lamellar ossifications in the cerebellum which were almost entirely petrified.

** [In German: "Tobsucht."]

§244. Fourth Form: General Confusion (paranoia anomala catholica)

This condition closely borders on idiocy, and is a frequent outcome of all soul disturbances with a violent onset. Since it can persist for years in the same form, it must be considered as an independent chronic disease. The patient is not childishly merry as one suffering from stupidity; he is not automatically active, like one confused; he is not restless as one confusedly frenzied; he has no concepts, no purposes, no desires any more, but still seems to be mentally occupied, in contrast to an idiot; he is vegetating as if in a dark dream.

Third Segment

Forms of Mixed Disturbances of the (morbi voluntatis inixti) (Genus: Timidity (ath a)*)

§245. First Form: Pure Timidity (panphobia)**

A mixture of melancholia, idiocy, and irritation of the power of reaction, with symptoms very similar to those of the older physicians' (for example, Sennert) melancholia hypochondriaca, and perhaps merely the most intense grade thereof. Fear and trembling at the sight of anything fast-moving in the vicinity, fearful apprehension of all kinds of misfortunes which might take place, suspicion of every man, the best friend not excepted, and thus also a distinct aversion to men (melancholia misanthropica, Sauvages); all these represent the main feature of the disease, with the other forms appearing only as symptoms. Unrestrained selfishness, one-sided training of a naturally limited intellect, several disappointments following exaggerated expectations from other people and from fate, morbid sensitivity and irritability; also the consequences of oppressive labor, sedentary, irregular routine, and major shocks produced by unfortunate incidents. All these are the foundation for the development of this disease as in independent form. The patient withdraws from any foreign touch, takes exaggerated care of himself, locks himself in, and fortifies his place of abode for fear of treason, burglary, or some imaginary punishment, by erecting barricades of chairs and tables in his room. He eats little and, progressively, wastes away. Thus, the elements of his disease combine to destroy him. The cses of this kind so far observed always had an unfortunate outcome, and timely aid can be offered to the patient only with much skill and much luck; but as soon as the disease has taken root, it is too late.

* The opposite of the Greek thymus: violent impulse, anger, courage; which can be accompanied by violent movements dictated by fear. This can be seen in the case of horses who, when frightened, rear, jump, and stampede, or else cannot be budged. As in animals, certain violent movements in men are dictated not by courage but by fear, as when, for example, somebody strikes out in fright.

** Not to be confused with the nosologists'panophobia, such as Cullen's; the word was coined by the author of this book and originates from the Greek phobos kata to pan. While this may be bad Greek, it does express most concisely the typical notion of fear of all foreign objects.

§246. Second Form: Timidity with Melancholia

(athymia melancholica) (melancholia errabunda, Bellin, melancholia silvestris, Mercati)

This is actually a more intense modification of the form just described but becomes an independent form; it manifests itself by a tendency to roam about deserted places, graveyards, and forests, and to flee from men and human habitations. This disease, which we have already repeatedly mentioned, has been best described by the ancients. It is also quite frequent in our own days, and usually ends in suicide.

§247. Third Species: Timidity with Dementia (athymia paranoica)

Demented patient not displaying any trace of melancholia, also, may manifest intense timidity. In many lunatic asylums there are patients suffering from foolishness, folly, and craziness, whose disease becomes a special form because of this particular component.

§ 248. Fourth Species: Timidity with Melancholia and Rage (athymia melancholico-maniaca)

This is the disease of the so-called possessed to the greatest extent; it is concisely but vividly described in the Bible. Extreme savageness and loss of humanity, accompanied by flight from human beings, characterize this disease.

§249. Postscript to the Science of Forms

In the last segments only a few forms were treated in detail, and of the others only the main features were given. This is because the attentive reader, who has followed the derivation of the forms, should find it progressively easier to notice the features of morbid conditions and to assemble them, so that, as in a musical score, it is enough to give a few main features for the reader to gain insight into the general condition. On the whole, it must be said that the exposition of the science of forms, and of the theory in general, must not be something lifeless, but the powers of observation of the development of different forms should be trained, and the time of training should be adjusted in accordance with the skill acquired. For this reason the description of the most complicated forms was actually the simplest, since in every such form we find the elements of the simplest forms, and need merely point them out. The only thing that remains to be done in order to conclude this presentation of the science of forms is to give a tabulated synopsis, so that the entire kingdom of the morbid conditions of the psyche can be surveyed at a glance. The nomenclature of nosologists is given, wherever applicable, but their considerations and classifications could not be reproduced, as this would have been a complicated and unnecessary task.

SYNOPTIC TABLE

of the morbid conditions of the Psyche by the systematic subdivision into orders, genera, species, and varieties laid down in the section Science of Forms.

1. Highest or Class Concept

DISTURBANCE OF SOUL (Vesania)

Character: permanent loss of freedom, unreason

Synonyms used by different authors: Desipientia. Insipientia. Insania, irisanitas, dementia, Cicero. Morbi mentis, Fel. Plater. Vesaniae, Sauvages, Cullen. Morbi mentales, Linn. Paranoiac, Vogel.

2. Order Concept

Gradual differentiation of morbid conditions of the psyche: (Vesania hypersthenica, asthenica, mixta).

3. Genus Concept

by generic differences of the affections): disturbances of the disposition (M. animi); disturbances of the spirit (M. mantis); disturbances of the will (Al. voluntatis).

4. Species Concept

(by specific differentiation of affections): simple and complex disturbances of the disposition, the spirit, and the will.

5. Variety Concept

(by conspicuous permanent features)

FIRST ORDER SECOND ORDER THIRD ORDER

SERIES: EXALTATIONS (HYPERSTHENIAE) SERIES: DEPRESSIONS (A STHENIAE) SERIES: MIXTURES OF EXALTA770N

WITH WEAKNESS (HYPERASTHENIAE)

First Genus

(Disturbances of the Disposition)

Insanity (Ecstasis)

Species 1. Pure insanity (Ecstasis simplex)

" 2. Insanity with dementia

(E. paranoia)

3. Insanity with rage

(E. maniaca)

4. Insanity with dementia and rage (E. catholica. Cf. note to § 204)

Variations of other authors

I. Eratomania Sauvages), furor eroticus (Bellin), melancholia erotica (Johnston)

2. Daemonomania Sauvages)

3. Melancholia metamorphosis (Willis), zoanthropica (Sauvages), lycanthropia, cynanthropia (Vett)

4. Metromania (v. Swieten), that

First Genus

(Disturbances of the Disposition)

Melancholia (Melancholia)

Species I . Pure melancholia (M. simplex)

" 2. Melancholia with idiocy

(M. anoia)

3. Melancholia with apathy

(M. aboyle)

4. General melancholia

(M. catholica)

Varieties

1. Homesickness (nostalgia)

2. Religious melancholia

(M. religiosa, Sauvages; superstitiosa; desperatio aeternae salutis, Willis)

Second Genus

(Disturbances of the Spirit)

Idiocy (Anoia)

Species I. Pure idiocy (A. simplex) " 2. Idiocy with melancholia

First Genus

Mixed Disturbances of the Disposition

(animi morbi complicati.

Cf. note to § 236)

Species 1. Quiet insanity

(Ecstasis melancholica)

2. Melancholia with foolishness (Melancholia moria)

3. Quiet rage (Auenbrugger) (Melancholia furens. The nosologists' Mania melancholica)

4. Melancholia with dementia, insanity, and rage (Melancholia mixta catholica)

Varieties of other writers:

1. Melancholia metamorphosis (at the peak of rage), with the following modifications:

a. Lycanthropia

b. Cynanthropia

c. Hippan thropia

is furor poetic.,

N.B. Within the limits of insanity

Second Genus

(Disturbances of the Spirit)

Dementia (Paranoia) Species 1. Folly (Ecnoia)

Sub-species:

a) Folly with insanity

(E. ecstatica)

Li) Folly with rage

(E. maniaca) y) General folly

(E. catholica)

2. Craziness (Paraphrosyne. Cf. note to § 212) Sub-species:

a) Craziness with insanity

(P. ecstatica)

(I) Craziness with rage

(P. maniaca)

3. Foolishness (Mona) Sub-species:

a) Foolishness with rage

(M. maniaca)

13) Foolishness with insanity

(M. ecstatica)

4. General dementia (paranoia catholica)

Third Genus

(Disturbances of the Will)

Rage (Mania) Species 1. Pure rage (M. simplex) " 2. Rage with insanity

(M. ecstatica)

3. Rage with folly (M. ecnoia)

4. General rage

(M. catholica) Varieties

I. M. continua (mato

2. M. continua chronica

3. M. periodica

4. Meiromania (furor uterinus)

5. Satyriasis

6. Melancholia saltans (Sauvages)

(A. melancholica)

3. Idiocy with apathy (A. aboyle)

4. General idiocy

(A. catholica)

Third Genus

Apathy (A bulia)

Species 1. Pure apathy (.4. simplex) " 2. Apathy with depression

(A. melancholica)

3. Apathy with idiocy (A. anoia)

4. Apathy with general psychic depression (A. catholica)

d. Boanthropia

2. Daemonomania (at peak of rage)

3. Melancholia errabunda seu silverstris (?)

4. Melancholia misanthropica, seu antipathica (?)

5. Melancholia taedium vitae sea A nglica

Second Genus

Mixed Disturbances of the Spirit

(morbi mentis mixti)

Species 1. Silliness (paranoia anoia) (Fat ailas, Vogel; Morosis Borsieri; Arnentia, Sauvages)

2. Confusion in the narrow meaning (paranoia anomala)

3. Confusion with frenzy (paran. anom. maniaca)

4. General confusion (paran. anom. catholica)

Third Genus

Mixed Disturbances of the Will

(morbi voluntatis mixti)

Generic concept: Timidity (A thymia);

see first footnote, § 245

Species 1. Pure timidity (panphobia); see second footnote to § 245 Melancholia hypochondriaca (Sennert)

2. Timidity with melancholia (Athymia melancholica) (M. errabunda, Benin :M. silvest ris, Mercati)

3. Timidity with dementia (A thymia paranoica)

4. Timidity with melancholia and rage (Athymia melancholico-maniaca)

III. THE SCIENCE OF QUALITY

Chapter One

THE ESSENTIAL QUALITY OF SOUL DISTURBANCES

§ 250. A great controversy centers on the question whether the various forms of morbid conditions of the psyche originate and have their seat in the life of the soul, or in the body, namely, in an overexcited, deranged, decayed, disorganized brain, or sometimes in the deterioration of other organs, such as the heart and the large vessels, or of the main organs in the abdominal cavity, such as liver, spleen, uterus, etc., or perhaps in the soul and in the body to equal extents. This question is of no importance if the human being is treated from a point of view other than the artificial, abstract, and truly obsolete dichotomy of materiality and immateriality (§§ 6, 150 — 152). Most people are still truly shocked if anyone presumes to cast doubt on the material nature of things, and almost no one believes his own existence to be anything beyond an existence that is mainly, if not exclusively, composed of the material, that is, of the inanimate being. Nevertheless, the future will certainly help to throw light on this matter, too, and the coming generations will wonder at the lack of intelligence and of feeling with which the concept of matter was understood to mean only something more or, rather, something else than Nothing. Not that we reject such a meaning: we do admit that matter is the basis of the world and the stuff of which the world is made. But we shall not elaborate this point. We have just found a way to bypass this concept and its opposite, making the point that everything that is or that seems to be derives from force, which is nothing but activity. The force, however it may manifest itself, is always equal to itself as activity, and if an indivisible (individual) force is outwardly manifested as body and inwardly as spirit, then it is obvious that these two opposite directions do not prevent this force from remaining individual and truly indivisible. If now the concept of force is replaced by the concept of life (and there is no life which is not a force, and which is not an activity), it becomes clear that the corporeal and the spiritual life cannot be distributed over the different so-called substances (material and immaterial essence), that there is thus no need to have a bridge from the one to the other (the great circle or quadrature of the metaphysicists), but that anything that affects one side of life must also necessarily affect the other, that there is no such thing as a purely corporeal or a purely spiritual life, and that even if the mental affections with which we are dealing were nothing but affections of the body, they would, by virtue of this very fact, also become affections of the soul, for a man is an individual, that is, indivisible. One may well ask at this point: does this mean that body is soul and soul is body? Not so; they always remain different manifestations of the same creative force, but are most intimately interlinked. Nobody denies this any more, but there is still a tendency to attribute the cause of mental disturbances to the bodily rather than to the spiritual side. To this we have already (§151) answered: the body alone is nothing, it has no significance in itself, but only as related to the soul or to the spirit in the wider meaning of the word, since in this life it is the body which is the carrier, supporter, and tool of the soul and of the spirit. This is most clearly indicated by human consciousness, without which there is no human life; and who would contradict his own consciousness? Human life exists only in consciousness and for the sake of it; should then the laws of consciousness not rule human life? Should then human life not truly be a life of the soul, even if the affection has its seat in the body? Our science of elements did nothing but bring forward proof that the reason and the nature of soul disturbances are to be sought in the soul itself; we shall therefore go on building on the foundations we already laid and shall no longer inquire if the soul disturbances are bodily affections (we fully agree that they cannot take place without a bodily affection, but just as firmly deny that their source is in the body), but shall merely inquire into the true quality of these morbid soul activities, or better soul sufferings, and this inquiry will now be our object.

§ 251. Our question accordingly is: what is the common, inner source of each and all the forms of soul disturbances described in this book, for the inner cause of an external manifestation is also its essence. All forms of morbid conditions of the psyche have this in common: they let the feelings, thinking, and actions of a man take place outside the sphere of reason and of freedom, and this condition is permanent. From the science of elements follow also the causes of this permanent unfreedom, or unreason: they are the mood of the soul, or the inclination to the unfree condition, and the compelling or enchaining stimulus. These two, the inclination and the stimulus, do not act each for itself, but in combination; indeed, they are in intimate union and intermixture, which relationship was compared to the act of procreation. Thus, all soul disturbances must be considered to be the products of the pairing of the inclination with the stimulus. Now the nature of the product of such pairing must necessarily be like that of its factors, which is purely psychic, in the strictest meaning of the word, that is, it is moral. Moral, however, means everything related to good and bad, to holy and unholy. But neither of these two, inclination and stimulus, can be good, or their product would not be a disturbance of the soul, but growth and prospering of the soul. The forms of soul disturbances prove exactly the opposite, they show us a deviation, a regression, or a total standstill in the growth of soul life. Thus, both the inclination and the stimulus, and their product, must be definitely recognized as evil. This consideration is completely ignored by conventional views on the morbid conditions of the psyche. But it follows from the above, and it is to be hoped from what we have proved, that a soul can become sick only morally; and, no matter how sharp the distinction made by a subtle psychology between these conditions and what is usually named moral diseases of the soul, e.g., vice and sin in general; it still follows from our point of view that disturbances of the soul are precisely the ripest fruit of moral disease. This is the true substance of all soul disturbances: it is evil in general. It now only remains for us to determine more exactly the nature of this evil.

§ 252. Evil is the opposite of good. The good, the holy, is the foundation of the fulfillment and of the perfection of everything that is and everything that grows. It follows that evil is that which is opposed to all this, that is, the principle of absolute destruction. Now the Holy Scriptures, to which we have attached our religion in the full gratitude of our hearts, offers us a solution of all enigmas related to the imperfection of this world; it has given a name to this principle of destruction, which very exactly describes its nature: the evil spirit. And here is where, as though by a miracle, or rather very naturally, our own theory of soul life is in perfect agreement with holy revelations. The true nature of man is his soul and his spirit, not as opposed to body, as material principle, that is, not as immaterial principle, which is an artificial concept, but in a much higher meaning, namely, that everything, including the so-called corporeal world, is nothing but a manifestation and a revelation of the spirit. Just as all external objects and all the forms we perceive in a dream are only the product of our mental activity, which is not able to impart independence or permanence to these products, so, too, are all objects perceived in our waking state the effects of a spiritual, creative activity: the same activity, in which we all live, suffer and exist: the Deity. From this aspect, everything that exists is spiritual, including all the so-called corporeal forms, from the largest stars in heaven to the smallest pebble on earth. Everything which has been fettered by law and form is force; and all force is the effusion of the Deity, a seed of endless development. We ourselves, as animate beings, are also such a force; we are also such a force as bodily beings, but are not aware of it in our corporeality or external beings, but only in our internal being, our spiritual outlook, which is precisely the self-conscious being itself. This is also what shows up "which is the spirit we are children of": is there light in us or darkness? There is a spirit of darkness, which is the Spirit of Evil, to which belongs all that is evil, including the sphere of mental disturbances. This Spirit testifies to his existence by his activities, just as the Good Spirit, the Spirit of Light, testifies to his existence through his. We are never independent, we always serve a master, be it the Master of Creation or the Master of Destruction. A witty writer once said that no greater favor could be done to the Devil than not to believe in his existence; and in this he was right. This is why our claim as to the nature of mental disturbances, namely, that they are the work and the nature of the Evil Spirit, will not be easily believed: everyone is confident that he can do without the Evil Spirit and is well able to do all kinds of evil without his assistance. But this is being overconfident, as concerns both good and evil. For a man is just as little evil due to himself as he is good due to himself. We are in fact nothing at all due to and by ourselves and merely lead a borrowed existence. This is to say, we are independent only in appearance, not unlike a flame which can only be created and maintained in existence through the concourse of oxygen and nitrogen. Our Ego is constantly fed by foreign nourishment; but it is important to inquire into the source of this nourishment. We thirst for evil from early youth and it is granted to us until we are more than satiated with it. No one loves good, everybody loves evil; and the excess of evil is a disturbed mental life. But this view has been banished from the circle of active men who enjoy life or who suffer through it; in worldly life we are too short-sighted to see anything other than the world and ourselves. We see neither God nor Devil; we are too busy, or too rational, or too proud to do so. And thus many are owned by the Devil without knowing it or admitting it to themselves; but as long as they retain their will the Devil owns them only partly, and only when soul disturbances have broken out are they totally owned by him. No matter what we say, there can be no mental disturbance without a total fall from grace. Where God abides, there is force, light, love, and life; where Satan reigns, there is impotence, darkness, hate, and total destruction. Thus, the mentally disturbed are inhabited by the Evil Spirit; they are truly possessed. We have already said that this view may appear absurd, but it is in fact no more absurd than the belief that those whose thoughts and actions are a search for truth are the Children of God. Briefly, we believe that the quality of mental disturbances is the communion of the human soul with the evil principles — this without entering here into the question whether individually this is a spiritual process or not — and not merely a communion with evil, because that is beyond doubt, but a total enslavement by it. This is the complete explanation for the lack of freedom or lack of reason in which all the mentally disturbed are held captive. We have discussed the nature of soul disturbances in general at great length because we wanted to stress the contrast between our views and those held by the physicians of the present day, as seen, for example, in the chapter De Maniis of a recently published work that has been widely acclaimed. We should no longer view life with the eye of death, spiritlessness, and immorality. The total separation of body and soul has already caused infinite damage; for the former being constantly before our eyes, has become the center of life, while the latter, being invisible, is set aside as something of doubtful existence. People work, speculate, and earn money for the sake of their bodies; and when we speak of life, we mean the body, while the soul, that is, the calculating intellect, is the servant of the body. Those who think in this way see no sense in considering human life from the point of view of good and evil; and our description of the nature of mental disturbances as originating from the Spirit of Evil will not be understood by these people and will be mocked by them; but it is nevertheless true, and it will be recognized when its day comes.

§ 253. Of what avail, now, is our explanation that mental disturbances originate from the principle of evil? Do we thus have a better insight into the substance of these disturbances? If we could only study this principle more exactly! It is, however, sufficiently characterized by the word destruction. Evil, despite all the inclination, is hardly able to destroy something created by the Divine Spirit, though it is well able to disturb the development towards perfection, i.e., to arrest or inhibit it, and we encounter many such inhibitions in particular and general experience. The name of soul disturbances was very appropriately chosen as the exact description of the nature of the working principle. The Evil Principle, which is prevented by the power of Good from achieving its final objective, dissolution, annihilation, destruction, attains its objective at least to a halfway point, the point of disturbance, of inhibition. Thus it appears as an inhibiting, retarding principle, a principle pulling everything that strives upwards into the abyss in which it itself abides; it is therefore the principle of fall, of gravity, and since gravity is the opposite of light, being darkness, it is also the opposite of the spirit. The spirit, in turn, can be considered to be the opposite of matter, and what we referred to as the Evil Spirit is thus even a physical or, rather, material principle, and wherever it is present in mental disturbance we consequently discern in this disturbance the inclination of the soul to become matter, in the sense in which we defined this concept in § 156. This in not very different from the views of other interpreters, to whom mental disturbances are material manifestations, but with this difference, that we end where they begin, and that we use this expression altogether in a deeper meaning. Those who have a conception of matter different from ours say that the origin and the seat of mental disturbances are in the organs, whereas we say that the organs are inevitably unnaturally affected by the entry of mental disturbances, which have a morbid effect, and may even cause morbid alteration of these organs. But all this is only because the soul (the ideal aspect of life) has ceased to obey the law of the spirit and now obeys the law of the fall, of gravity, of matter. Thus, disturbances of the soul become a material manifestation inasmuch as the soul, which has been deprived of light, that is, of its freedom and reason, appears to act or, rather, to suffer, in accordance with the laws prevailing in the world of gravity. In this connection we shall refer the reader to § 183, and shall merely say that the core, the substance, of mental disturbances, could be sought for only by searching for the law which they obey; for it is in the law that rules each being that its substance lies. But such a law is always a mere expression and manifestation of the spirit; and just as the good spirit of our souls is manifested by the law of light, reason, and freedom, the evil spirit manifests itself by gravity. This will conclude our discussion on soul disturbances in general.

(In German: "zerstbren." The author stresses the first syllable, zer (= dis), to show the connection between zerstOren (destroy) and stOren (disturb).]

Chapter Two

THE QUALITY OF DISTURBANCES OF THE DISPOSITION

§ 254. If we now consider the main forms of disturbances of the disposition, insanity and melancholia, we find that they are distinguished by altogether different characters; in melancholia the disposition has lost its world, and becomes an empty, hollow Ego which gnaws at itself, while the insane disposition is torn and removed from itself and flutters among the dream images and airy figures of the imagination. We find here signs of two opposite physical principles: the centripetal or contractive force, that is, a tendency to lose oneself in one central point and thus gradually fade out into nothing; and the centrifugal, or expansive force, that is, a tendency to expand without limit and thus also fade out into nothing. These two forces have their corporeal representatives in oxygen and in hydrogen, since the former is bound to metals, and the latter to narcotic plant principles; both are poisons, but are opposite in kind, since the destructive action of the metal poison proceeds towards the middle, and that of the plant poison towards the periphery. We cite this only as example and comparison, in order to present descriptively the concept of the affection of the disposition in melancholia and in insanity. If the disposition (which if completely healthy and uninjured is in its pure vitality life a pure dewdrop in which the sky is reflected) disintegrates due to morbid processes into its elements, as water is decomposed into its own elements by electric processes, then the above manifestations of disease come to the fore, depending on which one of the elements has become fixed. This parallel between the disposition and physical forces, although presented here for the sake of greater clarity only, has a deeper significance, namely, that long accepted by natural philosophers: the re-emergence of physical forces and laws in the sphere of the psyche. However, we would limit the validity of this parallel to the cases where the soul steps out of the sphere of freedom and enters that of coercion by (inanimate) nature. It now remains to be shown that this is in fact the case in both kinds of disturbances of the spirit, and that it is the manner of doing so that determines their quality.

§ 255. We shall begin with melancholia. It is only through reason that man can maintain himself in the sphere of freedom. He who never forsakes reason for even a single moment is always free, and the heavenly kingdom is his. But a number of powerful forces affect the heart of man and lure him away from the path of reason, so that he falls prey to coercive forces. Unresisting, he now is magnetically attracted or repelled, subject to the laws governing these forces of attraction and repulsion. To this, he does offer some resistance at First, but gradually his force of resistance decreases, until it is totally exhausted. From this moment on, the heart of man is like a freely falling object; he is blindly drawn towards the center of his desires and lives only in the force exerted by this center. He can no longer tear himself away and again his independence; his heart has become fused with the object of its desire. But, because in this condition the heart no longer belongs to the man but to the object, he is being seized by infinite torture, produced by the never-ceasing contradiction, namely, that the man is divorced from himself, and yet cannot depart from himself. This is truly infernal torment, for the nature of hell is to behold and feel that which is but one thing as something divided. In the case of melancholia, the disposition is lost in this feeling of not belonging to oneself; and this is the quality of melancholy and underlies all the various phenomena thereof.

§ 256. We might think that the substance of insanity, being the form of mental disturbance that is the opposite of melancholia, could not be due to a subjection of the disposition to the law of gravity, since the condition of insanity is due to being beside oneself. But this being beside oneself, just as the withdrawal into oneself in melancholia, is caused by a pull exerted by the object which is fettering the heart. The heart is just as much a captive of the object as in melancholia, only the nature of the pull is different. In melancholia, the object clings to the heart, weighs it down, and pulls it to ever greater depths, which explains why melancholia is a condition of depression. But in insanity the heart clings to the object, lives only in the object and is lost in the object; life has become a dream about the object; the disposition has been torn out of itself by the imagination. Thus, in this case, too, the disposition goes after a pull: since it has no force of its own, it is drawn forth. But any force which has been overcome by another force and is drawn by it obeys the law of gravity. Indeed, the insane disposition is vividly and powerfully excited, and inflames the imagination through its emotion: it is in a state of exaltation, of ecstasy. But this is not the free impetus of the imagination: the imagination is fettered; it is compelled to create not what it wishes but what it must. And this compulsion is precisely what constitutes the weight of spiritual gravity. And thus the quality of both, insanity as well as melancholia, is essentially that of sinking, of a fall into the realm of gravity, except that the direction of the fall is different in the two cases. And this is what comprises the great difference between the two diseases in the sensations of the patient; for whereas the melancholic disposition is driven back into itself by depression, feeling nothing but itself and its pain, in ever greater dissension, in insanity the disposition does not reflect upon itself, since it is altogether beside itself; and thus the misfortune of insanity is accompanied by the bliss of self-oblivion.

Chapter Three

THE QUALITY OF DISTURBANCES OF THE SPIRIT

§ 257. If we wish to be quite honest, we are bound to admit that disturbances of the spirit, too, have, if not their seat, at least their origin in the disposition. Nobody becomes demented unless his spirit clings with an inherent and great interest to certain objects. But since it is the spiritual activity and not the feeling which thereafter takes over, and since with no further involvement of the feeling dementia evolves exclusively in the field of the spirit in the narrow meaning of the word, that is, in the field of intellect, and since with the idiot it is the spiritual depression which forms the main character of the disease, it is reasonable to look for the quality of disturbances of the spirit, too, in the field of the spirit alone.

§ 258. Quality of Disturbances of the Spirit in General

Unfreedom and compulsion underlie all soul disturbances; and since all compulsion is an inevitable submersion of one quality in another one, the relationships which we have just described apply here, too, but in a different shape and manifestation. For the manifestation of the disposition differs in life from that of the spirit. Thus, the unfree spirit, both when exalted and when depressed, is subjected by the compulsion. This happens, just as in conditions of the disposition, when the spirit, here the intellect, deviates from reason. As long as the intellect is guided by reason, it is well-advised; and what would be more desirable than that this should be always the case! But as we have seen the disposition faring, just so fares the intellect: lured by outside forces, it gradually tears itself away from reason. Once this has happened, and the individual is dominated by the activity of the intellect, he begins to act contrary to nature, contrary to reason. And herein lies the cause of all chimeras and idees fixes: the intellect is now pulled away from its objects and cannot move in true freedom. This results in shifts, distortions, and perversions of concepts, as are manifested in the numerous forms of dementia. But this does not happen before the intellect has surrendered more and more to the external compulsion to occupy itself with fanciful imaginations. And it is this subjugation to compulsion, to always imagine and judge by a biased, and therefore always false impulse that gives rise to all kinds of falsehoods in the imaginations and judgments, which comprises the quality of dementia in general. General inability to conceive clear ideas and concepts, on the other hand, draw the spirit down into the realm of gravity on the other side, the side of depression. The demented person becomes magnetic and is attracted by the force of gravity to his objects; the idiot keeps falling deeper and deeper, since he can no longer rise to a clarity of ideas.

§ 259. Quality of Folly

Individuals who love the world but live in the intellect rather than in the senses, become, once they lose the freedom of the intellect, fettered to the concept of earthly things and their relations. Since these concepts are modeled on self-interest, and one-sidedly follow fancies and prejudices, it must follow that they are false, and it is this falseness of the concepts of the world that constitutes the nature of folly. He adapts the world to his concepts, since this is in his own interest, but his ideas contradict the natural order of things, though they correspond to his wishes; and this is what makes even the most subtle intellect fail.

§ 260. Quality of Craziness

The essential nature of craziness is an attraction to supernatural objects, and, due to the powerful desire to understand them, a misconception, a wrong, perverted application and effort of the intellect, and an attempt to place the limitless into finite bounds (which in itself turns a wrong philosophy almost into craziness); the clinging to these self-created bounds is what constitutes the inherent quality of craziness. Craziness lives in the supernatural in such a manner that punishment by confusion ensues. It is only with his disposition that man should aim at the Eternal: he should love the Eternal; if he does not love the Eternal and yet attempts to understand it, he sinks into the abyss of a disease, the form of which most clearly testifies to the impotence of the human intellect, for this intellect then strays into a sphere for which its limited, earthly, sense-bound substance was not created. This sinking of the intellect into the abyss of things is in itself an indication that it has fallen prey to the law of gravity.

§ 261. Quality of Foolishness

Man is naturally vain. His heart, his senses, and his understanding are directed to vanity, even when he dares to pull the Unchanging into his own sphere; for he measures it by the measure of his own vanity. It is the quality of this vanity that is most vividly manifested in foolishness. One who suffers from foolishness is the vain kat exokhen, one who has fallen down, but who, in his vanity that relates his own ego to each and every object, has lost his freedom and gone down, obeying the law of gravity. Even the usual vain person is unable to liberate himself from this inclination; how much more unable is one who has lost all self-control and is swallowed by the vortex of vanity! And this is the foolish individual. The quality of foolishness is his self-attachment, his persistent insistence that he is a person of excellent, exceptional value. There is no greater misfortune than to be a fool, because then one cannot separate oneself from one's own person. Foolishness, too, has its origin in the disposition; an exaggerated love and appreciation of self are its prime causes.

§262. Quality of Idiocy

If a condition of spiritual life is determined by somatic factors at all, it is there where a debilitated brain and nervous system, which manifests itself as such, can no longer light the spiritual lamp, and can no longer maintain the light circle of consciousness lighted by its ideas. Just as a lamp becomes extinguished when there is no more oil, so does the consciousness and all it contains in a brain which has been exhausted by life. The quality of idiocy, therefore, is: the lack of the spiritual principle of life, the source of which is the brain. "Just look at this," the critical reader will exclaim, "the author has suddenly become a declared materialist! " It would truly seem so at first glance; but if the opinions previously proclaimed ( §§ 6, 35, 151, 152, 164) by the author are recalled, we see that this conclusion is not only not against reason, but is rationally necessary. For we have not merely admitted, but even postulated, that the body and all that is in it is the carrier of the soul, and that it represents a direction of the creative life force which makes it possible for the living human being to begin and to develop his spiritual life. But we must not assume that because a vital brain is indispensable for creating spiritual light, or because this light is extinguished in an exhausted, injured brain, it follows that such a light is due to somatic conditions alone. Just as the lungs cannot breathe if there is no air, so spiritual, reasonable life cannot develop in the brain without the spiritual ether (sit venia verbo) which carries in itself the law of all life, that is, without spirit and reason. Just as life can only be born of life, so can spirit only be born of spirit. The Divine Reason was able to form our being in accordance with Its scheme and preconceived plan, but the "living breath," the spirit, It must constantly supply anew if there is to be anything spiritual in man. We do not produce reason inside ourselves, it is as little the product of our organization as is the air we breathe; we are born receptive to reason, to the spirit, which is around us spiritually as the atmosphere is around us materially, and always trying to enter us. But if we act against this spirit of reason, this "holy spirit", we are no longer receptive to it, and though we continue our bodily life, we are spiritually dead. And this condition is complete in idiocy and in related states. The nature of idiocy is an organically undeveloped or organically extinguished receptivity to the spirit for reason. This is why idiocy seems to be a purely organic condition, whereas in fact it is a negative spiritual condition, a "lack of spirit" originating from a lack of receptivity to the spirit.

Chapter Four

THE QUALITY OF DISTURBANCES OF THE WILL

§ 263. Both the science of elements and the listing of the simple and complex forms of disturbances of the will show us the way to discover the substance of disturbances of will. Our views on the substance of the will are explained in detail elsewhere (Dissertation Dc voluntate medici etc.) which is why here we shall restrict ourselves to those explanations necessary for an understanding of our subject. A man's will, like his spirit, has its roots in the Eternal Being. The will is a certificate of our divine origin, but it is how we use it that determines whether salvation or destruction is brought about. As long as the will remains undecided between good and evil, it is merely a capacity for self-determination, namely for freedom of action: choice. The hallowed choice, that is, that which sides with reason, becomes good, pure, or holy will. This will is the effective, practical reason, the reason that manifests itself as force. Such a will is never without a fruitful, salutary success. Whatever is truly good in this world, has been wrought, like the world itself, by this will which originated as creative, truly divine force. This will is the true creative element; but it is so only if it is fused with and permeated by reason, or rather, only the reasonable will is a true, genuine will. Now the human capacity through which man is destined to act, and which thereby becomes his will, namely choice, is infinite; in other words, it is free, else it could not be a carrier of the will, which is unlimited. But precisely because it is free, it needs some limitation so that it does not lose itself in the infinite, that is, so that it does not destroy itself; but this limitation must not impair its freedom. This limitation is given to the will by reason, which is the principle of freedom; choice is thus transformed by reason into a pure, truly free will; choice is reborn, as it were. This transformation is one of the rarest phenomena existing in the realm of man. But wherever the capacity to choose fails to obey reason but follows unrestrained desires, it degenerates into unrestrained passion, into a savage impulse of destruction; and once it manifests itself in man in this shape, true freedom goes down and, at first, rage appears in its horrible shape.

§ 264. As with other soul disturbances, it was attempted to explain rage, too, as a bodily disease, resulting from a sharp bile, worms, or a hundred other irritations. While such explanations would require a new explanation and it would be preferable to set out by an assuming an excitation of the vascular and nervous systems to be the bodily condition for rage, this would not solve the enigma of that phenomenon either: a deeper cause must be sought to explain the actions of the raging patient; for there is a difference between movement and action. There are many involuntary movements, but not a single involuntary action, for action cannot be imagined without willing. But there is such a thing as a forced, unfree volition, that is, a volition which acts under the influence of a blind, powerful stimulus. This happens when the will has separated itself from reason and is no longer determined by either feeling or intellect. For unless the will is determined by reason, it comes to be determined, depending on circumstances, by the feelings (pleasure or pain), the intellect (selfish advantage), or finally, blind impulse. The blind impulse knows no restraints and, therefore, neither does the will driven by this impulse; this will thus acts against all restrictions, that is, it acts destructively. This is the deeper cause underlying the actions of the madman. True, the loss of freedom by the man and its consequences are determined by his body, for the blind impulse itself is the consequence of irritation of bodily organs; a drunkard, for example, often acts like one suffering from rage. But this irritation of bodily organs is again psychic for it was built up, more or less rapidly, by vice, passions, emotional disturbances, etc. And the product of psychic factors, such as excessive bodily stimulation, in turn, has a psychic effect, namely, overexcitation of the will. It is thus seen that rage cannot be explained except on psychic grounds, and its quality is nothing but a blind, destructive action of the will.

§ 265. All that now remains to be done is to interpret the quality of apathy, which is the opposite of rage. Like rage, apathy too has its own organic conditions. Unless deprived of his willpower from birth or by innate organic imperfections, man can lose his will only by violent shocks or by gradual undermining of his somatic and psychic vitality. But we have earlier seen that lack of willpower is comprised of the inability to attain self-determination. Tracing the source of this inability, we find that, on the face of it, it is admittedly a physical inability that has paralyzed the willpower; but we must not be content with this, for this physical inability is caused by nothing else than a false way of life. The quality of apathy is thus seen to be the lack of exercise of the will, on the one hand, and the habit of letting the will be guided by outside stimulations which gradually lose their effect when the receptivity to them is exhausted on the other. Thus, apathy is nothing but exhaustion of the power of self-determination caused by organic weakness which, in turn, is caused by inertia and enslavement of the will.

§266. Final Observation

The nature of mixed disturbances of the soul can easily be derived from that of the simple disturbances, once the latter quality has properly been clarified. The science of substance as outlined here, obviously comprises but a frail beginning of such a clarification; nevertheless, we think we have indicated the central point around which all research in this field should move. We stated from the very beginning that our effort in this respect is but a rough drawing, and we are content to leave further work to the future. If we have succeeded in drawing the attention of the reader to the essential point, namely psychic corruption, and to view all the rest as resulting from the latter, then we have done all that is in our might. It will be found that the moments of the science of substance indicated here present, first of all a heuristic, but subsequently all other parts of the technique, in natural sequence. Even there where we attempt to treat disturbances of the psyche by way of the body, our treatment is in fact psychic; this is partly demonstrated in § § 1-54-158, and partly in the science of therapy in which we will treat the subject more thoroughly. The author is certain of one thing, at least: that inasmuch as he may not have progressed far, the path he chose is nevertheless the only one leading towards the goal, if such a goal be at all attainable in this field.

INTRODUCTION: ABOUT THE TECHNIQUE* IN GENERAL

§267. We have already discussed ( §§ 72,73, 74, and 81, 82, 83) the art of medicine, the extent of agreement of this art with art in general, the relation-ship between this art and theory, and finally the art's sources and the procedures. We shall now survey and summarize what we formerly merely indicated in separate and scattered places, and shall add what is needed for our present purpose.

§268. The physician in general, and the physician of the psyche in particular, is not an artist in the ordinary meaning of the word. The artist, be he a painter, sculptor, or musician, rules unreservedly over a perfectly passive material on which he imprints his creative spirit and his ideas. A psychic physician, or a somatic one, cannot do this. The object of his treatment is no dead, passive matter; it has a life of its own, with its own energy and laws which the physician must recognize, respect, consider, and treat after their own manner. This means that the physician in no way imparts freely invented, poetic ideas to his object; his influence must be adapted to the nature and the needs of his object, that is, the diseased life. A life which can no longer defend itself or take care of itself requires outside help, and such help must be given by the physician, but not otherwise than is dictated by the voice and the law of the nature of life. Thus, the physician is not master but servant, not of the patient, but of the sick life. To the patient he is a helper. It is therefore to be hoped that the difference between the physician and the artist has now been clearly enough stated, and we again object to the foolish name healing artist, which contains a double error and double presumption. For the physician does not heal any more than he is an artist in the ordinary meaning of the word; for even if the physician could heal by his will, his look, and his touch, it would not be he that heals but the force that has been invested in him, while he himself would only be the carrier of this force, just as a medicament is the carrier of a healing power.

* [Treatment.]

§ 269. But a physician does not, or at least should not, act blindly. He must act with attention, deliberation, and recognition; and the sum total of his recognition is the theory. But the theory is not a direct guide to his action; it merely leads him towards the means and rules which should constitute the foundation of his action; and the sum total of these means, their possession and the skill of their application, is known as technique. Thus, the technique grows out of the theory as the stem with its fruits grows out of the roots and, like it, is constituted individually and has to be shaped after its own manner. This is the mutual relationship between theory and technique. The next question is: how does the technique grow out of the theory? A general answer to this question has already been given. The recognition of the morbid features of the life of the soul, the various forms in which they manifest themselves, and their dependence on various elements tells the physician how to set the elements of healing against the elements of the disease, how to alter the mood of the soul through these healing elements, and thus eradicate the morbid manifestations (the forms of disease), if the circumstances allow, that is, if the morbid condition is still curable and the means employed are still able to effect the cure.

§270. The prognosis made from the faithfully observed morbid condition tells us if cure is still possible. The means to be employed to effect the cure are found by looking for the opposites of the elements of the disease, and the ways and means of their application will depend on the individual character of the morbid condition. This means that technique has several functions, some of which have already been mentioned. As a heuristic technique it teaches us how to find the opposites of the diseased conditions, and is thus nothing but the so-called general therapy, insofar as therapy is not an idle, empty plaything taken out of thin air, but understands itself and its task. In its capacity as science of medicaments it is the task of technique to collect the treasury of positive and negative influences of all sorts and degrees which have been so proved by experience, beginning with the so-called inanimate matter and ending with the activity of the living life itself, and to order them in accordance with the established heuristic therapy relations. Finally, in its capacity as science of therapy, technique prescribes complete treatments of the generically and specifically different forms of disease, and thus fulfills its ultimate task. While the business of technique is very varied, its development is exceedingly simple, and this simplicity guarantees its naturalness, its physical necessity. Although the available materials are abundant, this field of medicine of the psyche is not yet organized; and it remains for us to make an attempt to create order out of this chaos by founding a technique of the medicine of the psyche.

§271. We shall first take a look at the present position of the art of medicine of the psyche. Since the morbid states of the psyche are not understood in their substance but are considered to originate from a discordance of the organic orchestra, that is, from bodily affections, all efforts to reestablish normal functioning of the psyche consist in influencing the bodily organs. And strange as it may seem, such attempts are not infrequently successful, but by no means always. Yet we may say that these views and this method are now current, because the conviction that morbid states can only mean morbid states of the body is becoming increasingly common. The watchword of the day seems to be animus non aegrotat. It is indeed very convenient to cut the Gordian knot in this way. The English are leading the way, while the Germans follow close behind. But even the English, with their management or government, and the French with their so-called traitement moral are forced to admit that allowance must be made for the psyche as well; Reil, in Germany, even proposed a psychic method of therapy, though he failed to carry it out. Now, if the morbid states of the psyche had an exclusively bodily origin, such psychic allowances and suggestions would not be necessary at all, save for a psychic regime such as may be prescribed for a bodily disease. For even in cases of fever the physician may insist on rest, or on amusing the patient, or on the elimination of any unnecessary excitement. This is a good aid to therapy but not its main feature, which can only aim at the regeneration of organic normalcy. This should also be the objective in diseases of the psyche. It is accordingly inconsistent to speak of so-called moral treatment when the source of the evil resides in a malfunctioning vascular or nerve system, or in both, or in disorders of specific organs such as brain, liver, uterus, etc., and it is even more inconsistent if the mental patient is not receptive to any moral influence, or even to the psychic influence of his daily surroundings. Anyone who tries to influence the disposition, the intellect of a victim of insanity, melancholia, dementia, rage, or idiocy by coaxing, consolation, instruction, argumentation, encouragement, etc., will see how far he can progress in this way. But moral treatment can also be understood otherwise: viz., in the sense of a humane treatment, that is, a treatment which is only subjectively moral, and this is praiseworthy and is a sign that we are on the right path. But we must be careful not to extend this morality or humaneness too far, or rather not to apply them in the wrong way, which not infrequently happens. The course of action which is not only proposed and warmly recommended by some people but which is also sometimes tried out in practice, namely, that the patient be given all possible freedom, should only be countenanced when all hope of recovery has been given up, and the physician is unwilling to rob such patients of any enjoyment they can still get out of life, even if only by being childishly playful. But where there is still hope of recovery, it is improper to abandon the patient to himself and to his perverted behavior. What is needed in such cases is constraint, which is in no way cruelty or inhumanity but is necessary for the reeducation of such patients to the norm of reason. Restraint can lead a rough, uneducated fellow to culture, art, sciences, and all virtues; and it is through restraint that a man who has strayed from normal procedure and good order can be led back to them, that is, back to reason. It is those least deserving of freedom, namely maniaci, who love freedom best; and as long as they are left to themselves and to their perverted activity, even if only in an Autenrieth chamber,* no recovery is thinkable. The patients are only encouraged in their wrong actions and become enmeshed in them. They consider that what they do is right, and will keep no rules; and this perverted tendency grows stronger through being constantly satisfied. Briefly, for as long as such and similar patients have their will, nothing can be done with them. The author has nevertheless seen large institutions in which this respect for the will and freedom of the patient is the principal feature of the treatment. This is contrary to all true technique and is a proof of its imperfection. Thus, inconsistency and incorrect psychic treatment form part of our complaint against the view of diseases of the psyche which is so common today. But we also object to the crux of this view itself, which regards and treats such conditions as mere bodily affections. We do not wish to say anything against treatments which are only bodily and organic, or even purely mechanical; we recognize that they are valuable and necessary, at least at a certain stage of the art; but it is one thing to apply somatic treatment and quite another to consider morbid conditions of the psyche as mere somatic affections. It was, we hope, clearly proved in the theoretical part of this book that these are no somatic affections, and the proud maxim animus non aegrotat has been adequately disproved. It should also be clear from the above discussion (Elements, Chapter One) that all somatic influence is also a psychic influence, though an indirect one, which means that if cures are effected by somatic treatments, this is no proof of the somatic nature of the disease itself. But it is by no means the same which one of the two views is held; for the view according to which diseases of the psyche are somatic affections is more superficial and more restricted, and its scope of action will be correspondingly restricted if the other view is consistent. This is seen if we consider the Helleborus* of the ancients. In view of the great variety of possible diseases, this could not possibly have been suited to all of them, as is also seen if we consider the specific remedies employed by modern physicians: camphor, gratiola, tartar emetic, etc. According to some physicians, these in fact give good results, but according to others they do not. This is also true of the most reasonable and most highly perfected method of Sandtmann (§147). Even though it is called an indirect psychic method, it is really based on the view to which we have been objecting all the time. For, though it does not ignore the soul, as do other somatic methods, but applies its treatment to naught but the soul, it nevertheless conceives this soul to be nothing but a kind of electric tension of the central organ, which in morbid conditions of the psyche has been simply put out of order (in accordance with an earlier view of Reil's). It is concluded, accord-ingly, that the entire spiritual atmosphere (if this appellation be permitted), which should spread to the last peripheral ends of the sensory system, now fills the central organ only, and this is the source of the abnormal manifesta-tions of the psyche, which cannot be diverted except by peripheral counter- stimuli. Thus, in this way this so-called soul is treated through these indirect psychic counterstimuli in a purely physical manner by the lever law. This is not meant literally, for the lever law is a mechanical law, while the treatment is based on reason. Thus, Sandtmann's treatment of the morbid soul, while being physical, is still rational; for what would irrational physics be worth? But we have already ( §147) objected to the one-sidedness of this method, not because of its purely material foundation, but because people are treated by the lever law, even when in a morbid condition of the psyche, sometimes at random, sometimes to their greatest disadvantage, because of their unlimited force of resistance, which is not always evident, but is most noticeable if they are forced to do something.

* [The Autenrieth chamber, devised by the German psychiatrist Ferdinand Autenrieth (1772-1835), was a sort of movable stockade, used to isolate and move dangerous patients from one place to another. ]

§ 272. Thus, a systematic and comprehensive technique for treating disturbances of the soul cannot be found among the available methods, and our task is not given quite the right help. Nevertheless, we shall gratefully make use of any suitable matter collected by experience and genius, and shall often encounter surprising instances of discernment in the eye of the physician, and no less surprising cases of sheer good luck. In any case, our account of technique, as in our discussion of theory, in particular of the science of substances, is merely intended to pave the way and to indicate the true technique. The rest must be left to time, and to others with greater strength and perfection of spirit and will.

* [Helleborus (Eng. Hellebore) was the name of a group of plants whose substances supposedly had a therapeutic effect on mental diseases. Very popular in the Greek culture, it was used even later in Roman and medieval times.]

I. HEURISTICS

Chapter One

THE ORGANON OF THE HEURISTIC

§ 273. There are two properties which every true physician must have, two elements of the art of medicine which must never exist apart, even though they are opposite in nature: for theory, the correct observation; for practice, the requisite tact; both as pledges of medical talent which can no more be acquired than it can prosper without proper training. For the observation is trained and formed by theory, while tact is formed by technique. In theory, nothing can be arbitrarily invented but everything, just as it is given by natural laws, must be viewed and understood in a lawful manner; but in technique, free play can be given to combination and exploitation of opportunities, and the same inventive spirit which is harmful to theory is the guardian angel of technique.

§ 274. The technique consists in inventing that which is contrary to any morbid condition considered as given, namely, the means of cure and its application. The means of cure should not be considered as an isolated thing, but as a whole made up of moments which are opposite to those constituting the disease. The application should not be considered as a mere effect of these moments, but as an expedient attitude in general, be it active or quiescent; for the diseased life may require forbearance no less frequently than stimulation. It is the task of heuristics to find the expedient treatment.

§ 275. The true tact, the true genius of the physician, is manifested in his determination of a suitable treatment. Even a genius acts according to rules, though unconsciously, and if the rules are there, they can obviously be discovered. They are based on the nature and relations of things and beings in general, which are perceived by observation and understood by reason. Everything in nature is made to order and to measure, and can only be confused by man in his folly. Everything is based on the equalization of opposite relations, which is called balance in the physical world and justice in the moral world; only man can disturb the laws of this equalization, and if he does so, he proceeds towards his own destruction. Mental disturbance is the expression of the disturbance of this balance in the spiritual life, and the task of the art of healing is to restore the disturbed balance and to equalize the disproportions.

§276. It is always the extremes which bring about destruction; and everywhere the truth lies in the middle. The correct "middle" of human life is reason; and the elements of human life are only clear in reason. The healthy condition of man can only be maintained if the consciousness is clear; but this clarity no longer exists in any kind of mental disturbances, and it is our task to restore it. It will depend on psychic and bodily circum-stances; and violation of these circumstances is the origin of the psychic elements of the disease. These elements above all must be understood by the helper, and recovery is based on the establishment of their opposite, and thus, on the equalization of the unequal.

§ 277. But this equalization cannot be aimed directly at the elements of the disturbances but only at their products, which in the form of morbid conditions can be observed by the physician. These are the hieroglyphs which must be interpreted, and the magic pattern of the elements and their solution also mean the destruction of the power and the being of these elements. The kind and degree of the form of disease are given and determine the heuristic procedure. Heuristics must grasp the nearest ends of the morbid manifestations in order to gradually unravel the entangled skein.

§ 278. The first task of heuristics is to find out whether or not the given morbid state really needs help from outside; not infrequently the healing power of life itself brings back onto the right path an individual who has strayed from it. In such a case the only duty of heuristics is to find the moments when the doctor can quietly observe, that is, establish the rules of the anticipated method. But its next task is to establish a course of action when either exaltation or depression, or an alternating mixture of both, manifest themselves. Thus, heuristics must search for means to counteract these conditions; and this is its second task. Its third task is to find the specific methods aimed at eliminating the morbid manifestations of the disposition, spirit, or will. Its fourth task is to eliminate any distinct traces of somatic-organic affections which are associated with psychic disturbances and are their external, changeable manifestations. Furthermore, allowance must be made for sex, age, constitution, temperament, and personal situation of the patient, and the determination of the procedure suitable thereto is the fifth task of heuristics. Finally, since there are many diseased conditions of the soul against which the art of the doctor, at least in its present stage, is powerless, it is the sixth task of heuristics to undertake some sort of regulation of the anomalous condition in order to alleviate the fate of the sick and the complaints of those looking after the patients; and this is the so-called palliative method. It should be clear that there is really no most or least important point but that the attention of the physician must be given to all sides at once.

§ 279. But in addition to all these efforts, and independently of them, heuristics should also strive, in a quiet and unassuming manner, to find a way of restoring to normalcy the unhinged soul through bold, direct interference with its injury, that is, in a direct psychological manner (but not in the meaning of Reil), rather than through a competition of different rules or concentration of many different methods at a single focus; not through an indirect, but through a direct psychic treatment. Heuristics must create this force, or at least must postulate its existence, and must find ways of mastering it and the rules which govern its use. If this attempt is successful, all other methods will become mere auxiliary and minor procedures, and will be applied as main treatment only by those physicians who are incapable of raising themselves to the highest stage of their art. Heuristics is driven to take this course because there are so many cases in which all its resources are in vain and its ordinary forces ineffective, since it is the disease which is the more powerful. It has enough time to let its difficult work mature, since no one expects it to do more than it has done so far, and its attempt to complete what is missing is useless as far as its other attempts are concerned. But the gap in the art is too wide, and everything must be tried to bridge it. Heuristics risks nothing by making the attempt.

§ 280. Thus we may speak, though initially only in a tentative manner, about a direct psychic method of treatment of morbid states of the psyche, which will walk by the side of the combination of indirect psychic methods without disturbing them in the least, and if it is properly developed, all the indirect methods can be dispensed with. We shall accordingly divide heuristics in the meaning of the art of methods into two branches, the fruit of one whereof is the indirect psychic method kat exokhen, while that of the other will be called the direct psychic method. In our presentation one will follow the other, and the appellation method will be reserved only for the two opposing main treatment procedures, while all the members included in the indirect psychic method (which were also hitherto named methods) will henceforth be named moments of this method. Their provisional names may in future be replaced by better ones, but for the time being we shall establish the following system.

Subdivision la

Indirect Psychic Method

1st moment: negative treatment; 2nd moment: gradual treatment; 3rd moment: formal treatment; 4th moment: individual treatment;

5th moment: somatic auxiliary treatment;

6th moment: palliative treatment.

Subdivision lb

Explanation of the Direct Psychic Method in the Meaning Used in this Book

§281. We shall remind the reader that our previous considerations, as well as the list of moments just given, indicate that the scope of the indirect psychic method as we understand it is much wider than that given by Sandtmann ( §147). We shall say no more about this, since if he has followed all that has been said so far, the reader must well know that our view is the following: in whatever way the mentally ill are treated, a successful treatment must always be psychic, and since the patient can be affected by the various treatments only indirectly, it must be an indirect psychic success. For the truly mental patient will not let himself be influenced by reason unless it comes to him not in words but as a forceful action; and a man's psyche can be directly affected only by reason. Thus, the moments described in the preceding paragraph have only an indirect psychic effect, but their scope is much wider than the circle drawn by Sandtmann, which merely comprises the various counterstimuli.

Subdivision la

INDIRECT PSYCHIC METHOD

Chapter Two

FIRST MOMENT: NEGATIVE TREATMENT

§282. Where nature does its own healing, the physician must stand idle. But the question arises as to whether this healing activity of nature also takes place in mentally disturbed persons and, in general, if the lost freedom of consciousness can be reestablished at all through the laws of unconscious nature. If we conduct faithful observations of all the morbid conditions of the psyche, we shall see that in all such conditions the psychic nature is totally bound to the somatic, is totally lost in it, totally dependent on it and determined by it; therefore physicians can hardly be blamed for considering such conditions as bodily diseases. Erethism or torpor of the life of the brain or the vessels, morbid tension or exhaustion of fundamental organs active in the formative task, such as liver, spleen, uterus, etc., upset of the entire ganglion system; all these structures, separate or combined, persistent or alternating, are also carriers of morbid conditions of the psyche; and in as far as each morbid organ can be brought back to its normal condition by nature, that is, through organic vitality and organic laws (which is actually known to happen more or less frequently), we may conceive of a natural cure in this sphere of morbid manifestations as well. The only question is: to what extent is such a conclusion confirmed by experience? Before trying to answer this question it is necessary to define more exactly what we under-stand by natural help or natural cure.

§283. Neither a healthy individual or a healthy life, nor a sick individual or a sick life can exist when detached from outside effects. When we see one we thought dead wake up from his asphyxia in a closed coffin, because the stimuli of air and light were prevented from acting on him, and this oppressive force is sufficient to awaken a vital energy which is almost exhausted and needs nothing more than complete quiet, we may well think that no external influence was needed to maintain this life or to resurrect it, at least for a short while. But does not the fact that the patient was put in a coffin constitute external influence? Or is it no external influence that his coffin prevented the entry of air and light, so that the fettered live, once liberated from the bonds of external stimuli, could gather its forces anew?

Had the apparently dead patient been exposed to air and light, he would have in fact died, since his exhausted forces could no longer support these two stimuli; but the small quantity of them still available in the coffin was suited to his condition, and this was the external stimulus needed by nature to help him. This is so in all cases: there must be an external stimulus, even where nature is herself helping, and there is never an absolute but always only a relative help offered by nature. This fact is very significant for morbid conditions of the psyche: nature cannot cure them in the absence of favorable external circumstances; but such circumstances are always a matter of chance, as we are wont to say, and this chance is only seldom favorable. It follows that what is generally known as "spontaneous improvement" is a very precarious thing.

§284. This is confirmed by experience. It is not possible to protect mentally ill patients from adverse circumstances, be nature and chance as helpful as they may, even if no medical treatment is administered. Such circumstances cannot be foreseen. While merely somatic patients are not infrequently guided by a wholesome instinct, mental patients are not aware of such an instinct and may even be guided by it toward destruction quite as often as toward cure. Thus, such patients often tend to throw themselves into the water; while it must be admitted that many are saved by such a plunge, just as many drown, unless saved by a helping hand. Some have been saved by a wound if their instinct demanded that their blood vessels be evacuated, but such a cure cannot be performed without help. Others have been cured by the sheer force of nature, which opened varicose veins in their feet or in their anus; others by dysentery-like diarrhea, others by edema, abscesses, fever, and still others by the very violence of their attacks of mania. But all these cases are very rare, while the diseases themselves are very frequent. What have we then to expect from the negative, expectant, passive, procrastinating method? Can we apply it to every case, as Pinel advises?

§285. The answer of the thinking student, in view of the foregoing, must be: no! And this would have been the final verdict on the negative method, were it not for one of its precepts which has to be scrupulously observed, namely, not to forget to make due allowance for the patient's own vitality. Since, as cannot be denied, morbid conditions of the psyche dissolve into organic defects, even if these are merely dynamic, the fate of the psyche is thereby entrusted to the somatic organism, which obviously tends to balance its disparities. This organism is the means by which the morbidly excited psyche is quietened, and the morbidly depressed psyche is given a new tension. This organism must therefore be kept free of medical intervention in so far as it tends to do this task itself, and in so far as this is patent. The negative method is thus of conditional value, and its application, when properly understood, consists in avoiding arbitrary, overhasty, violent action, and in letting time do its work. This procedure does not speak in favor of the merely expectant method, for rusticus exspectat dum defluat amnis, but limitations are thus imposed on the arbitrary action of the physician if such an action may endanger the laws governing the nature of the patient. In every disease, provided it is organic in at least some respect, something must occur in order to balance disparities, and this is a natural activity which the physician must take into consideration, through a wise application of the negative method.

§286. All that still remains to be done is to list the laws which govern this method. Firstly, the physician must refrain from interfering with the sick psyche in any way, for such a psyche is not accessible directly, unless he has a forceful willpower, of which more anon. Secondly, the somatic organism, namely, the brain and ganglion system, the arterial and venous vascular system with their central points, heart, liver and spleen, and finally, the sexual system, which are carriers of morbid states of the psyche, must not only be considered but protected, since the affection of the organic life of all these points may possibly cause a lysis or a crisis* of the morbid state of the psyche. Consequently, these states, with their somatic foundation, must be treated as critical manifestations of the original suffering of the soul, since we often observe that the original affections of the soul (for example, unrequited love, wounded pride, unsuccessful speculations, etc.), which are the sources of organic affections, disappear together with the organic affections as soon as the patient is cured. Thirdly, the negative method must not set its objective too low, and should be applied not merely to acute but also to chronic conditions, especially when such a condition is periodic. For we know from experience that disturbances of this kind can be eliminated by the healing power of nature, even after they have lasted for several years. Fourthly, it should be remembered that the method must not be considered as indiscriminately applicable under all circumstances, but should only be applied for as long and in so far as the physician has no certain positive treatment at his disposal, and can clearly see that the sick life is indeed attempting to heal itself, as evidenced by various signs and manifestations.

* [Lysis means the gradual subsiding of the symptoms of an acute disease, in contrast to crisis which means its sudden change, either toward improvement or deterioration.]

This means that the negative treatment should not be applied if a cure can be effected more rapidly by positive treatment. Fifthly, even when the negative method is considered absolute, if it ever can be considered absolute, it should never be extended so far as to allow the patients to live entirely in accordance with their own arbitrary will, but they must be made to submit to law and order, a mechanical order if not a true one, and the method must not be allowed to interfere with the working of the institutions established for maintaining such order.

§287. While the nature and the guiding spirit of the negative method is hesitation, quiet expectation, and inaction, it must not be understood to mean lack of observation and attention into which the physician is all to easily seduced if he cannot treat his patients positively. The physician must bide his time like the general, act as a Fabius Cunctator,* but only in order to be able to strike the enemy even more powerfully at the proper time; this is not everybody's objective. This method is either misunderstood or not understood at all, and is thus willingly adopted by those who have no other counsel, do not wish to take too much trouble, and like to make things convenient for themselves, that is, by superficial physicians. And indeed, since this species of physicians is not likely to die out very soon, it is just as well if they content themselves with using this method rather than act blindly, for if the physician is unable to help, neither should he do harm; this is probably the greatest advantage of the negative method.

Chapter Three

SECOND NIOMENT: GRADUAL TREATMENT

§ 288. The negative moment must always be the first step in any treatment, no matter how positive, partly because this is a way of asking nature what it is prepared to do for itself to overcome, the disease, and partly because the physician must not begin to act until he has a solid foundation of observation and until he has carefully studied all the circumstances. What-ever the treatment he eventually intends to apply, his second step must be to bring the mood of the patient to the proper balance; this must be done not only at the beginning but throughout the course of the disease. Neither unrestrained excitation, nor motionless depression, nor a mixture of the two can achieve any useful purpose; all these states lead to the destruction of the patient. The physician must therefore take care, if possible, every day and every hour, that the excessive excitation does not wear out the patient, that the excessive depression does not paralyze his vital forces, and that the continuous succession of morbid tension and depression does not result in a victory of the disease. All these conditions are not signs or manifestations of a helpfully active nature but merely of a nature which has fallen prey to suffering and,since it is incapable of resisting or helping itself, needs external help to restrict the force of the disease, and its own defeated forces need assistance from outside.

* [Fabius Cunctator refers to the Roman general Fabius Maximus (died 203 B.C.) who defeated Hannibal by avoiding direct conflict.]

§289. The state of excitation itself follows certain steps in the ladder of affections: it is on the highest rung of the ladder in mania and related morbid states, on the second rung in insanity and conditions involving insanity, and on the third in the various kinds of dementia. From this rung down, the excitation not merely decreases, but in the absence of complications and the appearance of intermediate conditions it altogether disappears. For melancholia, idiocy, and apathy are the exact opposites of excitation, namely, depression. Thus, for remedies against excitation we can speak about the gradual differentiation of diseased conditions of the psyche with reference to the first three rungs only.

§290. The general name for these countermeasures is restraint or depression. This needs no further explanation, for it is the essence of the task itself. But we must consider the types and degrees of depression: for it is clear that they must be different in mania, in insanity, and in the numerous manifestations of dementia; for the will, the imagination, and the thinking power are three different forms and energies of the creative power of the psyche, which must each be treated in its own way. The will, which is the capacity for action, is manifested in mania as the destructive impulse; it must be restrained in the sphere to which it is related, namely, in the real, three-dimensional sphere. The will must not be given material access to the objects it desires and must be stopped in its path. The unnatural, overtense force must be thrown back onto itself and pressed back into itself and thus be brought to a standstill. This must not be done just once or occasionally, or halfheartedly, but as often, with as much intensity, and with the application of as much restraint as is necessary to oppose the diseased manifestation of the will. As a result, the excessive exaltation is led off mechanically, while the eccentric active power is brought back to norm by force of habit. The general means of restraint is force: it ranges from the mild force of love to external, mechanical-spatial constraint. It is the English who have brought this treatment to perfection. There are many different ways and means laid down in the science of remedies under the heading restraining measures.

§291. The excited imagination encountered in insanity must be quieted in a different way. Only the real, waking life can bring the patient back from his dream world. Through vivid sensual impressions or through the excitation of general consciousness, the straying spirit, preoccupied with motley- colored pictures (insofar as it acts as a formative force and serves the sick disposition which animates it, and prescribes the direction in which it should move and the objectives it should aim at), can be brought back to itself, at least temporarily. These impressions must be made available regularly, periodically, and with as much variation as possible. The particular means to this end should be listed as means of distraction; the inventive Reil must be credited with much that is available in this branch of therapy.

§292. The kind of excitation prevailing in all kinds of dementia is again different: folly, craziness, and foolishness must be calmed in different ways. This treatment is a most difficult art and requires the greatest understanding; for the majority of patients who are sick in this way are intelligent enough to be able to form their own opinion of the persons watching over them, unless these persons happen to be intellectually far superior to them; and it is surprising to hear the most accurate, the most penetrating judgments pronounced by such patients about those who would be masters over them. If the intellect be active in a perverted manner, it can be vanquished by intellect only. The most appropriate and powerful means to be applied in such circumstances is what the French call esprit; it is to be hoped that the physician treating such patients be endowed with the gift of this nation that he may moderate the excessive exaltation of the play of ideas by suitable counterstatements and contradictions which will counteract the ideas of the patient. A simple contradiction or a reasonable speech will not produce the depression, but will merely render the patient more embittered or more excited; but a perverted idea which is in strict contradiction to that of the patient will have the desired effect. But there is unfortunately no grammar of witty sayings, such as can be found in Pinel's treatise for counteracting foolishness. These are the fruits of a witty moment; and thus there is a gap in the science of therapy of the psyche.

§ 293. Nevertheless, it is still easier to depress the morbid exaltation in mania, insanity, or dementia than to excite the depressed disposition in melancholia, the depressed spirit in idiocy, or the depressed will in apathy. But even here, as is known from experience, serious attempts are not invariably unsuccessful. But how can the melancholic be encouraged if we are powerless to eliminate the object of his worry or of his fear? How can we encourage the idiot, since we cannot inspire him with a new spirit, or the apathetic, since we cannot give him new willpower? Unless the physician has superhuman forces at his disposal, there is obviously no question of direct therapy or cure; but we are not speaking of such means. We must accordingly look for an indirect treatment of the psyche which is related to the gradual nature of these diseases.

§294. We can cause others pain much more easily than pleasure; but pain is also a kind of stimulation, and such a stimulation can have a beneficial effect on the melancholic as an indirect stimulus of the psyche. The melancholic can be awakened from his withdrawal into himself and can be torn away from the monotonous ideas which are gnawing at him through bodily sensations only. Loneliness, inactivity, or a closed room are poison to him, and anything that can stimulate his body and keep him in action should be tried. Everything that is suitable in this respect should be listed as distracting, exciting, and pain-producing measures.

§ 295. The idiot needs not so much stimulation as revivification. Can we infuse new blood into his veins*? Then, incidentally, why could not transfusion be applied here? Both idiocy and apathy are the pure antipodes of rage, which is the feared result of transfusion, but which cannot be attained by transfusions in cases of deep depression of the vital force. Thus, if those suffering from idiocy or apathy could be revived by new blood, their dry brain and nerve fibers would also absorb new nourishment, and a new receptivity for the spiritual principle, reason, and for free will would be awakened. This is not the place to develop this idea in more detail, or to describe the particular means of revivification, which will be found in their proper place in the science of therapy. It is certain, however, that no spiritual revivification can take place until the somatic organism has gained new receptivity to all kinds of vital stimuli and has regained a certain measure of force. This also applies to victims of apathy, except that these must also be supplied with suitable stimulation, even by pain-producing means if necessary.

* [Blood transfusion was considered by many a useful treatment of mental disorders in the 17th and 18th centuries.]

§296. This is the treatment by opposites of the opposite morbid conditions of the psyche, in as far as their affections are gradual, for both exaltation or depression. But these conditions are considered here in their pure and simple state only (of the first and second order). It is obvious that mixed diseases (of the third order) must also be cured by mixed gradual treatment, that is, suitably measured, alternating excitement and depression. In general, the proper measure is the supreme law of all gradual treatment, and the physician must not lose sight of this for a moment; it is indeed a test of his technical tact. To excite too much, even when excitation is needed, causes harm; the same applies to excessive depression, even when depression is the right treatment. This "too much" includes too long. Too little, as regards both the intensity and the duration of treatment, is always wrong, as is every half-measure; it is often as a result of their excessive caution and uncertainty, or of their recklessness and exaggerated confidence in themselves, that the most gifted physicians are brought into disrepute and the most excellent reputation is sullied and belittled.

Chapter Four

THIRD MOMENT: FORMAL TREATMENT

§297. Patients with a sick disposition must be treated differently from those with a sick spirit, and patients with a sick will, again differently, since it is the disposition, the spirit, and the will, respectively, which are sick, and their diseases are specifically different. There are also specific differences between insanity and melancholia, which are both diseases of the disposition; between dementia and idiocy, diseases of the spirit; and between rage and apathy, diseases of the will. Finally, the complicated mixed disturbances differ substantially from the simple forms. The question now arises: can anything be done against the definite forms as such? Is there a special formal treatment?

§298. We have already said (§281) that there is no direct treatment, if such a treatment be understood to mean reasoning with the patient, offering him consolation and encouragement, or calming or even reproving him. The entire apparatus recommended by Reil, psychological action on the senses, the imagination, reason, feelings, etc., is also useless, simply because the patient is not receptive. But is this indeed always the case? Do we not see that many such patients can be persuaded to do or not to do something by coaxing or severity? Can we not see that many objects and many persons make a vivid, often beneficial impression on their disposition, on their imagination, and that such patients can be made to do several things, even if these are only mechanical occupations, and that they then often feel better? All this may be true, but only in the case of individuals in whom the disease (insanity, melancholia, rage) has not yet fully developed, or of those who are already on their way to recovery, or who enjoy lucid intervals in their chronically morbid condition. Thus, we shall not retract our statement but shall definitely restrict it to cases in which the form of the disease (see Science of Forms, Part I of this book) is already fully developed. In such cases there is only one rule for all these diseases, idiocy and dementia, melancholia and insanity, rage and apathy, etc., namely, that none of these can be treated by direct psychological methods in the usual way.

§299. In cases where the forms have not yet fully developed, or the patient is on his way back to recovery, or if lucid intervals occur, as in periodic forms, we may properly apply the formal treatment, that is, we may act directly on the energies of the psyche which are particularly involved, and can thus variously influence the disposition, the spirit, and the will of the patient, in accordance with the needs of the moment. Here we can take one of the two courses: we can either act immediately and directly on the affected energies, that is, change the sadness of the disposition by a show of compassion, by giving the patient occasion to rejoice, by making him listen to music, etc., or counteract the defiant, rigid will by the determination and superior strength of our own will, etc.; or else we can affect one kind of energy by means of another, for example, we can influence the will through the disposition, the disposition through the imagination, the imagination through the intellect, etc. The individual cases and the specific circumstances must determine which one of these two courses, or perhaps both, are to be chosen. Here, we have only indicated the general conditions of these two modes of action.

§300. It is an indispensable condition of direct action on the disposition, the spirit, or the will that these energies be receptive to such an action. These energies have a certain independence, even in sick individuals, which by no means avoids direct external contacts but is reinforced by them into a kind of rigidity. Thus, many a disposition is opposed to consolation or diversion, just because someone from the outside wants to console or to divert. Many an intellect refuses to understand truths offered to it by another intellect, just because this would mean understanding an idea other than its own. Exactly the same is true of will, and most people tend to refuse to do things they know they should do. It follows that when applying direct action on certain energies, the greatest caution is required, lest such a futile action also interfere with the treatment proper. In other words, care must be taken lest the patient become unwilling or distrustful and oppose the efforts of the physician because of the useless treatment previously administered. Only a gentle disposition, receptive senses, and a flexible will can be treated directly. It is the task of the science of therapy to tell us how this is to be done.

§301. The most natural procedure is to begin by working on the energy which is the most receptive. Some individuals are insensitive to emotional upheavals, and it is useless to attempt to determine their inclinations or to subdue their will in this way; but their intellect may be open to conviction, it may be the most sensitive part of their nature, and they may allow themselves to be guided by it. Thus, a physician who knows how to gain sway over their intellect has thereby won their sympathy, indulgence,and obedience. But others are immune to any reasoning, even were it to be presented in the form of the most rigorous mathematical proof.* They are not accustomed to determine their behavior in accordance with the rules of reason; they must be influenced through their feelings, senses, and imagination, which are the softest sides of their nature. Insofar as we can humor them in these regions of their being, we can influence their actions. Finally, there are others who have an insensitive disposition and insensitive intellect but can be affected and directly guided through their will. These patients are the worst, the lowest, and the commonest. They are the most oppressed and the most to be pitied, since their lack of independence prevents them from rising to the height of human dignity, and a slavish will is often encountered outside lunatic asylums as well. It is nevertheless encouraging that such individuals can still be influenced in some manner, and can thus be brought back to at least mechanical normalcy. But if even this last gate to psychological treatment is closed, nothing can be done.

This also explains why women cannot as a rule be reasoned with by other members of their household. The reason of women is not receptive to masculine demonstrations, that is, it cannot be swayed by them, but only by senses, emotions, or imagination; and their will can be swayed through this reason or without it. Whoever wishes to guide women must have one of these moments on his side, depending on whether the woman is of a superior or inferior type. Feminine stubbornness, popularly known as "women's pigheadedness," from which no woman is exempt, is probably the result of the fact that members of our own sex appeal to the intellect or to the will of women directly in order to reassert what they consider to be their rights.

§302. The ultimate target of the medical treatment of mental patients must be the disposition of those with a sick disposition, the spirit of those with a sick spirit, and the will of those with a sick will, insofar as formal treatment of morbid conditions of the psyche as definite forms of disease is intended or is possible. The main task is to change the mood of the disposition, to correct the intellect, and to direct the will. In insanity, the disposition which has inflamed the imagination must be quietened; in melancholia, in which all imagination and all active forces in general are extinguished, the disposition must be given a new life. In dementia, those suffering from folly must have their perverted notions of worldly things and their relations converted into correct, natural views; the crazy must have their intellect, which is flying above themselves, returned to its natural sphere. Finally, the foolish must have their foolishness made clear to them. Insight is the magic word for all delusion, all deceit, and all error, even in the so-called healthy condition. No psychic treatment is of any use in idiocy or apathy, because there is no force which could be thus affected. But the physician can try his skill on rage, and it is his task to fence in and to hold the will which has gone wild, and to make it submit again to the rule of law. He who knows how to master himself will also know how to teach others to master themselves. The science of therapy must reveal the motive forces (lever) and their laws to enable the will to be tamed, the intellect to be corrected, and the mood of the disposition to be changed. Our own task was merely to point out the nature, direction, and conditions of the formal treatment, for although this is not the first, immediate, principal, or most helpful element in the therapy, it is nevertheless an essential treatment which cannot be neglected and which gives powerful support to the therapy as a whole. If it is applicable, and we have taken the utmost pains to enumerate the cases in which this is so, the physician who proceeds with intelligence and skill, with enthusiasm and persistence, will hardly ever fail to obtain some successful results.

Chapter Five

FOURTH MOMENT: INDIVIDUAL TREATMENT

§ 303. Strictly speaking, the treatment of a patient should be individual with reference to his disease. But there is also a treatment which is directed at the individual, which we shall call here, in this special sense, the individual treatment. We must take into consideration sex, age, constitution, temperament, personality in general, that is, the character, education, tendencies, habits, and finally the individual circumstances of the patient, namely, his civil, national, and family status. All these must be considered in succession.

§304. Firstly, as regards sex, the second sex, which is more delicate and more excitable, is generally treated more gently and with due regard to this excitability, while male individuals, who are not so impressionable, should be treated with more vigor. There are, however, many exceptions to this rule. First of all, there are many females who are neither gentle nor excitable, in body or in spirit, but who have a bodily constitution resembling that of a man and possess a manly strength or manly stubbornness, and there are males who are just as sensitive and excitable as women. Obviously, in such cases the mode of treatment should also be inverted, since it is harder to bend stubborn women than men. Secondly, even if the patient is really delicate, it is often inadvisable to protect and to encourage this delicacy if it is too marked, that is, if it is morbid and even forms part of the disease itself; for to do this is to increase the evil, and the more one pampers a person, the more of a weakling will he or she become. In such cases it is advisable to be serious and severe, and not let oneself be deluded by the apparent weakness. There is more force in a weakling than either he himself or the physician would think possible. Moreover, in morbid conditions of the psyche, the nature of the patient may change altogether, so that naturally gentle women become unrestrained and wild, whereas energetic, lively men may become subdued and timid. Thus, the rule of treatment according to sex is not absolutely valid; it must be adapted to the circumstances in every case; but in all cases, and no matter what the sex of the patient, opposition to reasonable rules and harmful wilfulness must not be tolerated. Such opposition is often displayed toward medication [ordered] by the physician and to occupational therapy. With reference to these two moments, great consideration must be paid to sex, since women must have special medication owing to monthly periods, pregnancy, etc., and women are also unsuited for certain occupations. For example, military exercises may be suitable for men but are quite unfit for the female constitution.

§ 305. As regards age, we shall distinguish between youth, middle age, and old age. These three ages differ mainly in the ease with which they can be affected, the first being most receptive, the second less so, and the third least receptive. This difference will determine the chance of success of the treatment, and thus the intensity of the efforts made by the physician. Several English and French physicians, for example, recently Esquirol, have published tables of recovery with reference to age, from which it is clear that there is less hope of recovery at a more advanced age. This is related to the vital forces prevailing at different ages. Much influence is exercised by mere force of habit, which becomes stronger with age, until it can no more be overcome. The physician must bear this in mind to spare himself superfluous efforts.

§306. The constitution must be especially considered when administering strong medicaments, and also when imposing work and demanding efforts of the patient, in both male and female patients. For even though most mentally disturbed individuals are not very excitable and can bear strong stimuli without any danger, this rule is not without exceptions. Even individuals with an apparently strong constitution may break down under the burden of vigorous treatment persistently applied. Thus, for example, treatments designed to intensify salivation, even when properly applied, may greatly debilitate apparently strong patients; in particular, it may depress their intellectual capacities, while in other cases it is not only harmless but actually salutary. The same applies to the pouring of cold water over the head of the patient who sits in a warm bath. This powerful stimulant cannot be borne by some patients with apparently strong constitutions but it saves others. This is even more striking when several powerful treatments are combined, such as the salivation cure by means of calomel and cold head showers in a warm bath. The author of this book observed a case in which this treatment, pursued with persistence, ended in the death of the patient. Cox's swinging machine* is another treatment which should be applied with the greatest caution, and every consideration should be paid to the constitution of the patient. A delicate bone structure is not always indicative of a weak constitution, and a solid bone structure need not necessarily mean that the constitution is strong. The author has seen slightly built women withstand very grave diseases and strong medical treatments to which solidly built men succumbed. But we have no more accurate indication of the constitution than a slight or a solid build. Strict attention should accordingly be paid to quid valeant humeri, quid ferre recusent.

* [Cox's swinging machine (or rotatory machine) was a sort of chair suspended on a rotating hook which, by creating centrifugal movements in the patient tied to it, supposedly led to his improvement. It was first described by the English psychiatrist James M. Cox (1763-1818) in his book Practical Observations in Insanity (1804).l

§307. The temperament should be observed from two points of view: firstly, with reference to its reaction to medicaments, and secondly, with reference to its reaction to psychic treatment in general. Lively temperaments, such as the sanguine and the choleric, bear irritation and stimuli less readily than the phlegmatic and the melancholic. The former tend more to inflammatory and the latter to paralyzing diseases, and there-fore the former are more responsive to negative, depressing treatments, and the latter to positive, exciting ones. However, psychic experience shows that the gentlest, softest treatment should as a rule be applied to patients with sanguine and choleric temperaments, since these are the most changeable and the most easily excitable, whereas temperaments of the opposite nature must experience a more vigorous, more strongly interfering attitude. Very recently, the author had occasion to observe a highly intelligent man with a choleric temperament, who had the misfortune to fall prey to folly at an advanced age. His entire disease took an enforced, unnatural course, since his temperament had been disregarded from the outset in the psychic treatment, or rather in the entire attitude of the physician. This patient had been exposed to various stimuli and irritants, with the result that his naturally very mercurial temperament became irritable to a point bordering on mania, which weakened him more than it should have on account of lack of sleep, his refusal to take any nourishment, etc. Thus, the strictest consideration for the temperament of the patient is one of the first duties of the physician.

§ 308. In general, it is just as much to the credit of the physician as to the advantage of the patient if the latter's entire personality is taken into account; otherwise, much damage may be done. The traits of the patient's personality to be considered are his character, education, tendencies, and habits. Gentle, flexible, benevolent natures must be treated differently from those which are rough, rebellious, and malicious. The former need the utmost mildness and friendliness, the latter must be impressed with marked seriousness and insistent severity. Kindness and love make the bad fellow even worse; a rough, brusque attitude makes mild persons timid, excited, or even refractory. An educated, intelligent patient must be treated differently from an ignorant, dull one; the former must have intellectual appreciation and reasoning and must be given the opportunity to exercise his intellect as soon as his illness permits, while a rough, spiritless individual must be mechanically occupied in a suitable manner, since he is not receptive to a finer intellectual approach. The patient's inclinations and habits should be respected and taken advantage of, provided they do not actually promote the disease and are not harmful. This is because, firstly, they may provide some indication of the nature of the disease and of the patient, and secondly, because they give the key to many a curative treatment, since the life of the patient depends on his inclinations and habits, and because their satisfaction or lack of satisfaction at the right time and in the right manner binds the patient to the physician and makes him submissive to him more than any other treatment. We thus have a veritable rudder with which we can steer and divert the patient in the desired direction, provided that he is still capable of expressing his inclinations and habits. All doctors of the psyche agree that this satisfaction is the best means of encouraging and stimulating the patient, whereas refusal to satisfy such inclinations is one of the best means of restraint at the disposal of the physician. As an example, we shall take snuff. The offer of a pinch of snuff made at the right moment often works half-wonders. It is the first duty of the physician to study the habits and inclinations of his patients, and a physician who fails to do so does not know his patients and is not fit to treat them.

§309. Finally, a very important moment is an exact knowledge of the individual situation of the patient, which is often the sole explanation of the disease, or at least of its main features, and is thus a clear indication of what is beneficial or harmful to the patient. The more we know of the individual situation of the patient, the more indications we gain of the proper treatment to be followed. The less we know of it, the more difficult will our task be. Very much depends, for example, on whether a patient who previously held public office had assumed it willingly or unwillingly, had occupied it efficiently or inefficiently, and whether he had been successful or unsuccessful in its execution. Or whether he had failed to obtain a greatly desired office or business, or had failed in it, or generally, whether or not he had been brought up and had worked in accordance with specific talents and inclinations, or whether he had suffered an accident, a slight, or frustration of his dearest hopes. It is just as important if someone is integer vitae scelerisque purus or if serious sins or crimes are burdening his conscience, or whether he had enjoyed general respect or suffered from general contempt. Briefly, the patient's station in life has the most significant effect on his psychic condition and merits the most accurate study. The nationality of the patient is also most relevant to his condition. How different if a foreigner falls sick far away from home or is sick in his own land! How important is the longing for one's own country, for the loved ones so far away, for one's own friendly, accustomed surroundings! Such longings can even produce a specific disease known as nostalgia. Whenever a case of disease of the psyche occurs, at home or abroad, how different is the course of the disease in people of different nationalities! An Arab and an Icelander can both fall victim to mania, but the former is driven into mania by the heat of love, and the latter by his consuming anger; the former rages in song, the latter in murder. Such vast differences do not occur at very great distances: how different is the course of a disease of the psyche in different Europeans according to the temperament of their countries, their climates, and their soils! How different is the behavior of northern and southern Europeans! Holland, England, Germany, and Switzerland are the countries which produce melancholia, while Spain, Italy, and France usually produce more lively psychic affections. But, as we have said, at home or abroad, if an Italian, a German, a Frenchman, etc., falls sick with a disease of the psyche, due regard must be paid to his nationality when deciding on the medicaments and the psychic treatment. Even in somatic diseases, the medicine of each country is very different, and indeed must be so. We Germans are inclined to smile at the "tisanes" of the French, and at the light southern treatment in general, but such a treatment is the custom of the land. Thus, any foreigner who falls victim to a mental disease must be treated, if not by a doctor of his own nationality, at least in accordance with the custom of his own land. To disregard this is to the disadvantage of the patient. And, last but not least, the domestic circumstances of the patient are very important; indeed, we are most inclined to consider this moment as the most important, for no relations are more intimate than domestic relations, even if the patient leads a nomadic life. No physician needs to be told how very important such an influence can be, or what the all-inclusive term family relations means. The economic situation is also included in domestic circumstances. It is of decisive importance, not merely for the mood of the moment but for the entire life, or at least for long periods thereof, if one's relatives are loved and loving, or hated and hating; whether they support the patient or refuse to do so, or perhaps are themselves badly in need of support. It is very important if those directly around us lead a well-ordered, clean, pure, noble, lawful, spiritual, and seemly existence, or if the opposite is true. For a man sees and feels through his own world. If he always sees and experiences that which is repulsive, his blood is turned; and blood is the seat of life, at least according to the views of the ancients. Finally, a difficult economic situation is a hellish torment, most of all to weak, fearful, and hesitant souls, and more than anything else can produce and maintain mental disturbance. Even fear of being poor, even an imagined fear, can do much harm. Who can say he has never seen such unstable people? Nothing of this should be missed by the physician of the psyche, nothing must be considered as too insignificant to be worth observing. Even if he cannot help, the physician will at least learn why his efforts must remain vain.

Chapter Six

FIFTH MOMENT: SOMATIC AUXILIARY TREATMENT

§310. This treatment, although its ultimate result is psychic, is called somatic because it directly affects the bodily organism. It is called auxiliary because it is only a link in the entire chain of the other healing moments, and not a vital one, but merely an auxiliary of the others. For the elements of all mental disturbances, namely, the mood of the soul and the stimulus, though partly caused by somatic conditions, are still essentially psychic, that is, moral, and can be removed only indirectly by somatic treatment. This remark is not in any way intended to detract from the importance of this treatment, which has already been acknowledged (§278), but is meant to show it in its proper perspective.

§311. Since the medium through which one man can influence another is always something spatial, that is, something bodily or material, be it merely air or light, and since we can affect the psyche of another person only through his physical organism, it follows that material agents and bodily affections are needed for spiritual communication as well. Thus, we always require somatic means, which are as many as the ways in which a man can be affected by his nearest and more remote environment. These are also needed to satisfy the conditions of gradual, formal, and individual treatment. They include the entire field of nature and art which can be mastered by man. Light and air, water, garden and field, food and drink, all medical and surgical healing devices, also: enjoyment and abstention, reward and punishment, work and leisure, various ways of distraction or concentration at different cultural levels; all these are effects which cannot be imparted without somatic media and somatic affections.

§312. But this is not what we mean when we speak of somatic auxiliary treatment. This treatment is merely aimed at eliminating somatic hindrances and at treating the imperfections of organic functions and the bodily organism. The objects of this treatment are the functions of digestion and respiration, the skin and the genital system, vascular and nerve systems, insofar as these are defective because of dysfunction of the respective organs. This treatment is thus conventionally medical and follows the indications of somatic medicine, which are less frequently prescribed for mentally disturbed than for ordinary patients. The complaints treated here are isolated instances rather than real, acute diseases. They include insomnia, constipation, dryness of the skin, congestions, convulsions, and paralysis which in mental patients, especially chronic cases, must be very carefully observed by the physician if he is to cure them. Below we shall regard these complaints from the heuristic point of view.

§ 313. Insomnia in diseases of the psyche was observed even by the ancients, as can be seen, for example, from the rules established by Celsus. And, indeed, morbid excitation is maintained by insomnia to no small extent. But it is not enough to search for the various causes of the insomnia, which is obviously necessary if it is to be totally eradicated, but we must also observe how far its effects may be salutary as well as harmful, and the treatment must be suited to the results of this observation. The sources of insomnia are usually psychic-somatic, but any sphere of life taken alone can be the exclusive cause of it. Even if we are healthy, we cannot sleep if we are intensely preoccupied with some object; we cannot sleep if we are constantly kept awake by some irritation of the blood, nerves, skin, or abdomen; if both causes happen to coincide, sleep is even less likely. This is also the case if the patient is mentally disturbed, and for this reason sleep-inducing medicaments (narcotica) are seldom indicated. Since the causes of the insomnia of such patients are seldom properly investigated, the insomnia is only rarely over-come. Even if the psychic and somatic irritations of vascular and nervous systems, intestinal tract, skin, sex organs, etc., are found, insomnia cannot be eliminated in all cases. But are we always aware what we demand of our-selves and of nature when we wish to eliminate insomnia? Prolonged insomnia exhausts the vital forces, wears out the organs themselves, aggravates the general condition of the patient, and drives him to the last extreme; but who knows if this deterioration of the general condition and the excessive tension may not presage relaxation and incipient return to normalcy? We often observe that the most violent manias and mania-like conditions are reduced by sleeplessness from their climax to relaxation, quiet, and even sleep. To make the patient relax or sleep by force would do even more harm than would the prolonged insomnia itself. Accordingly, unless it is clearly seen that sleep is driven away by external stimuli which can be eliminated, it may be best, at least in the initial stage, not to treat the complaint, but to observe it carefully. If we desire to help, the seat of the irritation must be known exactly. A purge, bleeding, vesicatories, a glass of old wine, and more rarely opium and similar medicines, may be helpful on different occasions; and the individual cases can be distinguished by the diagnosis of the somatic physician.

§ 314. Constipation is always a bad sign, and one which very frequently appears at the beginning of diseased conditions of the psyche. Both exal-tation and depression can be responsible for its appearance and persistence. It has a harmful effect on the condition of the patient. Physicians who treat such conditions always administer either mild or drastic purgatives, both at the beginning and during the entire progress of the disease. Some physicians prefer the former, others the latter: suum cuique. Not every patient, and not even the same patient at all times, can bear the same treatment, and the individual excitability must be known exactly. No harm can,be done if the treatment is begun with mild medication, as suggested by Pinel. Everything at its proper time. Bisogna adattarsi (that is, one has to do the best he can), says the Italian, and every physician should repeat this motto to himself every day and apply it in his treatment of the sick. We should add that in the treatment of constipation itself purgatives alone do not always help, and bleedings and baths may be required to overcome it. This must be determined by experience. Also, it is not sufficient to administer purgatives once or several times to cure constipation. In fact, the worst cases of constipation known to the practicing physician are often those produced by purgatives. To cure constipation means to restore the tone of the intestinal tract. Somatic therapy tells us how this is to be done.

§ 315. The skin was observed and treated by the ancients, even much more carefully than by us, both in mental and in other patients. Baths and frictions were daily routine, so that the sick and the healthy alike enjoyed a fresh, active skin. In most mental patients, especially in melancholics and in maniacs, the skin has a dead appearance and resembles dry leather or parchment more than a living organ of secretion. No one needs to be told how much this affects the nature of the vascular system and its contents. We must accordingly regard the skin as an organ which in these morbid conditions requires being considered first, and through which a decisive effect can often be exercised. It is one of the first duties of the physician to render it receptive to stimuli, and thus also to restore its role as a stimulant of other organs. We do not mean stimuli which are applied to the skin in order to produce an indirect psychic effect, but only of the revivification of the skin. Here, the ancients must be our teachers and our models. Thus, baths and frictions are to be recommended; and why not also massages, which are even today used to such good purpose in the Orient? But here, too, doctors disagree about baths. Pinel, for example, disapproves of cold baths. Here, too, everything must be done at the right time and place. The tepid bath is an excellent sedative, while hot and cold baths stimulate and revive in opposite cases. Cold baths do nothing to help a dessicated, almost dead body, while a hot bath is no use to one whose blood is boiling. What use is Currie's pouring of water in internal heat? Or Schmucker's compresses on the head? * Therefore, give cold baths to maniacs, hot baths to melancholics! In general: the more powerful the excitation and the tension of the vascular system, the colder the bath should be; the deeper the depression, the hotter the bath should be, and the hot bath water should be taken from a mineral spring if the patient is lucky enough to be near such a spring.

§ 316. It is only in cases of evident congestions of the head and chest that other means must be employed, and neither a cold nor a hot bath can be used immediately and directly, without suitable preparation. It has already been said that congestions in general must be treated in a specific manner. They are always passive symptoms and must never be tolerated. The physician must first trace their source. This will often be found in the abdomen; and such a case must be carefully diagnosed and cured. But congestions may also be brought about by a generally over-tense vascular system; this may be accompanied by special stimulation of the cerebral system, or else the stimulation of the cerebral system may appear alone. A true plethora can be treated only by bleeding; false plethora only by draining, as prescribed by somatic therapy. Cerebral affections are treated in the same manner. The two cases must be carefully distinguished, since any mistake is very harmful to the patient. This is why bleedings are so often contraindicated in mania, but this is not to be taken as a general rule. Pinel, too, is against bleedings, while other physicians regard bleedings as the only effective treatment of mania. The one-sidedness of these views is evident. Mania may be asthenic or hypersthenic, just as plethora may be true or false.

* [These were obviously two contemporary methods of using cold water externally to relax patients in a state of manic attacks.]

The author of this book had the occasion to observe a completely exhausted onanist, who fell victim to periodic attacks of mania with all the signs of violent head congestion. His eyes were bloodshot and glittered fearfully, his face glowed, his neck arteries pulsed; the patient could be restrained only with the greatest difficulty. He died of utter exhaustion. Who would be so reckless as to advise bleeding under such circumstances? Especially as it is well known that it is not the strong bodies which convert their plastic material to a mass of muscles, and even less the spongy bodies which deposit it in the fat cells, that can withstand a serious loss of blood, however unrestrained their behavior during attacks of mania may be. But it is the lean bodies, with the so-called stiff fibers, which accumulate a rich reserve of plastic substance in the filled vessels that acts as a stimulus of disease, and depending on the circumstances, creates inflammations of all kinds and plays an important part in manias. In such cases the blood gushes out of the vein, as though rejoicing over its liberation from the prison in which it had to rage against itself, in a wide arc, rapid and hot, and as soon as it is caught in the vessel it forms a yellow or a green crust, and thus displays its morbid excess of plasticity. Who can say that bleeding is inadvisable in such cases? Here it can produce only relief and peace, and not weakness or idiocy, even when it is repeated several times and large quantities of blood are withdrawn, until the inner storm has abated. Here the blood is only a burden which is taken from the patient, a burden which oppressed the organism, a mean feeling which inspired him with fear and drove him to distraction. This is an opportunity for the opponents of the psychic origin of mental disturbances to turn our own weapons triumphantly against us and tell us that this morbid condition of the vascular system and its contents is a clear proof of the bodily nature of mania. We would like to remind them, however, that this morbid condition is only the product, the final result and the imprint of a totally perverted way of life, which for so long in an unnatural, psychic and somatic way has become overtense, overfilled, and overexcited by passions, strong drink, and luxurious living in general. The life has strayed from all measure and all order and has so far forgotten all the objectives of reason that now the storm in the bodily organism is merely an external reflection of the internal condition, the former being caused by the latter and not vice versa. We again see that the view according to which mania or any other mental disturbance is a purely bodily condition is very one-sided.

§ 317. It is known that mental disturbances, especially periodic mania, often alternate with epilepsy, the latter being a kind of crisis of the former.

It is regrettable, however, that the crisis again becomes a periodic form of disease, or rather is repeated periodically and is never completely decisive. On the whole, once such crises have appeared, it is clearly seen — and this is also confirmed by experience — that the patient will remain in a morbid condition for life, in spite of all the arts of medicine. The same is true of paralyses which sometimes appear instead of epilepsy. Once this change in the form of the disease has taken place, the task of the physician becomes simpler, and the physician must at least attempt to eliminate his bias for schematism in accordance with the rules of his art, as supplied to him by somatic therapy.

§ 318. This ends our description of a few of the most common cases which require somatic auxiliary treatment. We do not end this here because no other such cases are known but because it was only our intention to show that the physician of the psyche cannot avoid acting as a physician of the bodily organism, no matter how lofty the standpoint from which he contemplates mental disturbances and how wholeheartedly he appreciates their mental aspects. Somatic auxiliary treatment will always remain one of the main chapters in psychiatry, even though such a treatment will not be required in all cases. Many of the mentally disturbed, especially when their condition is persistent, enjoy not only apparent but real good health. In fact, the task of the vegetal organism appears to proceed with fewer impediments and more perfectly if the life of the psyche is less active.

Chapter Seven

SIXTH MOMENT: PALLIATIVE TREATMENT

§ 319. Just as negative treatment must be the first, so the so-called palliative treatment must be the last to be applied. If we take the word palliative literally, it is obvious that a palliative cure is worse than no cure at all; for to hide or mask a disease, so that it is not apparent, as not infrequently happens in syphilitic complaints, means to make the evil worse. Fortunately, however, mental diseases cannot be masked, unless the patient is removed out of sight. It is preferable, accordingly, to use the word in its broader meaning, namely, an attempt to ease the suffering due to diseases which apparently cannot be cured. This must therefore be the main treatment in institutions which are no more than asylums and do not claim to cure diseases. In hospitals, palliative treatment is an essential condition of the behavior of the personnel in general towards the patients.

§ 320. The lot of those who may still perhaps be cured and of those suffering from mental disturbances which are considered incurable can be eased in many ways: firstly, by treating the patient with due regard to his individuality, that is, his qualities and inclinations, temperament, character, education, etc.; secondly, with reference to physical suffering or unpleasant sensations in general, whether or not these are connected with his disease; thirdly, with reference to his bodily and mental welfare, diet and care, clothing, accommodation, environment in general, small distractions and amusements, as well as occupations or jobs of work which are suited to his forces.

§ 321. Firstly, with reference to the treatment of the patient in accordance with his individual character; this must differ according to where the patient lives: in his own home, in a hospital, or in an asylum. Physicians agree that, as a rule, it is not good for the patients to live with their families, even if they are treated with the greatest friendliness and helpfulness. The patients do not acknowledge this, and now hate most those they ordinarily love best; thus the members of the family, too, gradually become impatient or indifferent and lax, especially as mental disturbances usually last for a long time. But very often mental patients cannot live with their family at all, for a household is meant to be lived in by persons respecting law and order, whereas such patients overthrow all law and order. It is therefore no wonder that the patients think that they are in repulsive, hostile surroundings. Moreover, no matter how good their intentions, relatives, friends, or servants are ignorant of the proper treatment to be applied, with the result that the patient is sometimes treated with too much consideration, and sometimes with too much severity, and is invariably stimulated to wild excesses through the well-meant zeal of those around him. But not infrequently those around the patient simply try to push him aside through neglect, through all kinds of slights, and through hostile and generally inappropriate behavior. It is then obvious how great the misery of such patients must be, and it is not at all surprising that they soon change for the worse beyond all recognition. Therefore, by the time the patients are finally sent to lunatic asylums, their forms of disease are distorted, degenerated, or piecemeal. The author of this book had occasion to administer prolonged treatment to an idiotic young girl, who had sunk to an animal level. She had become insane through love, and raging through harsh treatment, and then, after her forces were exhausted, she became an idiot, and could be brought back to a semi-human condition only after treatment in an institution for several years. But even in lunatic asylums of former days and in many such asylums in our own day, patients are not infrequently treated in contradiction to their individual character, if such institutions are imperfectly organized, mainly as concerns discipline. For this reason, institutions such as the hospital at Sonnenstein or the asylum at Waldheim,* in which these imperfections have been largely overcome, cannot be praised highly enough. Pinel already indicated, vigorously and humanely, the most important measures which must be implemented in this respect, while Reil acquired lasting merit for himself by his exhaustive listing of ideas for an improved organization of such institutions. All the ideas that could be realized at the time and under the circumstances were, in fact, carried out in these two institutions: wise and vigorous supervision from above; expedient, generously provided equipment; and suitably chosen personnel. All these make it possible to ensure that the first and last duty of the physician, namely, consideration of the individuality of the patient, is fully implemented in these model institutions, and we cannot but wish that all other institutions will soon follow in their footsteps.

§ 322. Secondly, for relief of the bodily and mental sufferings of mental patients, much can be done by careful, well-organized medical and surgical care. A healthy diet, salutary premises, and maintenance of cleanliness will do much to relieve the diseases which are already present and to prevent possible outbreaks of new diseases. Mental patients often suffer from chronic physical complaints of various kinds: ulcers, hernias, digestive disorders, etc. If these are neglected, they make their general condition much worse. Patients may also suffer from acute diseases such as intestinal or rheumatic fevers but are less sensitive to epidemic diseases. Patients treated by the author of this book include several with chronic complaints, who have to remain in bed for periods of several weeks or longer, and require somatic medical care and treatment. Since they do not complain much, but suffer physically and lie quietly in their corner, they could easily die of neglect without anybody knowing why; this would hardly be to the credit of humanity in these abodes of misery. A recently published pamphlet by Dr. Hainer in Waldheim exposed much worse practices, such as beatings, heedless constraint of the patient, and even imprisonment of the patients in chains in dark, damp places where vermin reign.

* (The hospital of Sonnenstein, in Saxony, opened in 1811 under the direction of Dr. E. G. Pienitz. In 1817, the asylum of Waldheim was transferred there. Enlightened methods of treatment were introduced in it under the influence of Esquirol.1

§ 323. Thirdly, for the actual welfare of mental patients, very much can, in fact, be done, provided that this task is undertaken with seriousness and love. The main requirements are those already mentioned: a healthy diet, good accommodation, cleanliness, and also suitable, comfortable clothing, which must be adapted to the needs and habits of the patient and the season of the year. Much can be done to improve the welfare of the patients by walks in the fresh air, country trips, small distractions and pleasures, and by occupying those fit enough to work in the garden, in the fields, in housework, and in various workshops. Reil submitted excellent re-commendations in this respect, which deserve careful attention. These have been partially implemented in some places after having been modified according to circumstances.

§ 324. It must again be stressed that the mental hospitals and asylums in Saxony are much better in this respect than many others. In his travels this author saw many other institutions which are not in the same class at all. The beautiful and healthy location of Sonnenstein is quite exceptional. The buildings, down to the last detail, are suited to their purpose, friendly, and cheerfully furnished. The entire environment is extremely pleasant; everything possible has been done to provide for gardening, agricultural occupations, indoor tasks and recreation, as well as outdoor games. The sick inhabitants of the institution seem to be members of the same family as the healthy, and are in fact treated as members of the family who are minors or sick. There is no trace of inhumanity, recklessness, or neglect. Both higher and lower officials know their duties, their position, and their limitations. The entire institution is aimed at healing the sick, or at least at preventing deterioration of their condition. The asylum at Waldheim is no less praiseworthy in this respect. Despite the large number of chronically disturbed patients of all kinds in this spacious institution, it is most peaceful and smoothly run, and the patients receive the best care, both economically and medically. Here, too, patients are taken on attractive walks in charming gardens, are allowed to breathe fresh air, and can enjoy themselves and pursue their occupations without being disturbed or disturbing others. It is particularly praiseworthy that an exact daily routine is adhered to and is carried out by all patients, except those whose condition is weakest or most degraded, mechanically and from force of habit, but still willingly and without grumbling. For it is exactly the mechanical habit which affords the best relief of the sorry state of chronic mental patients. Physicians or even laymen who have seen these two institutions will testify that our creditable mention is not dictated by some blind patriotism, but is no more than the rightful due of the persons ensuring such wise and gentle care. And when the present book, sooner or later, is set aside as no longer useful, this mention of the two praiseworthy institutions will at least remain as something worth noting, and the time will be praised which produced not only many perverted human strivings, but also activities which were unmistakably just and beautiful, and are even now bearing fruit.

Subdivision Ib

PROPOSALS FOR A DIRECT PSYCHIC METHOD

Chapter Eight

PRESENTATION OF THESE PROPOSALS

§ 325. All the moments of the indirect psychic method so far described still leave much to be desired; for not only do most chronic conditions defy all attempts at medical help but many diseases with an acute initial stage, even when the physician is able to treat them at this early stage, inevitably pass into the chronic stage. The easiest to cure are the essentially bodily affections in which the psychic anomalies are merely accompanying symptoms. These can be seen in fevers with deliria, in which the deliria disappear after the storm in the bodily organism has abated. Here the principal moment is fever as the somatic affection; there are also idiopathic- somatic affections which are not accompanied by fever but also symptomatically attack the psychic life and interfere with it; all of these, e.g., worms, are powerful irritations of the ganglion system. The author has seen a delirium, which exactly resembled mania, disappear as a result of one drastic purge, since it was merely a reflex of the ganglion system irritated by worms. But mental disturbances proper, which result from a morbid soul life, are not of this type, even if they are accompanied by an affection of the somatic organism: the roots of the evil lie deeper, and a more radical treatment is necessary. In the indirect psychic method such a treatment is mainly directed at the somatic organism but should really be directed, in a direct psychic method, at the sick soul itself, in the most decisive, rapid, and sure manner, if such a procedure were only possible. It would be the crowning achievement of heuristics to invent such a method. In his dissertation (see above) "De voluntate medici medicaniento insaniae" (that is, "On the Will of the Physician in the Treatment of Insanity"), this author had the temerity to propound a hypothesis, which may appear paradoxical, but only seemingly so, because it claims that man possesses a force which is not evident in his ordinary, everyday life, and is therefore assumed to be nonexistent. This seems to be the proper place to discuss the main features of this hypothesis and to subject it to the test, not merely to the test of theoretical criticism, but above all to the test of experimental practice; for here only experiment can give the final answer.

§ 326. We must realize that men, with all their science and art, are degenerate and crippled beings. Our highest capacity for art and science is as nothing compared with the abundance of the vital force, insight, and efficiency which could be ours if we could only break the fetters of our sinful existence and breathe in the element "of the wonderful freedom of the children of God." This is not fashionable hypocrisy, slavish pietism, morbid mysticism, a fantastic dream, or blind superstition, but the result of a quiet, considered, clear contemplation of human nature insofar as it can serve us as the ideal of the utmost purity. We may be reminded, if we proceed carefully, that the word ideal may negate our presumption, since an ideal is something that cannot be realized. This we must deny. The purity and honesty of a human being and everything that is connected with these and follows from them are by no means unattainable but can be attained only by way of religion. But we recognize no other truly religious standpoint than the saving faith which was brought by Christ into the world and was proclaimed by the Apostles. Since this is not the place, and neither is it our task, to defend this point of view or to lay down dogmas, we have to bear with all shoulder shrugging, head shaking, etc., on the part of the reader, and must not be surprised if he refuses to continue reading. All we can do is to exclaim with Goethe:

"Eines schickt sich nicht fur Alle.

Sehe Jeder, wie er's treibe;

sehe Jeder, wo er bleibe;

und, wer steht, dass er nicht falle."

* [What is seemly for one is not seemly for another; each man must decide what he is to do; each man must decide where he is to stop; and he who stands must see that he does not fall.]

The author now announces to all who will listen that his purpose in life is the saving faith which "leads from the power of Satan to God," and that his soul will find no peace except under this watchword. This belief is and has a Divine Power: it is the power of the unshakable faith in the eternal Power, Wisdom, and Love in which we "exist and live"; it has the power to raise us above our own selves and our selfish existence and above a decaying world and the Kingdom of Darkness with its nightly terrors, to free us from the bonds and fetters of death, that is, of mortality, to which every believer is chained, and to lead us into the Kingdom of Light and Love and Force. We are powerless if deprived of faith, if we rely on nothing but ourselves, on our material possessions, our insight, our love, that is, on our selfish instinct; for our force is a broken reed, our insight a blind guide, and our love a restless desire which is never satisfied and which devolves upon mortality. But we are strong in and with the Faith, that is, in the pure, firm attachment to the eternal, holy Existence or the living Truth, and in our inseparability from and identity with this Truth; for this means faith. Faith is a total devotion of our being to this eternal, holy Being, who has manifested Himself to us in the most glorious clarity and magnificence in Christ, in the Word, in the Reflection, in the Source and Abundance of eternal life. This faith saves us, liberates us, and purifies us of all stains and impurities of our finite nature. When immersed in this faith, filled with it, and penetrated by it, we are purified and made holy, we are inspired by a new, higher life and its vital force, and have entered the Kingdom of Light and Love. The Apostles lived and acted in this faith; this faith was the anchor and the principle of their lives, and thus, filled with the Divine Spirit and Divine Force, they stand higher than other people, despite their simplicity and humility. Whoever has attained this faith — and this faith can and should be attained, unless we willingly prefer to harbor the Evil in us — does not merely stand above all that is changeable in this life but his faith and his force can do what no one else can do: he can heal various diseases by sheer will, sheer touch: for, whatever is touched by a saint itself becomes holy, that is, healthy. The Apostles could do this by the Force of the Holy Ghost which was in them; and this Ghost is the Spirit of Faith and Love; for Love is the Life of Faith. There is no reason why everyone of us could not achieve this under similar circumstances, so that we can confidently call on everyone to be strong in the measure of his faith. But where is this faith? Who has it? Who acts through it? The author has never seen anybody who had real faith, the faith of Jesus Christ and of the Apostles. Everyone knows and feels that he is very far from this goal; but if he has not reached it, he cannot gain the reward, which is this divine power. We are sunk in the nothingness and impotence of evil times, from which we hope we shall soon be liberated by the Good Spirit. But in fact we have only to fight the evil that abides in us and which we willingly worship and obey. We have to fight it just as willingly by the force which can be ours if we would only seriously and earnestly look for it: through the force of faith, so that evil may be overcome and be no part of us unless we surrender ourselves to it. This agreement, this aversion to evil and love of good, this love of God was required of us by the Savior Himself as the condition for our sharing in all that is divine; and the Savior thus put mankind on a high level, as He never required men to do anything without their own free will, and He never forced them to do anything. This is then what we have to do, what we have to give: to turn away from evil and to love good. Every moment that we refuse to do evil, we are one step nearer to the realm of purity, purity of heart and faith, to the Kingdom of Heaven in which Jesus Christ eternally lives and in which we too should live forever. But we are often unfaithful and turn back to evil in our unguarded moments, through the overwhelming force of habit; were it not so, we would feel the purity, clarity, and bliss of the Kingdom of Heaven (compared to which all earthly joy is an empty, foolish bauble), more often, more richly, and more strongly than we now do during the brief moments which flash through our dark life like lightning. The hate of evil is the element of the love of good, which is in turn the element of faith; it is through faith that we participate in the Divine Nature in which the spirit and force are hidden, and also the power of healing through will, glance, and touch.

§ 327. We repeat: only a man without religion will regard all this as a fable, and only a man living in the finite and trapped in it will think it impossible "The natural man understands nothing of Divine Spirit" is an old saw, but it is as valid today as it ever was. But it has also been said: "Let us work and not grow tired" and "pursue holiness, without which no one can see the Lord." However much we push it away through mockery, demonstration, work, or pleasure, it still remains the purpose of life, with which we should be so familiar that we see it in every aspect of life and regard it as a condition of any productive action. We should therefore not be surprised that the work of the physician, in particular of the physician of the psyche, is also built on these foundations. A soul is a force which is nearest to another soul. If an impure soul can corrupt a pure soul, it follows that a healthy soul, the force of which lies in God, can also make a sick soul healthy. But the medium of all activities, nay, the spiritual primeval force of creation, is the will. This must be present as a force before it can act as a force. And thus, let anyone who would be a virtuoso of living strengthen his will, purify it, and make it holy, and he will acquire a force which can achieve what are usually called miracles, and which is will animated by faith. But, as a holy man said, faith is not everybody's business, and it is no wonder that salvation and the will which saves life come to very few men only. It is surprising, however, that even a wild branch of faith, that is, natural faith or self-confidence and the will animated by it (the croyez et veuillez of Count Puysegur*), in the form of the so-called magnetic agent, can do even as much as was in fact achieved in cures which were proved by faithful observation. It is now generally recognized that if the influence is zoomagnetic, the will of the person exercising the magnetism is a conditio sine qua non. It must accordingly be concluded that the will, as an absolute force, has a capacity for producing, spreading, or conducting force, which is typical of its nature, nay, which is its nature, and manifests itself in its full purity as creative force. But it is bound in man in several ways and in several degrees and appears only in a few individuals, in those who are the most vital and the least vulnerable, as a true force and activity, at first by chance, but later deliberately, through sufficient self-confidence. But this acquired force is never as powerful as the force which is given, and which is a talent, or rather an instinct, given to men with healing powers, who are no more gifted in other respects than their fellow men, but in fact are usually less gifted. This is the origin of the healing powers enjoyed by some of the common people, which may be spent or weakened by abuse, and which usually, upon investigation by the authorities, proves to have disappeared; it then immediately becomes clear that these people can do nothing and are either imposters or dupes of the force which they imagined they possessed. For this force is like money; whoever does not know how to keep it will soon lose it. Vox poputi, vox Dei. If many thousands are attracted by a healing power which has accidentally manifested itself, there must be something real about this power. For even if a few of these people are fools, sentimentalists, imposters, or victims of superstition, this cannot be said of all of them. But the individual endowed with such a force wears himself out. The reason is not the manifestation of the force through effort, for this is easy for him, since the force is a gift and is not produced by effort. It is a healing spring which needs no spur to gush forth. But the man, the carrier of the force, wears himself out if he is surrounded, day and night, for weeks and months on end, by sick people of all kinds whom he is expected to help. Thus, what happens to him is what happens to a good magnet which is made to carry more than it can: it lets its burden fall and the excessive effort makes it lose its force. Moreover, we must consider the effect of the changes which gradually take place in the disposition of such individuals. The ever- increasing crowds, the ever-growing repute, the admiration, the respect, the honors which border on worship, the many proofs of gratitude offered in the currency of the land, all this stupifies, intoxicates, corrupts, fascinates, and spoils such people, pollutes the source of their power, and eventually makes it run dry. This is the reason why such people usually come to a bad end, why they themselves are finally surprised to see that their powers have failed them, and then, driven by the necessity of preserving their repute and their income, take refuge in imposture. Such impostures are usually discovered, and the work of these doubly miserable people finally comes to an end.

* [The Count Armand-Marie-Jacques de Chastenet, Marquis de Puysegur (1751-1825), a layman pupil of Mesmer, used hypnosis on many people affected by various conditions with considerable success. (See reference # 20).1

§ 328. We have deliberately dwelled on the fact that healing by willpower is a gift: the will of some people is endowed with this force, the will of others is not, just as some rocks may contain veins of noble metals, while others are barren. But, as stated at the very beginning, it is also an acquired skill, which originates from exercising self-confidence, not unlike the art of swimming. No one can swim when he finds himself in deep water for the first time; but those who have learned how to swim, know that the less they were afraid to sink, the faster they learned to swim; the opposite of fright and of doubt is confidence, trust, and faith. The deeper this faith, the more can be built on it. The faith in our own powers is as strong as they are, that is, it must eventually decrease and altogether disappear. But the faith which we described at the beginning, and which is called Divine Force in the Holy Writ, is not subject to the fate of everything that is mortal and finite. This source will never run dry; but only those can blissfully drink of it who meet the conditions indicated above. This is not easy. For who would willingly renounce his self, his own selfish nature? And these qualities, these forces cannot be bought at any other price.

"Und setzet ihr nicht das Leben ein:

nie wird euch das Leben gewonnen seyn."

* [Unless you wager your life, you will never win [eternal] life.]

§ 329. Thus, like Puysegur, we also postulate the believing willpower as the healing power, but we attribute to it higher powers than does the French magnetizer,* namely, we postulate that it is able to affect disturbances of the soul directly. The reader will find it very difficult to believe that such a therapy and its successful outcome are possible, for the following reasons. Firstly, since our plane of living is low, we cannot imagine anything like the force of the believing willpower; it means nothing to us, it does not exist for us because it is absent in us; for we recognize only what we experience, and we know only our own personal willpower and experience. But at the same time this shows us that a deep energy lies dormant in this willpower. Whoever has begun from nothing and has achieved something, in whatever manner, whether the industrious farmer, the artisan, the active merchant, the artist, the scientist, the hero, or the statesman, and is now in possession of land, skill, money and material possessions, or is in art, science, or command over men in peace and war, knows well that he would have acquired only very little of these if he had not worked with all his strength and had not persisted in his efforts. And what is the human force which could achieve all this if not willpower? Let a man be deprived of his willpower and his life will stand still, for the clockwork is then deprived of its mainspring. But we employ our will instinctively, without knowing it for what it is, and often do not employ it at all, for our innate or acquired indolence will not allow us to. Under such conditions how can we think of a powerful, believing will-power? Secondly, we are also incapable of understanding how mental disturbances can be cured by willpower. But do we really understand any cure at all? We may describe natural processes in terms which we understand, but this in no way means that we speak or understand the language of nature. When we see that a cause is followed by an effect, we are forced to conclude that there was a meeting of forces and that the stronger force has overcome the weaker. Even in ordinary, everyday life we notice that one individual can affect another, and one personality can influence another: a glance or a word from a forceful, impressive personality, be it loving, commanding, or threatening, when directed to a weaker personality immediately produces sympathy, obedience, or fear in the latter. We must admit that even in everyday life a soul can influence a soul and a will can influence a will; why should we then not admit that a healthy, forceful personality, with his spiritual vitality enhanced to the utmost by the breath of the Divine Personality, may be able to affect an individual with a diseased psyche? It is only a question of experience producing facts which show us that such an influence has indeed brought about favorable changes in mental patients, similar to those which are brought about in the physically sick through a magnetic touch. This would be sufficient to postulate the direct psychic effect, that is, the spiritual agent and its effect through spiritual contact. Unfortunately, no such cases have been reported, but the reason for this has already been stated: it is that our willpower is bound and can only be liberated by the higher faith of the pure soul. The opponents of our hypothesis will have things all their own way until someone will succeed in raising himself to the height of pure existence, from which the worldly mind recoils and shudders, but which nevertheless can be aimed at and attained by anyone, as seen in the simple maxim "pursue holiness," which should be obeyed by all who do not mock at and do not disbelieve in the Divine.

* [Probably: hypnotist.)

§ 330. Anyone who has made the believing willpower his own, will stand so high that he is not in need of any advice on how to use it. For this is quite clear within him, and he surveys the relationships of the limited, miserable, earthly existence with the free glance of the spirit; his entire being is immersed in the ether of pure life, which is not limited by the base existence; he is a clairvoyant while in a healthy, wakeful, and conscious state, just as the pretended clairvoyants instinctively are when sick and asleep. Briefly, he needs no directions; and those who have reached this state will need no instructions. In his oft quoted dissertation the author of this book gave a few rules for treating mental patients by the application of will. But since the will, if it is to be fully effective, must be quite free of the chains of bondage, and since this is only possible in a state of pure faith in which the mist in front of the mind's eye disappears, there is no need to repeat it here, since the main thing will always be the creation of the agent, which, once present, will know how to proceed.

§ 331. It cannot be questioned that, if this agent should prove to be helpful in certain types of soul disturbances, it will also prove beneficial in others, even of an opposite nature. For the will which is animated by faith and love (love being an element of faith) must be just as able to soothe cases of exaltation as to uplift cases of depression. Thus, this agent should be effective in all mental disturbances. The question arises as to whether everyone who finds faith will also find the strength of healing willpower in himself and will be able to use it at will, just as he is able to use any other power, such as the power of memory or of reasoning. If this question cannot be answered to our satisfaction, our proposal will become not merely paradoxical but imaginary. It may be said that pure willpower "arises from God's will, and identifies itself with God's will; and if it is not God's will that mental disturbances may be healed through the force of believing willpower, that is, through the Divine Power, what can man do then?" Or we may also say: "this healing willpower is God's gift, given by God in His wisdom to anyone whom He thinks should have it, and not to anyone who thinks he should have it." But the truth, which can be found by anyone who sincerely looks for it, never leaves us in doubt for long. It is a contradiction to think that a man who has been liberated from the slavery of sin, who is animated by the living force of faith and by the Divine Spirit, still remains just as impotent and just as vulnerable as he was in his natural, that is, depraved, degraded state. No, he is now an instrument of God, God works through him, God manifests Himself in him; and how can this be expressed otherwise than through a spiritual and forceful deed? Thus, God manifested Himself in the Apostles, for they believed in Him, and will thus manifest Himself again in anyone who believes in Him, for it is said: "even if ye have as much faith as a grain of mustard" etc.; otherwise we have to hold God's manifestations as nothing, and have to doubt the truth of God, even God Himself. If a man has become "a new creature" through faith, he has become a creature which is powerful in God; for previously he was impotent. Let us therefore have faith and we shall help. Whether we shall be able to help in all cases, and whether our help will be equally effective in all cases, will depend on the measure and on the perfection of our faith; for we can attain no higher perfection than liberation from the slavery of evil, and we can enter the kingdom of faith only insofar as we have left behind the kingdom of sin and ungodliness. The God-hallowed man obviously lives quite differently from the godless man, but his path is always that of good deeds and love. And if those who have fallen from reason are the most miserable, what better favor can they experience than the restitution of that which is the most valuable? And who can restore it except the one who has it? But only those who have faith can restore it; for, in the language of the Apostles, they have attracted Christ, in Whom the life of Godliness abides. It is thus their proper function to show the path of truth to those who have strayed from it and to liberate those possessed by the evil spirit, in whatever shape this spirit might manifest itself.

§ 332. This is the visionary theory, or rather a practical hypothesis, in a nutshell. It is offered to the reader so that he may now sit in judgment on the author who dared to propose it. For it is indeed a bold venture to advance such views at a time when the darkest, most slavish mysticism is about to devour the fruits of three hundred years of free research (in which it can, however, be successful only apparently, for only a brief period of time and only to bring about its own annihilation), and in a science such as medicine which has always enjoyed the greatest freedom of research, since these views seem to aid and abet this mysticism and be directed against all research. It will be said that all the efforts of physicians in past ages to find the rules obeyed by a healthy and a sick life and to clarify the nature of the healing powers and of the cure itself will thus be destroyed. Is this what we want? Is this not reckless? Is this reasonable? We thus invite the old barbarism to return and fling doors wide open to superstition and all that this means. This argument might just as well be anticipated by the author, before a reviewer can use it. But may he also say a word in his own justification. We shall leave aside the question as to how far medicine has or has not achieved its objectives and how far such an achievement is at all possible. We must state, however, that if it be really a discipline which enjoys the greatest freedom, then it should investigate all proposals, no matter how strange they seem, provided that they offer the slightest chance of success. This is all that the author has done, namely, he has recommended a new agent against the most powerful evils and has stated the conditions under which it may become available. These conditions are obviously very exacting, and one who would meet them must needs become an altogether new human being. But this is no reason for rejecting the proposal, for the old type of man, whom we seem to like so much, is nothing very special, and it will be no great loss if he ceases to exist. The only question is: is this possible and is it salutary? We may not consider it salutary in a certain sense, since it involves the loss of our entire personality; but, as has just been said, this is no great loss; however, as regards the possibility of such a metamorphosis, only experiment can decide. Now what is the purpose of this experiment? It is "make yourself free! " But true freedom is impossible without the recognition of truth, and this is in turn impossible unless we renounce sin, evil, and the ungodly. And now it is our turn to inquire in all seriousness: is this a principle of darkness? Is this something mystic, sentimental, spirit- destroying, or spirit-enslaving if we make a proposal which originates directly from the mouth of God: "As ye remain in My teaching (as ye love God and not the world), so will ye know the truth, and the truth will make ye free." It may be said: "very beautiful! very pious indeed! but what has all this to do with medicine?" To which we answer: It has much to do with medicine, for "heavenly bliss is useful in all things." We would ask the reader not to consider this saying an old wives' tale but something which is valuable and relevant to all aspects of life, and thus also to that part of it which we know as knowledge and ability, or as science and art. Enough! There will always be things which are "an annoyance to the Jews and folly to the Greeks." Moreover:

Si quid nosti rectius istis

Candidus imperti; si non: his utere mecum.

II. THE SCIENCE OF MEDICAMENTS

Chapter One

THE ORGANON OF THE SCIENCE OF MEDICAMENTS

§333. It would perhaps be advantageous to replace the terms "medicament," curative agent, by the term "curative forces" were such a procedure not inconsistent: for not all medicaments are curative forces (for example, a purge), while curative forces become medicaments only in as far as they are used by the physician for his purposes. The science of curative forces would be endless, for there is nothing in nature that cannot manifest itself on some occasion as a curative force. But the science of medicaments is quite sharply delineated, since it reaches only as far as we can establish the objectives of the cure and can survey them. It should also be clear that the subject as discussed in this book will be limited to medicaments to be applied to cases of mental disturbance.

§ 334. If medicaments vary with the objective of the cure, they must also be classified in accordance with these objectives. We shall retain the term "objective" of the cure, for otherwise the term "medicament" would be meaningless; but it should be remembered that the physician does not cure, but only acts or activates various forces to foster the cure or recovery, which are inherent in the diseased life, while this nevertheless acts independently. We named the procedures used by the physicians "methods," and distinguished between indirect and direct psychic methods. The direct psychic method (which we could only outline, since it can only be realized by a special self-education of the physician, and can be the fruit of a bold and successful experiment or a series of experiments) already contains its own medicament, or is its own medicament: namely, the willpower, enhanced in the special way described above; and we shall therefore speak of it no longer. The indirect psychic method was subdivided into six different moments. These would include all of the curing objectives and thus also the subdivisions of the medicaments, were it not for the two which do not effect cures: the negative and the palliative moments; the former because it does not consist in action but in the complete absence of any action, and the latter because its objective is not to cure but merely to alleviate the diseased condition. Since even alleviation cannot be brought about without using appropriate means thereto, it follows that the palliative medicaments should be listed as an appendix to the list of medicaments, which should be arranged in accordance with the four main moments: gradual, formal, individual, and somatic assistance.

§ 335. But we must first define the concept and the nature of a medicament. A means, an agent can affect the sick life so as to assist the cure, be it directly or indirectly, vigorously, or mildly, permanently or to a certain perceptible extent, and only then is it a medicament, and not otherwise. Accordingly, agents which experience has proved are effective in certain cases, and only in those cases, can rightly be named medicaments. Those which have not been proved by experience to have this effect can only be regarded as potential medicaments until their effect is confirmed. But in an earlier (5333) section, the medicaments were differentiated, and we now wish to discuss this again. For in the most general sense a medicament is anything that serves as a cure, whether or not it contains a healing power in itself: for example, restraint of the patient, keeping the patient in isolation in a solitary, dark place; but in the strictest sense medicament is a positive agent, a force which produces a cure: for example, cold water, purges, tonics, etc. And irrespective of the realm of nature, including the realm of elements, to which this medicament belongs, and of whether an artificial instrument is or is not used in medication, or, finally, of whether the action is organic or psychic, it will be a medicament if its effect is salutary and if a desirable change takes place. Thus, all agents, be they elemental, mechanical, chemical, dynamic, organic, or psychic are medicaments in the strictest sense of the word as long as they meet this requirement. But we shall deal not only with these, but also with the other type, that is, medicaments in general. We shall thus deal with whatever has been experienced, or thought out, or invented, or is still to be invented, which may bring about recovery, and which is known to have a beneficial effect, except the direct psychic method, which has been dealt with elsewhere. Let us then survey all the medicaments in accordance with their various relations to the objectives tabulated at the end of § 334.

§ 336. As concerns, firstly, medicaments of gradual treatment, these were listed in the chapter on heuristics (§§ 289-295) in connection with exaltation and depression, under the names of restraining, deflecting, exciting, and revivifying medicaments. Since each of these four kinds includes medicaments from different sources, each such column or genus includes different species of medicaments, which will be named after the domain from which they are taken. Here we have to distinguish between elemental, pharmaceutical, surgical,* dietetic, and psychic medicaments. The employment of the so-called elements belongs to the elemental (or physical) domain: cold, heat, darkness, light, electricity, galvanism, mineral magnetism, and water. The pharmaceutical domain includes all medicaments prepared in pharmacies which may be effective under certain conditions: purges, tonics, depressants, sedatives, laxatives, and change-producing drugs. The surgical domain includes, firstly, the medicaments which are usually considered as such: external irritants or deflectants, medicaments producing reddening, those producing blisters, eczemas, and tumors, and those which keep them, and those which withdraw blood and other humors by external application; secondly: mechanical apparatus intended to hold the patient still or to make him move. The dietetic domain includes hunger and thirst, food and drink, sleep and wakefulness, exercise and repose. Finally, the psychic domain (kat exokhen) includes everything performed in order to produce an indirect, positive or negative psychic effect, that is, supplying the patient with or withdrawing from him anything which will result in the excitation or depression of the morbid psyche, in a direct or indirect manner. All these types, when ordered in accordance with the conditions of their respective genera, which concern gradual treatment, are medicaments of the first class.

§ 337. As regards, secondly, medicaments of formal treatment, or medicaments of the second class, these include three genera of medicaments, for the disposition, the spirit, and the will, respectively, used for treating these three disturbed energies. The first genus contains medicaments counteracting disturbances of the disposition or (5302) medicaments producing changes in the disposition. But since pure disturbances of the disposition are of two opposite kinds (insanity and melancholia), this genus is subdivided into two opposite species: soothing and exciting medicaments. The second genus contains medicaments for disturbances of the spirit, or (§302) correcting medicaments. But since the main feature of dementia is fixation (idee fixe), while that of idiocy is its opposite, loosening (diffusion into lack of perception and lack of understanding), nothing is more natural than to search for medicaments of opposite character to cure these opposite species of disturbances.* Thus, this second genus also comprises two species: the loosening medicaments for dementia and the binding medicaments for idiocy. Finally, the third genus comprises medicaments for disturbances of willpower, or (§302) directing medicaments. These are again subdivided, in accordance with the two opposite affections of rage and apathy, into two species: means of restraint and means of encouragement. But we must bear in mind that these three main types of energy of the psyche cannot invariably be affected directly, and (§299) where this is not possible, they must be affected in a roundabout manner, by means of other energies. This is the origin of subspecies such as soothing and exciting, and loosening and binding medicaments, and also means of restraint and means of encouragement, which, owing to their special nature, cannot be discussed here.

* These include those previously called mechanical auxiliary treatment and surgical apparatus; but we clearly mean the word surgery in a very wide sense, corresponding to the Greek kheir and ergon, meaning manual work, manual performance, performed for the sake of certain curative objectives.

§ 338. Thirdly, as concerns medicaments of individual treatment, or medicaments of the third class, this class (§303) includes all medicaments used or usable with reference to: first, sex; second, age; third, constitution; fourth, temperament; fifth, personality; and sixth, the individual condition of the patient. Thus, it contains six genera of medicaments, the names of which should be derived from the names of their relationships. But since (§§ 304-309), as in the preceding class, each of these genera is divided into two opposites, which in general are those of mildness or severity, so too each genus of medicaments must also be divided into opposite species, the mildly exciting and the strongly exciting, respectively. A detailed description of these will be found in the appropriate chapter on the science of medicaments.

§ 339. Fourthly, as concerns medicaments for somatic auxiliary treatment, or medicaments of the fourth class, we have referred the reader (§§ 312-314) to the science of somatic medicaments. For here advantage is taken of everything this science has to offer for disturbances of the functions of digestion, respiration, skin and sexual systems, and the vascular and nervous systems, while the psychic science of medicaments must merely indicate the class and genus of the medicament and the individual medicament to be applied in the somatic treatment. In § 312 we listed the main cases in which somatic help is urgently needed: insomnia, constipation, dryness of skin, congestions, convulsions, and paralysis; in addition, special attention must be paid to the viscera in the lower abdomen: liver, spleen, pancreas, sex organs, and the ganglionic and nervous systems, and the very frequent loss of strength thereof, which determine the functioning of all the other parts. In all these cases somatic treatment is useful, and it is our duty to at least list some of the medicaments used for this purpose.

* The phrase in § 302: "No psychic treatment is of any use in idiocy or apathy ..." is a view which was formerly held, and which we believe will be amended.

§ 340. Finally, as concerns palliative treatment, we have already said that palliative medicaments can only be mentioned in an appendix. But this is also the place to discuss the diet of the patients, since this is the main part of any treatment; and we must survey the most necessary and the most salutary diets. These are known to include not only food and drink (which must be studied according to their genera and species) but also exercise and repose, and occupation and rest in all their varieties. This is the final chapter of the science of medicaments.

§ 341. At the end of this organon we should note that correct measure and purpose must be observed in the application of all genera and species of medicaments. The wise physician ensures that he never loses sight of his objective and of the need for moderation. We have already (§296) said a word or two on this subject when dealing with gradual treatment. Too much medication or too little medication, with reference to both dosage and duration, must always be avoided. Physicians, even somatic physicians, tend to go to extremes, especially as they are wont to draw general conclusions from their few successful cases. As is well known, there are physicians who are famous for their vigorous treatment, and who succeed through heroic cures, just as there are others who are cautious by nature and never use any but the mildest medicaments, but are just as successful in other cases and swear that their method is the safest. But we may be fairly certain that in cases which are at all curable, and in which intensive treatment is unsuccessful, mild treatment will prove more successful, and vice versa. It follows that a physician who knows how to apply either of these two methods at the right time and in the right place will also have twice the usual success in the treatment of diseased conditions of the psyche. Clearly, the application of this principle in the choice of medicaments is a difficult art. It must be based on persistent and faithful observation and suitably applied experience. In general, there is no better teaching of the treatment of both healthy and morbid lives than life itself; thus, in so far as we require external proof and confirmation, and these are necessary at all moments of medical treatment, in the choice and application of medicaments with reference to their kind, degree, and duration, we are best instructed by iuvantia and nocentia,* in both somatic medicine and medicine of the psyche. We should finally remark that the reader should not be surprised to find the same medicament listed under different groups and different classes, since the same medicament may serve different purposes and may act in different ways. This is the advantage of our subdivision in accordance with the object of the cure, since the effect of all medicaments is relative, and may differ in degree and in kind, and therefore medicaments cannot be applied as stereotypes, as they were formerly. Moreover, this subdivision emphasizes the fact that the science of medicaments as a whole is not an absolute, independent discipline, as it is usually considered to be, not without resulting confusion, but is a vital link in the closed chain of technique.

Chapter Two

FIRST CLASS: MEANS OF GRADUAL TREATMENT

A. Medicaments Which Depress Excessive Excitement

§ 342. First Genus: Means of Restraint

The patient can be restrained and his excessive excitement moderated, by either removing the stimuli which caused, maintained, fortified, or renewed the excitement, or restraining the excited activity itself and compressing it into a narrower sphere of action. Both objectives can be attained in various ways by different kinds of medicaments included in this genus.

First Species: Elemental or physical means of restraint

* [lucantia (from the Latin iuvare = to help) and nocentia (from the Latin nocere = to harm) were terms given to broad pharmacological categories.]

1. Cold. Since the atmospheric heat around the patient, the heat of the sun in summer and that of the heated room in winter, and also the body heat of the patient himself markedly enhance his excitation, it follows- that cold will prove very beneficial in such cases. Thus, the excited patient must be kept in a cold or in a cool, well-ventilated place. Then his heat must be withdrawn by that excellent vehicle of both heat and cold, water. Thus: cold baths, the pouring of cold water over the head, or cold compresses (Schmucker's artificial compresses). Cox advises to place a mud cap on the patient; another technique is to let ether evaporate on the shorn scalp of the patient. Even a simple haircut has a cooling effect. Harke let the hair of an insane girl be cut off, and found that she was more quiet four hours later, and complete recovery ensued after eight days (but surely not solely as the result of the haircut? ) (Hufel. Journ. Vol. XXV, Pt. 2, p. 69). If the season of the year is propitious, the best medicament is an ice cap applied to the shorn scalp. If conditions are favorable, it may be advisable to bind a bag filled with mercury to the head, to replace ice in some measure. The degree and the duration of the general or local application of cold must be determined by the circumstances. Sometimes a cold bath of only a few minutes duration is sufficient; in other cases baths taking several hours are not too long.

2. Darkness. It was already noticed by Celsus that some excited patients cannot tolerate light. If this is the case, keeping the patient in darkness, or even in a totally dark room, can be uncommonly salutary. The author had occasion to observe an insane woman who made a permanent recovery after a few days in a totally dark place, after several other treatments had no result. But under such conditions the patient is exposed not only to darkness, but also to silence and loneliness (see psychic medicaments).3. The silence of the remote place of confinement. Daily sounds, human speech, everything which shatters the air, excite the patient or else prolong and intensify his excitement. Thus, silence is a powerful though negative means of reducing the excitement of the patient, even if it does not lead to complete recovery. Such silence can only be maintained in remote places or between thick walls.

Second Species: Pharmaceutical means of restraint.

These are medicaments which produce moderation of excitation, with-out deflection. According to the kind of stimulus which is producing the excitation, it may or may not be eliminated by pharmaceutical means without deflection. The source of the excitation may be excessive sensi-tivity or irritability, that is, weakness of the nervous system, which can be eliminated only by dietetic means or by so-called nervina, narcotica, and roborantia. Or it may be an orgasm of the vascular system, against which depressing and soothing medicaments are recommended; or else both con-ditions are present, when the combined treatment is applied.

First Case: Irritability of Nerves.

A. Nervina. These reduce the irritability and thus also the excitement by raising the nervous energy; but if applied in excessive amounts, they depress both these factors of nervous activity.

1. Camphor. (Reil, Fieberlehre, Vol. 4, p. 461). Reil recommends camphor in small doses if the patient lacks energy (and if this is the reason for his excessive excitement) and in cases of nymphomania. If camphor is applied in large doses, the irritability of the brain seems to be directly reduced. The dose is five grains four times daily; this may be increased to one scruple. At the same time the patient should be given distilled vinegar, diluted with water; some physicians recommend doses as large as one dram. In such a treatment danger of accidental harm to the patient is great. (Pargeter, p. 62; Simons in Richter's chirurg. Bibl., Vol. VII, p. 771). Paracelsus, Etmiiller, Sennert, Doldus, Werlhof, Jordens, Triewald, BOnnecken, Herz, Paulitzky, Willemse, Schiinheyder, and others applied camphor with success (Murray App., Vol. IV, pp. 499-503). Perfect medicated most of his patients with camphor. Kinnear (Phil. transact., Vol. XXXV, p. 347; Pargeter, p. 114) cured several insane patients with this medicament. Locher (Obs. pract., pp. 57-74) very successfully combined camphor with vinegar. Auenbrugger believes that camphor is an excellent medicament in various cases of insanity. Cf. Reil's Fieberlehre, Vol. 4, pp. 463-465 (Auenbrugger: Experimentum nascens de remedio specifico sub signo specifico in mania viroruni, Vienna, 1776). Dobson (Samml. f. pr. Aerzte, Vol. XIII, p. 647) administered three drams of camphor to a maniac during 24 hours, in doses of 1 scruple each, and then the same amount again during the following 12 hours, whereupon the patient recovered. Schneider (Horn's Archiv, Vol. VI, No. 1, p. 50) cured a case of mania with camphor and poppyseed juice. Hufeland (fount. Vol. 23, No. 1, p. 178) cured an insane girl by introducing a mixture of four grains each of tartar emetic and camphor, and two drams of gum arabic mucilage into her open vein. This treatment was repeated on the third day with doses increased by one-half. Cox (pract. Bemerk., p. 148) found that the effect of camphor was uncertain. Cf. Auenbr., loc. cit., p. 16, where more writers are mentioned. See also Willemse in Harlem. Abhandl., Vol. XIV, p. 3. Samml. f. pr. Aerzte, Vol. I. No. 3, pp. 46ff., Vol. III, p. 347; SchOnheyder, Coll. Soc. Havn., Vol. II, p. 176; Herz, in Selle's n. Beytr.

2. Musk. Reil (Fieberl., Vol. 4, p. 459) recommends musk in cases of disturbances of the spirit due to disappearance of skin rashes accompanied by cramps. Locher (Obs. pract circa luem vener. epilepsianz at mazziam, Vienna, 1762, p. 62) managed to pacify a number of maniacs and to cure one of them completely by daily administration of XV—XX grains. Medicus and Morgenbesser (Nicolai Recepte and Kurarten, Vol. I, Pt. 2, p. 238) successfully administered eight grains every eight hours against mania. Pargeter (Abh. fiber den Wahnsinn (translation), p. 64) administered musk made into pills with gum arabic in daily doses of six drams to one ounce. Cox (Pratt_ Bemerk. (translation), p. 154) noticed no help from musk. Perfect (Annalen, 4th case) administered musk in combination with other medicaments with good results. Thilenius (Med. u. chir. Benterk., p. 234) successfully applied large doses of musk in addition to administering other medicaments.

3. Naphthene; Haller's acid; Castoreum; Asafoetida; Valeriana and similar medicaments should also be mentioned here.

B. Narcotica. These medicaments depress the sensitivity of the nerves and thus also diminish the resultant irritation by producing temporary paralysis of the nervous energy, provided they are administered in large doses; in small doses their effect is just the opposite.

1. Atropa belladona. Oberteuffer (HufelJourn., Vol. IX, No. 3, p. 100) claims that the application of belladonna in various types of diseases of the psyche is useless. Hufeland, on the contrary, recommended the following formulation in cases of melancholia and mania: E. Extr. Belladonnas one-half scruple, Extr. Gratiolae 3jj. solue in Aqu. Laurocerasi 3j. Dosage: 30 or more drops three times daily. Reil (Fieberl., Vol. 4, p. 458) recommends deadly nightshade leaves. Evers (Murray Appl., Vol. I, p. 450) administered such leaves with satisfactory results in doses of V grains, with the same amount of rhubarb, and neutral salt purges between doses. (Cf. Schmucker's vcrm. Schr., Vol. I, p. 173). Greding (Med. Schr., Vol. I, pp. 114-173) relieved many raging epileptics in this way, but could not cure any. Minch (Obs. pract. circa usum Balladonizae, pp. 17, 21. Beobaclztungen, Pt. 2, p. 105) and others (Ludwig, Diss. de Belladonna Jena, 1789; Buchhave, Act. Soc. Hain., Vol. II, p. 176; Samna. f pr. Aerzte, Vol. XIV, p. 617; Remer, Hufel. J., Vol. 17, No. 2, p. 127) discuss cases with successful results. Thilenius (Med. and chir. Bemerk., p. 237) cannot recommend belladonna, no matter how persistently applied. Cox is also not very enthusiastic about this medicament, or other narcotica. It should be noted, in addition, that the purity of the preparation greatly affects the influence of belladonna as a medicament.

2. Daiwa Stramonium. Fieberl., Vol. 4, p. 456). It is administered as extract, one grain 4 to 6 times daily; the dose is gradually increased to as much as half a dram per 24 hours. Stork and Rees each cured two insane patients by administration of this medicament (Murray, App. Med., Vol. 1, p. 459). Greding experimented most with this medicament. It produced stupefaction and increased the volume of all secretions. He cured several epileptics by administration of this medicament but could not cure a single demented patient. (Gred. sammtl. med. Schr., 1790, Vol. 1, pp. 37-103). Allione successfully administered thornapple extract with camphor for frenzy. (Flora Pedemont., Vol. I, p. 103.) With this medicament Grandidier was able to cure a case of nine-months-old frenzy, which had not yielded to any other medicaments (Month's Arzn. M. L. p. 282.) Schmalz (Chir. und med.- Vorfalle, p. 178) used the medicament to cure a case of mania alter-nating with melancholia. Barton (American. Annalen, Vol. 11) recommends this medicament for insanity without fever. Hufeland (Journal, Vol. IX, No. 3, p. 189) noted very good effects produced by Tinct. stramonii in case of insanity.

3. Hyosciamus niger. (Reil's Fieberl., Vol. 4, p. 457.) The extract is to be administered in doses of one grain 4 times daily, and the dose is gradually increased to one or two scruples in 24 hours. Greding (sammtl. med. Schr., Pt. I, pp. 1-36) noted relief in several cases, but no patient recovered completely, and in many cases there were harmful effects. StOrk (Murray App., Vol. I, p. 450) and Fothergill (Mem. of the Medical Soc. of Lond., Vol. I, p. 510) administered this drug successfully (S. Pargeter, Abh. fiber den Wahnsinn (translation), p. 66). Cox (Pratt. Bemerk. fiber Geisteszerriittung (translation), p. 151) recommends henbane as a sedative, but the medicament scarcely ever gives a complete cure. (The following should be noted: all these medicaments and those listed below we can recommend only when certain indications are present, whereas most physicians administer them in order to effect a radical cure. It is interesting to follow the results of these efforts, but their one-sidedness, and the consequent lack of success of the treatment, must also be pointed out. This aspect of medical treatment will be repeatedly discussed further on.) Thilenius (med. und chir. Bemerk., p. 237) found extr. Hyosciami very useful, and reported that its sedative effect was even stronger than that of opium. Hyosciamus albus has a milder effect.

4. Opium. This medicament in a weak camphor tincture with saltpeter was usefully employed for insanity (Perfect, Annals of an Asylum for the Insane (transl. by Heine), Hannover, 1804). This was applied by Perfect for the first time, together with a seton between the shoulder blades, foot baths and kali tartaricum every 2 to 3 days. Reil (Fieberl., Vol. 4, p. 460) recommends opium in cases of asthenic dementia with erethism without any material cause. Again, according to Reil, opium reduces irritability and soothes violent brain activity. He also recommends opium as a means for producing euphoria in demented patients who also suffer from depression. (Rhapsodien, p. 182). Selle administered opium after adequate purging for persistent excitation of the brain. Chiarugi reports that poppyseed juice was most effective in melancholia. Young (Jahn's mat. medic. Vol. 2, p. 728) cured a first attack of rage produced by anger by administering four grains of poppyseed juice. Ferriar also found this medicament useful in many cases. Wendelstadt (Samml. med. u. chir. Auftrage, 1907) reported several cases in which mania had been suddenly cured following sleep induced by strong doses of poppyseed juice. Cox (pract. Bemerk. (translation), p. 150) saw not even a temporary, let alone permanent, advantage in administering opium. Odier„ who translated the writings of Cox, expressed his surprise at this statement and tells of a case in which poppyseed juice was very effective. (Gutting. Anz., 1809, p. 106). Nevertheless, Cox recommended that a dose of opium be administered to a patient the evening before he is to receive an emetic, since in this way the dose of emetic can be reduced. See also van Swieten, Comment., Vol. III, p. 517. Friborg, Comment. Soc. med. Harm., Vol. II, p. 176. Samml. flpr. Aerzte, Vol. III, pp. 340 ff.

C. Roborantia. These medicaments exercise a magnetic attraction, and thus reinforce the energy of the nervous system and consequently reduce the excitement originating from irritability produced by weakness. This group includes all the somatic types and grades of these medicaments. We shall list here a few of the specifically acting . . . force of the . . .*

Cinchona bark. This medicament was recommended by Reil for idiocy accompanied by complete debilitation or intermittent idiocy (Fieberl., Vol. 4, p. 467), but is very suitable for application in the case of all diseases of the kind we are now discussing, since the above case indicates enervation with consequent excessive irritability, which results in powerful excitement accompanied by the most violent attacks of mania. Ferriar (Bemerkungen fiber Wahnsinn etc. (translation), p. 93) cured a woman suffering from loss of consciousness within one month by administering cinchona with poppyseed juice and aromatic substances.

* [ Some text missing in the German original.]

Second Case: Orgasm of Vascular System.

We do not intend to deny the effectiveness of Spec/flea (and why should we, since everything in this world must have its opposite), without inquiring into how they work, but shall merely report the results. The medicaments listed below have the strongest effect:

Digitalis purpurea. Pulv. fol. Digital. purpur. (we must not forget to add: in umbra siccat.) 1 to 4 grains, or Tinct. digital. purpur. gtt. XXX to LX. Even though it was reported by Reil (Fieberl. Vol. IV, p. 459) that the effectiveness of this medicament in the case of dementia had not yet been adequately confirmed, Cox (Benrcrk. fiber Geisteszerriitt. (translation), pp. 131 ff.) has only praise for it. -It deserves to hold the first place next to emetics. It usually produces a cure when an accelerated blood circulation accompanies the disease. It works partly through depression of the circulation, and partly through the nausea it produces. The first dose should be a few drops of the tincture or half a grain of the powder; the dose can then be increased up to amazingly large amounts. ... No case should be considered as incurable until a cure by digitalis has been attempted, and the administration thereof should be continued for as long as some effect is evident."* Cox illustrates the power of the "red thimble" by the example of a patient to whom digitalis was administered, and whose condition was then entirely dependent on his blood circulation: at a pulse of 90 he was constantly raging, at 70 fully reasonable, at 50 melancholic, and at 40 half dead. Doses of the "thimble" which maintained the pulse at exactly 70 effected a complete cure.

2. Aqua Laurocerasi. In the same way as Cox was able to alter the pulse and the psychic temperature through the administration of digitalis, so could Thilenius (Med. and chir. Bemerk., Frankfurt, 1789. Species: mania and melancholia, pp. 194 ff.) completely alter the psychic temperature by administering an aqueous extract of cherry laurel, which produces a complete change of blood. How very strange! When patients suffering from hypochondria, melancholia, and mania were bled, they gave thick, viscous, black blood; Thilenius diagnosed black bile as the source of these evils. After an aqueous extract of cherry laurel had been administered for several days, and the patients were again bled, their blood was nicely red, and had a completely natural consistency, and recovery was complete. Thus, Thilenius was ahead of the most recent observations on the change in the blood as a result of treatment with an aqueous extract of cherry laurel. He combined (p. 237) the latter with Tart. solub. and Tart. emet. and administered doses of 30-80 drops three or four times daily. (Cf. Sarnml. f. pract. Aerzte, Vol. I, No. 2, p. 101; Vol. XX, pp. 288-295. Spandow du Callice: Diss. de laurocerasi viribus venenatis ac medicatis, Groningen, 1797.) Thus, the old saying: in sanguine vita still deserves to be remembered. Speaking generally, our predecessors made a more thorough study of the agents able to produce changes in the blood than we think necessary nowadays. In particular, the so-called blood-cleansing medicaments should not be neglected as much as they have in fact been.

3. Anagallis. Its action seems to be similar to that of the medicament just described. Bruch (Diss. de Anagallide., Argentor, 1758, p. 17) recommends the administration of anagallis in cases of melancholia and mania which originate from an atrabilious constitution, just as Thilenius recommends an aqueous extract of cherry laurel. The plant may be administered in its natural form as pressed-out sap, as a decoction, a preserve, or an extract. Bruch also quotes the names of other doctors who used this medicament with success.

4. The following medicaments also form part of this group insofar as they affect the blood and not with reference to their purgative or counter- stimulating effects: calomel, niter, hellebore, aloe, etc. The author believes he noted that aloe produced a depressant effect, or how else can we explain the anti-inflammatory effect of calomel? * Other effects of these medicaments will be described in their proper place.

In the third case, where the immediate reason for the abnormal excitement is excessive nervous irritability and an orgasm of the vascular system, the previous two groups of medicaments are unsuitable. Medicaments to be recommended in such a case are mineral acids, or better, the luckily discovered Haller's acid.

Third Species: Surgical means of restraint

Here we shall discuss only the second type of surgical means, namely, the mechanical apparatus which, according to the circumstances, can keep the patient still or make him move in order to cure his disease. This is not unlike the setting of broken limbs in a mechanical device in the proper position, or the adjustment of strained joints by mechanical countermotions. Many such devices are available, according to the degree of restraint to be imposed on the patient.

* [Retranslated from the German. I

* [An apparent non sequitur.]

1. Straitjacket. The straitjacket is a well-known English invention. It is a jacket made of a strong material, which is closed at the front, while at the back it is open and has straps which can be buckled and sleeves which are so long that when the patient wearing the jacket crosses his arms over his chest, the sleeves can easily be passed round his back and again to the front and there be bound together with the broad straps fitted at their closed ends. Similar kinds of long trousers may also be slipped over the patient: they are in the form of a sack with a dividing wall and prevent the patient from escaping just as effectively as the straitjacket prevents him from injuring himself or others with his hands. It is undoubtedly one of the best inventions which can be used to restrain the patient without binding him and without injuring him, in any way. The same is not true of the means of restraint which will now be described.

2. The sack. An ordinary sack made of ordinary material, with a length and circumference suited to the height and girth of the patient, fitted with straps at its open end, and completely or partly covered with wax cloth to prevent the entry of light. Experience has shown that the patient in the sack is in danger of asphyxiation and of falling victim to convulsions. For a detailed description of this device, see Sandtmann's publication, which has already been quoted on several occasions.

3. Confining belt. A wide, well-upholstered belt made of strong leather which is passed around the body. The belt is fitted with loops through which straps are passed to attach the patient to his bed or to another piece of furniture. Both sides of the belt have open, wide straps with soft lining and with buckles to tie the patient's hands. The feet are bound in a similar manner in a double harness with a dividing wall. This harness also has loops to fasten the lower part of the body to the bed, etc., as well. The bedstead to which the patient is strapped must have an opening in the middle to catch the excrements in a vessel put underneath the bed, but the bed of the patient must consist of a well-upholstered mattress and a well-stuffed pillow. The patient should be covered with a woolen blanket. Since all patients who have to be restrained in this manner are less quiet in a horizontal than in an upright position, this arrangement is much less suitable than the former.

4. Confining chair. This is an armchair, which may be of different breadth or height, is comfortable to sit in, well-upholstered at the back, the sides, and the seat, lined with leather, with wide arm rests and strong legs which can be screwed to the floor. The seat has an opening for the buttocks of the patient. The back of the chair has straps for the neck, the chest and the body. The sides of the chair have straps with a soft lining for the thighs and feet. These must be applied so that no undue pressure is exerted on the patient. A footstool about 6-8 inches high is also provided so that the feet of the patient do not hang down. Here again the feet can be held down with straps. It is not at all easy to bind the patient so as not to cause him pain and at the same time make it impossible for him to slip out. It is well known that such patients are very strong and very supple, and very precise skill is required to restrain them without doing them any harm. Hence, the large number of well-padded straps. Extensive observations made by the author led him to the conclusion that the chair is completely harmless; the patient can remain bound in the chair for weeks on end without incurring the slightest bodily harm. If the straps are not properly adjusted, edema may appear on one or other hand after a few days, but disappears within 24 hours after the patient has left the chair. In any case, after a few days, the patient usually becomes submissive enough to be let loose. The author has repeatedly observed that men and women, who could not otherwise be handled, became mild and submissive, and even came to their senses after being left bound to a chair in a dark, lonely place. He therefore cannot agree with those who find this treatment harsh and cruel. If indeed some patients cannot be cured without being restrained, and without being restrained to a severe degree, then the author believes that this kind of restraint is by far the best and is most wholeheartedly to be recommended. For to bind the patient with the constraining belt alone, while allowing him to move freely otherwise, is only a half-measure. The straps by which the patient is bound to the bedstead do not eliminate the disadvantages of the horizontal position; also, since the arms and legs are held at only one point, the limbs are free to move just enough to produce skin abrasions at these points, or possibly to slip out of the bonds, and this can only be prevented by making the straps tighter. Thus, a severe edema soon appears; the limbs become cold; the abraded sites of the limbs bleed and become inflamed, and ulcers form. The author noted that even this mistake occasionally had beneficial effects, since the pain and the bandage made the patient take notice; but it must not be recommended on this account. However much we may praise the straitjacket, we must note, first, that patients who display very wild behavior can soon slip out of it, and, second, it does not fulfil the true purpose of restraint, because the patient does not feel at all restrained by it, since he can walk about quite freely. This again is only a half-measure. The sack, admittedly, gives the fullest restraint, and does so in the most painful manner; but it is unsuitable because of the danger of asphyxiation, an epileptic fit, or apoplexy (and not because of the fear and pain caused to the patient: for both are means of healing; thus, surgical operations are also pain-ful, but must be carried out all the same). This danger of apoplexy, as well as the danger of lethal hemorrhages, is also a very grave objection to the medic-ament to be described next and which is strongly recommended by Cox. It is used in an improved, that is, in a more dangerous form in one of the great German institutions, but is really suitable only for the most desperate cases for example, Cox's 19th case (loc. cit., p. 171 of transl.)].

5. Cox's swing or swing machine (cf. Cox, Remarks on Mental Disturbances (translation), p. 159), for which the original idea must be attributed to the famous Darwin. An ordinary chair is suspended in the air from a hook fastened in the ceiling by means of ropes tied to its legs, and is set into circular motion by rotation. Alternatively, the apparatus may be set up according to Darwin. A pole is fixed between floor and ceiling by iron rods, so that it can execute a very rapid rotary motion. It is fitted with a horizontal arm, by which it is set in motion, and from which a small bedstead may conveniently be suspended. Or else a chair with the patient tied to it is affixed to the pole, and the pole is set in motion with the aid of a rope wound around it, in the same way as a top. (Reil, Beytriige, Vol. I, p. 617). Dr. Horn was the first to introduce the swing machine into Germany, and he considerably improved its design. We are awaiting his report on the subject, to which the reader is referred.

6. Aurentieth's mask. (cf. Autenr., Vers. s. d. pr. Heilk., Vol. I, No. 1, p. 223). A mask-like device, by means of which screaming and roaring of the raving patient are rendered more difficult, but by no means impossible. It must be considerably improved, or rather its design should be altered so that the patient is prevented from opening his mouth, while able to breathe freely through the nose. Such screaming is just as ineffectively prevented by

7. The pear. A piece of hard wood, with the shape and dimensions of a medium-sized pear, has a crossbar fitted with straps which can be tied at the back of the neck of the patient. Since the oral cavity of the patient is more or less filled by this instrument, the patient can obviously utter no articulate sounds, but he can still utter stifled screams, which is the more undesirable as the patient has to make a greater effort to do so; except that he might grow tired of this effort and become quiet. This is actually the purpose of this device, which must not be condemned as cruel, since its aim is to produce one of the most healing restrictions. Just as badly brought up children, or rather spoiled children, give vent to their malice through screaming and thus enjoy themselves, so unruly patients give vent to their rage and obstreperousness by screaming and roaring if they cannot do so in any other manner, and tend to scream more the more they are forbidden to do so. If they are prevented from screaming, they lose their only remaining weapon (since they are restrained) and must finally acknowledge their total impotence. Nevertheless, an efficient muzzle, which would not have the disadvantages of the mask and of the pear, has not yet been invented.

8. The box. This device resembles the casing of a grandfather clock, such as may still be found in the halls or rooms of old families. It is as tall as a man, and it has an empty space in the place of the clock face. The head of the patient is put inside, and his face is then displayed in place of the dial. The patient is thus rendered ridiculous, which is the purpose of the device. The mentally disturbed, who are usually quiet and are able to experience pride and shame, are punished in this way for infractions of rules that they were told to obey. However, discrimination must be exercised in the application of this punishment, since such restraint, the main purpose of which is to put the patient to ridicule, can embitter him just as easily as make him mend his ways. We shall now merely mention, without giving a de tailed description:

9. Autenrieth's chamber, which should in fact be called a large cage, as it is designed in this form. Its purpose is to ensure that the raving patient does not flee or injure himself or others, while he is still able to move freely. For a detailed description of this device the reader is referred to Autenrieth himself (Autenrieth's Versuclze fur pract. Heilk.,Vol. 1, No. I, p. 212), and to Hainer in the pamphlet already mentioned. We find ourselves unable to recommend it in any way, for the following reasons. Firstly, use of the contrivance precludes any curative achievement; for if the patient is allowed to rage as much as he likes and move about within the space allotted to him, he remains master of himself and acts according to his own will. Now it is precisely this will which is bad and which must be restrained, since the whole power, the whole form of the disease is concentrated in it. Autenrieth's chamber thus prevents all medical influence on the patient. Secondly, even if our only purpose is the safety of the patient, who must be prevented from inflicting injury on himself, it must be remembered that the patient can ram his head against the wooden bars of his cage just as effectively as against a stone wall. For such patients often tend to butt their heads against obstacles. Finally, since in any hospital or asylum, which very rarely contains fewer than a hundred, or often some three hundred, mentally disturbed of all kinds, there are almost always a few candidates for Autenrieth's chamber, or, since it may happen that several such patients qualify for the chamber on the same day, are we to lock them all together in the chamber, since all are to receive the same care and treatment? And if we do not wish to do this, how many such chambers must we build for each institution, and at what cost? We must therefore repeat our former conclusion: the proper place for such patients is the confining chair. Here their rage will be spent in a short time, or rather, since they are prevented from violent gesticulation, hitting out, stamping, etc., and if possible also from screaming and cursing, they come to their senses much sooner. Half a dozen such chairs are still cheaper than a single Autenrieth's chamber. The author has often seen great improvements brought about by the confining chair but has never witnessed the slightest harm. If this device proves to be of no use, and the patient should break all bounds (literally speaking), we still have the swing machine.

10. Lacing. This simple procedure, which is the last one to be mentioned, is especially suitable for mentally disturbed female patients who need restraining not so much on account of their wild behavior but because they display morbid stubbornness and refractoriness, and because of their perverted actions, and who would only laugh at mere confinement in a straitjacket. Such patients are first confined in a straitjacket, laid on their bed, covered with a blanket, and laced to the bed with ropes applied over the blanket, just as ropes are drawn over babies' cradles or as women are wont to lace their corsets. Thus, the same procedure serves for both confinement and punishment, since the patient very strongly objects to being treated like a child. After a few hours the patient begs for his freedom, and the author has seen very satisfactory results obtained by this treatment.

Fourth Species: Dietetic means of restraint

1. Hunger and thirst. Hufeland (Journ. der pr. Arznk., Vol. I, No. 2, p. 290) has great hopes of curing disturbances of the disposition by fasting, and thus bringing such dispositions back to earth from their imaginary worlds. Man feels his limitations only in his needs, so that hunger is an effective means of restraint. The same is true, to an even greater extent, of thirst. The objection to this cure is that a patient who has decided to fast unto death cannot be subdued by such means. One such patient was subdued by Cox by the application of his swing machine. Midler (Hufel. J., Vol. XX, No. 1, p. 171) related two cases to illustrate the obvious benefit of hunger cures. A case of senselessness, accompanied by frequent epileptic attacks, which had resisted the most expedient treatments for three years, was cured in four weeks by the application of this method. The patient received two ounces of lean meat and two ounces of bread twice a day, at midday and in the evening; he also received a daily ration of three pounds of sarsaparilla decoction, and in the morning and evening five grains of powdered belladonna leaves and five grains of powdered rhubarb. When the patient subsequently again indulged in immoderate eating, the disease returned but disappeared every time he returned to moderate eating habits. But this case is neither a true hunger case nor does it represent a pure observation. For was not the strict diet merely a medium to improve the effect of the pharmaceutic drugs? The second observation is purer. Depression and insanity in an 18-year-old peasant boy had been ineffectively treated with Helleborus and Gratiola, but were subsequently completely cured by a hunger cure that lasted for six weeks. The patient received two ounces of bread and two ounces of lean meat twice daily, at midday and in the evening, and drank a strong extract of rad. Bardanae. Even Celsus utilized hunger, not as a radical medicine but as a treatment preliminary to the cure in many cases, or else as punishment, together with fettering and beating. The author, too, often punishes disobedience and bad manners displayed by the mentally disturbed by depriving them of food.

2. Sleep. This is clearly the mildest and gentlest means of restraint. The ancients must have attributed highly beneficial effects to sleep in morbid states of the psyche, since they very often recommended it and had at their disposal numerous means for harmlessly inducing it. According to Celsus (III, 18), "Omnibus sic affectis sumnus et difficilis, et praecipue necessarius est: sub hoc enim plerique sanescunt." It might be thought he was describing a degree of magnetic sleep, since he described the method of Asclepiades, who rejected all truly narcotic drugs, since these often cause lethargus rather than sleep. He recommended instead that the patient be given nothing to eat or drink during the first day, and not be allowed to sleep. He should have water to drink in the evening, and then be given a light friction: "ita, ut ne manum quidem qui fricaret, vehementer impriineret." Celsus applies the same treatment on the following day. According to him, this is a means for inducing sleep, which is so heavy that too strong a friction may bring about lethargus. Lethargus through friction? This is what the ancients called it, if the patient could not be awakened from his sleep. Is this not magnetic sleep, which was unknown to the ancients and was therefore feared by them as an unnatural kind of sleep? Still, according to Celsus, narcotic drugs should be administered if friction is ineffective: "Prodest ad id, atque etiam ad mentem ipsarn componendam, crocinum unguenturn cum irino in caput datum. Si nihilominus vigilant, quidam somnunz moliuntur, potui dando aquam, in qua papauer aut hyoscyamus decocta sit: alii mandragorae mala puluino subiiciunt: alii vel amonum vel sycamini lacrimam fronti inducunt. Plurimi, decoctis papaueris corticibus, ex ea aqua subinde spongia os et caput fovent." The last-named treatment, which is less dangerous than the others, could be tried even today, but not without first taking into account any possible contraindications. Celsus recommends a few other remedies, which may be the best of all: the sound of a nearby waterfall; physical exercise; rocking in a hammock (which is practically speaking a kind of swing machine); cupping the shorn back of the head. We may add, for our part, that if it is possible to remove everything which might disturb the patient's sleep, he will fall asleep in his own good time.

Fifth Species: Psychological restraints of excitation

We are not referring to the psychological effect as such, but to the restraint exerted on the excited patient by all kinds of psychological effects. Reil's negative-psychological or stimulus-withdrawing method was aimed at producing depression or at limiting excitation by affecting the general feeling, the senses, and the brain of the patient, although he himself did not state this clearly. The method here discussed includes all this and more. It will be seen that the method involves the use of many medicaments which have already been discussed, but in a different connection.

1. Restraint of excitation by acting on the so-called general feeling. The major category in this group is that of tangible punishments, which we shall again encounter below as means of restraint. They are: hunger and thirst; cold, applied as immersion in cold water, pouring cold water over the head (these should be applied to patients who are sensitive to this treatment, dislike it, but can stand it), prevention of sleep for patients who wake up from sleep even more excited than before but become tired and submissive through enforced wakefulness; this treatment may appear cruel but is in fact beneficial; the patient is awakened every time he is about to fall asleep; administration of emetics, not as a means of producing a purge, but as depressant, since nothing is so effective against excessive excitement as persistent nausea. This is preferably achieved by mixing tartar emetic in the drink of the patient, who then takes his medicine without knowing he has done so, and thus does not resist and is not additionally excited thereby; the doses should be adapted to the sensitivity of the patient. The swing machine, which has already been mentioned on several occasions, and which will be mentioned again, is an even more powerful depressant. Finally, patients who are able to should be made to do physical work, in order that they might spend their forces, and then their excitement abates: wood cutting, wood sawing, carrying heavy burdens, turning of machines such as mangling laundry, pumping water, etc. Also, however objectionable this may appear to some people, corporal punishments such as slaps in the face, birching [whipping with a birch stick] of the posterior. But these punishments must be administered in the presence and on the instructions of the doctor, since they must be applied with caution.

The author has seen very satisfactory results yielded by these remedies, which are often the only ones which make any psychological impression on the patient. Thus, after due warning, he administered a sharp slap in the face to a mad woman who kept abusing him and others whom she wanted to impress by her pretended superiority. The result was that not only was the woman brought back within the bounds of good mariners, but that he gained so much domination and influence over her from that moment on, that she willingly submitted to all his instructions. After her recovery, although she had not forgotten anything that had happened to her during her sickness, she never showed any ill will towards him, as is often the case with such patients. Pinel tells of a similar case of a young man, who had believed himself to be a Swedish prince and had displayed a correspondingly insolent behavior, but was brought to his senses by an unexpected box on the ears administered by his (female) nurse. The author himself has administered strict but cautious birchings to some of his patients, with similarly satisfactory results.

2. Depression of excitation through the senses, or rather withdrawal of sensual stimulation. These means include the previously recommended darkness, the quiet of lonely places, and sleep, insofar as this can be brought about without harming the patient, which not only calms the energy present, but also reduces the tendency for the energy restored by sleep to become excited again. According to Cox, such a sleep is induced by his swing machine.

3. Limitation of the excitement through the spirit, where this kind of treatment can be applied. Reil, basing himself in part on Pinel, recommends reading, recounting of what has been read, copying, learning by rote, simple counting, mechanical handiwork, running errands, etc.

4. Limitation of the excitement through disposition: withdrawal of human company, especially of stimulating companions, and also of objects which have a particularly exciting effect on the disposition; wherefore removal of the patient from his home and his home life is particularly beneficial in these cases. This group also includes calming the disposition by making the patient keep company with merry, pleasant individuals, by making him listen to music, etc. There are also punishments of ambition: deprivation of customary amusements, pleasures, occupations, putting the patient to shame in some way such as ordering him to the box in front of others; this must obviously be done very cautiously.

5. Limitation of excitement by restraint of the will: here everything that has been listed under 1-4 can be considered as a means of restraint and subordination of the will. This may be as mild as bringing one's own personality to bear on the patient, or reproving and threatening him, or as severe as fettering, the swing machine, the box, physical labor, corporal punishment, hunger, imprisonment, etc. The richer the materia medica psychica in means for restraining the will of the patient, somatically or physically, negatively or positively, directly or in a roundabout way, the more helpful will it be to the doctor, whose alpha and omega must be to subordinate the sick will to the healthy.

§ 343. Second Genus: Means of Deflection

This genus includes all the means included in the method of Sandtmann-Horn, even though some of these have already been mentioned under the first genus. These are the remedies referred to by Sandtmann in his paper as indirect-psychic, or counterstimulating, or pain-producing, and their basis is "the law of peripheral antagonism against the central tendencies." Since in this method excess excitement is restrained by deflection, we shall denote these means as deflecting. As we have said, some of the remedies already discussed will reappear here in another connection.

First Species: Elementary means

In these we shall include only cold, as applied through water. Cold baths, applied to the entire body or to parts of it, result in an abatement of the excitement and anger and produce sleep, as they have a twofold effect as a peripheral stimulant against the central stimulant: by reducing the unnaturally intense action of the heart and of the blood vessels, and by arousal of fear. Even merely washing the head with cold water, enveloping the head in wet towels, especially if the hair has been shorn, has a beneficial, deflecting effect, as can be seen from the fact that the coldest compresses immediately become hot. A sudden immersion of the excited patient in cold water and the application of shower baths by means of sprinkling or hosing, or pouring cold water from above, are preferable to all other applications.

Second Species: Pharmaceutical means

These begin with evacuating medicaments, viz.:

1. Emetics. Doctors are in almost unanimous agreement as to their usefulness. According to Cox (Pract. Bemerk. (translation), p. 118), emetics are preferable to all other medicaments; they have proved to be very effective in all types and all degrees of mental disturbances, and even in all stages of any one mental disturbance, and most of all in cases of melancholia, not only because they free the stomach and the intestinal tract of solid obstructions, which are often a material cause of these diseases, but also through their general shock-producing effect on the body as a whole, including irritation of the tissues of the stomach and of the nerves. If there is no definite indication, it is almost always desirable to administer an emetic, which often effects the cure by itself. If there is a plethora of blood, bloodletting should precede the administration of the emetic. If the patient has difficulty in vomiting, he should be given a dose of opium the evening before. Contraindications include a tendency to apoplexy (even if it has gastric causes? ), inflammation of the vital viscera (even biliousness or herpes zoster? ) or hernia. The last-named complaint must be considered, but is not invariably a contraindication, since its advance can be prevented; but care must be taken lest it be of the strangulated variety. Preparations of antimony are preferable to all others, namely tartrated antimony, then wine of antimony, and for athletic patients, antimonial glass. Ipecacuanha is too mild and often produces mere nausea, but no vomiting. Cox administered hazel root, without any results. Preparations of mustard, sea onion,etc., are too mild to be used. If a dose of opium has been administered the evening before, a small quantity of the vomiting-inducing principle will prove sufficient. If the patient cannot be made to swallow anything, a strong solution of tartrated antimony should be rubbed in near the stomach or a cataplasm of tobacco leaves applied in the same place. Zinc sulfate has also been applied with success.

Reil (Fieberl., Vol. 4, p. 474) warns against any roughly empirical application of emetics, since there is a danger that this is what may happen in the hands of a physician who gives unlimited credit to Cox's evaluation of these medicaments. Generally speaking, the climate, the constitution and the conditions of life of the patient must also be taken into consideration. Haslain (Beob. fiber den Wahnsinn p. 92) noted that attacks of paralysis were often the result of the application of emetics. The well-known treatment consisting in the production of nausea, which has already been mentioned and which is recommended by Cox, seems to be safer. Ferriar (Bemerk., p. 90) ordered this cure for eight days to a raging woman, and then he administered whey with Epsom salts and an opiate in the evening. She was also occasionally purged with hellebore root. She was cured. Midler (Hufel. Journ.,Vol. XX, No. 2, p. 122) cured the insanity of a woman with a very delicate constitution by administering tartar emetic according to the following formula: R. Tart. emetic. gr. XXIV. sole. in aq. font. calid. oz. IV. Only after this solution had been used three times in the course of several days did the woman vomit a thick, blackish-green fluid, and she then became more tranquil. The treatment was continued after a few days, and the woman recovered completely after she had excreted a large amount of impurities.

This is the proper place to mention white hellebore which was used as an emetic even by the ancients, and is recommended by, for example, Celsus (III, 18) in cases of insanity (Si imagines fallunt), if the insanity is of the gay kind, for he prefers purge by black hellebore in the case of insanity combined with sadness. In any case, hellebore, whether or not it has a purgative or an emetic effect, is a very important medicament of a deflecting, counterstimulating type, which has a powerful effect on the ganglionic system (the ancients tell of repeated cases of pharyngeal spasm which resulted from the application of hellebore and which were often fatal). But since Helleborus albus is used as an emetic, the following records must be quoted. Rademacher (Hufel. J., Vol. IV, No. 4, pp. 82 ff.) administered two drams of powdered jalap every 3 days to a woman in childbed, who had become raging 14 days after childbirth, with the result that she excreted large amounts of putrid excrement. This dose was repeated four times, whereupon the woman became quiet, but did not talk much sense. Thereupon he administered a daily dose of 3 grains of powdered Helleborus albus and thus effected a complete cure. Greding (Sdmmtl. med. Sao. Vol. 1, pp. 179 ff.) produced a complete cure in 5 out of 28 patients by administering powdered Helleborus albus; other patients were markedly relieved, while others were quite unaffected. (But why should we expect a medicament to be of help in all cases? ) Wendt also found this remedy to be very useful (Agassiz Diss. de therapia maniac, Erlangen, 1785), as did Hahnemann (Hufel. Journ., Vol. 2, pp. 556 ff.) and Auenbrugger, (loc. cit., p. 8). Lorry's (Vol. II, pp. 288-320) information about applications of hellebore in antiquity is also very valuable. Perfect (Annalen, 5th case) denies outright that hellebore has any use.

2. Purges, digestives, and enemas. This group includes black hellebore, first and foremost. As is well known, the entire psychiatry of the ancients is based thereon, but they had nothing else with which to affect the intestinal tract. We are richer, and have our medicaments more under control than the ancient physicians had theirs. A few of these physicians did not think much of this remedy, and recommended the use of lapis Armenius instead of Helleborus even in those days. Gratiola has a similar effect. Lentin (Hufel. Journ., Vol. I, No. 1, p. 71) cured three cases of insanity and madness by means of Gratiola. He first administered 3-5 grains of white vitriol as emetic, and then gave powdered Gratiola leaves, half a dram in the mornings and 10 grains in the evenings, whereupon a large amount of Kdrripf's infarctus was evacuated. He then gradually reduced the doses. On this medicament see also Reil's (Fieberl., Vol. 4, p. 481; Stork, Med. pract. Unterr. Vol. l2?l, p. 36; Sommer, Diss. de virtu to et vi med. Gratiolae, Regiom, 1796; Kostrzewski, de Gratiolae, Vienna, 1775. In Vienna three demented people were cured in this way. Bucholz (Hufel. Journ., Vol. 2, p. 142) applied it as an enema in cases of insanity. Many doctors, including Pinel, prefer milder medicaments. Mutzel's medicament against melancholia and insanity is well known. Mutzel's prescription is Tart. tartaris Mell. despum. aa. 1 dram. Aqu. comm. oz. Vjjj. He administers the preparation at first every two hours, and then only three times daily, in the morning, at noon, and in the evening, one tablespoonful each time. It was his invariable practice to administer a mild purgative after eight days, whereby melancholia and insanity were cured (see Weikarts philos. Artzt., No. 4, p. 268). Cox (Bemerk. (translation), p. 137) prefers salt medicaments, in particular acid potassium tartrate. If a powerful medicament is required, he chooses calomel; he selects aloe for obstructions of uterine vessels and suppressed hemorrhoids. Contraindications are: general weakness, delicate bodily constitution, undue sensitivity of intestinal tract, and loss of weight. Perfect often applied acid potassim tartrate and castor oil. Hufeland (Journ. der pr. AK, Vol. XIV, No. 1, p. 185) tried the effect of alkaline and strongly purging mineral waters, in particular the Karlsbad water, for treating melancholia caused by inactivity of the abdomen. Finally, we must still mention anthelmintica. Thilenius (Med. u. chir. Bemerk. p. 237) cured a case of mania by the elimination of worms and of worm mucus. The reader is also referred to Perfect's case No. 53. Thilenius also warmly recommends Kämpf's enemas for melancholia in the literal sense, but the present author never noted any effect of these enemas, in spite of prolonged observations.

3. Counterstimulants in the narrow sense of the word. Here, tartar emetic in refracta dosi must be mentioned first. It produces nausea and affects the nervous tissues of the stomach. The second medicament is calomel, which affects glands, first and foremost the salivary glands, whereby a powerful counterstimulus to cerebral excitation is produced. The author has often seen definite cures of psychic affections, manifested by violent excitement, brought about by the counterstimulus of the salivary glands, produced by calomel. For a description of two such cases, see Zeitschrift fur psychische Aerzte, edited by Nasse. We shall also quote Perfect's second case, in which calomel, administered until salivation resulted, produced a permanent cure. Perfect subsequently administered a douche, mild purging with Kali tartaricum, and bark. Even Cox, who is no great friend of mercury, recommends the application of calomel in such cases, with due attention to the intestinal tract. The high efficacy of counterstimulation of the salivary glands can be seen from the fact that a voluntary strong salivation produced a complete physical and mental cure in the case of a man who had been paralyzed in both legs and whose mind was affected (Vicat, Samml. auserl. Abh. fiir pr. Aerzte, Vol. XIII, p. 337; see also Perfect's second case). Hunger is also a very important counterstimulant, because it makes the patient feel his dependence strongly, and because stimulation of the nerves of the stomach is an excellent means for deflection of brain stimulation. Nevertheless, hunger has also been known to produce excitement of the brain to the highest degree. The author knew a maniac who displayed an attack of mania after every period of protracted hunger (he lived in the direst poverty). The attack was always preceded by a state of insanity, which the patient greatly enjoyed, and for this very reason often sought to bring about-by deliberately starving himself. However, this is a dietetic remedy, and thus out of place in this group; we shall accordingly conclude this series of pharmaceutical-deflecting medicaments with narcotica. These medicaments, which have varying degrees of specificity, all affect the ganglionic system and thus furnish a strong counterweight to cerebral excitation. One of the best-known experiments on this subject is the well- known one of van Helmont with Aconitum napellus. Similar effects are given by Belladonna, Hyoscyamus, Datura strammonizim, and by opium itself. Practicing physicians use the expression calmative when referring to the effect of these products in mania or in cases of violent excitement. Thus, for instance, it was reported by Thilenius (Med. und chir. Bemerk., p. 237) that he had observed the beneficial effect of extr. hyoscyami, since its calming effect was even stronger than that of opium. Locher succeeded in calming a few maniacs by administering 15-20 grains of musk daily. This can only be explained by assuming that the ganglionic system is affected, even though musk is not considered to be a narcoticum; nevertheless, there is something of a narcotic in it.* Selle says explicitly that he is in the habit of administering opium, after sufficient purging, in cases of persistent excitation of the brain. How are we to explain the sudden cure of mania after sleep brought about by strong doses of poppyseed juice, as reported by

* Since it is the specific property of musk that, unlike narcotica, it does not produce excitation as its first effect, musk is not considered to be a member of this group. However, the author has seen soporose and apoplectic conditions produced by moderate doses of musk.

Wendelstadt (Med. u. chir. Auff., 1807)? Obviously by equilibration: the highest excitation of the ganglionic system must be in equilibrium with the brain system; and thus results sleep = 0 and with it indifference, that is, cure of the morbid conditions. This seems to be the key to Hahnemann's homeopathy, which is an invention not to be ignored.

Third Species: Externally (surgically and mechanically)

deflecting medicaments

1. Sternutatories are extracted from Flor. Serpill., maioran, arnic. G. Guaiacum and Euphorbium. They are easily administered, since many of these patients willingly take snuff.

2. Excitants of the skin and of the general feeling, strong frictions and brushings, tickling, itching and stinging by insects, bedbugs, ants, maggots; whipping with nettles; birching; blistering plaster; mustard plasters, douches, setons, but only on the most remote parts of the body, since when applied to the head, the excitation only mounts (Reil and others), scarifications of the head, cuppings (recommended by the ancients) and trepanations, except after injuries to the head. (Hufel. Journ., Vol. 3, No. 4, p. 695). Perfect (Suppl., pp. 11 and 12) saw only two cases in which the application of vesicants to the head proved beneficial. Pargeter (p. 55) complains of their unsatisfactory effects. Cox (p. 148) also considers them ineffective. However, Chiarugi repeatedly expressed a different opinion, and his hundred case histories contain several where, according to him, the cure was attributed exclusively to the effect of the blistering plaster. Cox (p. 157) praises artificially induced ulcers, fontanelles [sic] and setons. The same can be said of Perfect (case 61); Pargeter (p. 54) also considers them useful. Other beneficial measures are moxa [Chinese Moxibustion: mugwort herb processed into a punk that is lit and burns the skin], glowing iron, burning sealing wax. Especially recommended is inoculation with skin eruptions, mainly mange. Mutzel (Med. und chir. Wahrn., Samml. 2, p. 60) in this way cured a patient who had vomited only once when given XXV grains of tartar emetic, and had been little affected by showers or immersion in water. Reuss (Dispensat. univers. Argent., 1786, Vol. 2, p. 232) noted that raging patients were cured by inoculation with smallpox; Chiarugi saw melancholics cured by pustules, and the insane cured by psoriasis and scabies. Thilenius (Med. und chir. Bemerk., p. 236) cured a demented patient by inoculating him with scabies. The author saw a girl, who had been idiotic for several years, become gay, cooperative, and active when a scabies eruption, which had formerly disappeared, returned again. The same can be said of the skin eruption produced by rubbing in Autenrieth's ointment. Plunging the patient into cold water was recommended and very successfully employed by Reil (Aphorism., p. 192; Fieberl., Vol. IV, p. 483), Willis, Boerhave (Aphorism., § 1123), and v. Helmont (Demens idea, p. 228). Van Swieten (Corn. Vol. III, p. 524) also gives examples of cures effected by immersing the patient in cold water.

This is the proper place to discuss bloodletting. This seemed to the ancients and to their successors, with few exceptions, to be an indispensable measure in mania and melancholia. In more recent times, bloodletting has had about as many protagonists as opponents. It is certain that bloodletting, like everything else, can do as much harm when applied at the wrong time as it can do good if carried out at the proper time. But the question as to the proper time for bloodletting is not easy to answer. Thus, according to Cox, bloodletting should be resorted to only in congestions and in cases of true plethora of blood. However, both these concepts must be more precisely defined, or rather, since they are indeed meaningless (because they do not probe the depth of organic relations, but are purely mechanical), they should be exchanged for others, which are a better expression of these conditions. It seems to the author that the safest procedure is to bleed only if there are distinct signs of idiopathic overtension of the vascular system. The physician should not be misled by a red complexion, which is often caused by a nervous or gastric condition. It is certain that bloodletting, whether effected by opening the vein or by application of leeches, has often proved to be very beneficial (cf. Perfect, Allione, Chiarugi, et al.). As to the exact rules to be followed in bleeding, these must be determined by somatic therapy. The discussion on this group of medicaments will be concluded by describing the external medicaments recommended by Sandtmann (De quibusd. remed. etc., pp. 86, 99, 100 ff.) as excellent means of deflection. First: rubbing in a powerful tartar emetic ointment over an area the size of a thaler on the shorn scalp. Sandtmann noted that this treatment is effective for calming restless and noisy patients, and for rendering refractory patients obedient. He disagrees with Cox and Reil that such irritation of the head only complicates the disease. Furthermore, he and Chiarugi recommend the suspension of the patient by ropes. Finally, he recommends Cox's swing machine, which was introduced in Germany in 1807 by Horn, who markedly improved its design and renamed it "threshing machine." Sandtmann has given a detailed description of this machine (p. 102). Contraindications to the use of this machine are rare; it must be cautiously employed if the patient has a tendency to congestions. In general, the number and frequency of the swings must be adapted to the organic individuality. He describes (pp. 104 ff.) its symptoms and results: vertigo, fear, paleness, anxiety, nausea, vomiting, bowel movement. The powerful shock to the disposition subdues even the most refractory patients. Further results are tiredness, sleepiness, and a deep gentle sleep, which often lasts for many hours. According to Cox, reason often returns on awakening, and the patient becomes more receptive to other treatments.

Fourth Species: Psychic means of deflection

These include the influencing of the patient by fright or intimidation, but also by the magic force of music, by viewing beloved objects, by a stay in the open in pleasant surroundings, all according to the receptivity of the patient. In general, by distracting the patient or putting him to work, in accordance with the circumstances.

B. Medicaments Stimulating the Abated Excitement

§344. Third Genus: Means of Excitation

These medicaments differ in degree and kind, and counteract every genus of depression.

First Species: Elemental stimulants

These include the stimuli exerted by fresh air, light, heat (tepid or warm baths; the warmth of sunlight), and cold. Cold may act as both depressant or stimulant, and is an important remedy in the latter capacity: washing in cold water, cold baths, cold showers. This group also includes electricity and galvanism, as well as mineral and animal magnetism. As regards electricity, it was reported by Bertholon de St. Lazare (Anwend. u. Wirksamk. der Electricitiit. Vol. 2, p. 39) that negative electricity should be employed in cases of mania, and positive electricity used for asthenic affections of the psyche, including idiocy. But Mr. Bertholon is very much mistaken if he thinks that he can withdraw stimuli from the patient by the application of negative electricity, since stimulation by negative electricity is no less powerful than stimulation by positive electricity, and the former is the opposite of the latter but is not a deprivation of it. Thus, his recommen-dation is based on a misunderstood principle. Cox did not notice any permanent beneficial effects obtained by the application of electricity, except in the case of obstructions in the uterus. Perfect (cases 106, 107, and 108) completely cured three patients by the application of electricity, but most patients merely experienced temporary relief. Birch (Perfect, p. 404) was able to cure two cases of melancholia by the application of electricity only. Wohlrab (Diss. de usu electric. medic., Leipzig, 1796) also quotes a few successful treatments, in particular of melancholia with dementia. The author himself witnessed some of the efforts of this active worker, but cannot recall that he observed any striking effects. Galvanism was tentatively recommended by Reil as treatment for idiocy. The present author applied the mineral magnet in the form of plates, fabricated according to the rules of the art, but cannot agree with the praises of other workers, since he himself found the magnet ineffective. His friends, for example, Wolfart, praise animal magnetism, including its application to disturbances of the psyche. Nasse has not yet noted any effect. The author is uncertain as to the significance of what he himself has seen and believes that such magnetism may be effective in certain cases. It is necessary, first and foremost, to provide adequate force: for if the force is inadequate for the burden, no effects can be expected.

Second Species: Pharmaceutical stimulants

These include naphthene, phosphorus, essential oils, mustard, and vanilla. Vanilla (epidendron Vanilla) was recommended by Reil ( Fieberl., Vol. IV, p. 468) for affections of the spirit involving paralysis. Rajus recommended vanilla as a specific medicament for melancholia and frenzy. Pargeter (Abhandl. fiber Wahns. , p. 110) relates four cases of melancholia which were cured by vanilla. Such medicaments also include nutmeg, pepper, galangal, castoreum, China tea, veronica, sage, peppermint and balm-mint drops, lavender, rosemary, etc. Cox (p. 156) recommended the ingestion of cantharides if the patient proved insensitive to all other medicaments.

1. The "errhina," in the form of (Reil, Fieberl. Vol. IV, p. 481)

Third Species: External and surgical stimuli

Tobacco, mayflowers, marjoram, balm-mint, white hellebore, powdered guaiacum, powdered euphorbium, the vapor of boiling hypochloric acid (Pargeter, p. 67). 2. Irritation of the skin by blistering plaster, douches, setons; rubbing the skin with the hand, with a flannel cloth, with a flesh brush, whipping with nettles, birching, scarifications. LOffler (Hufel. J., Vol. III, No. 4, p. 695) made cuts into the scalp of a patient suffering from chronic insanity, kept the cuts festering for a long time, and effected a complete cure in this manner. Thilenius (Med. u. chir. 13 emerk., p. 236) strongly cupped the top of the head, and after 12 hours applied a blistering plaster with cantharides powder to the cupped site. The festering was maintained, and the patient recovered. According to Perfect (case 60), a raging patient received a hard blow on the head during a paroxysm, which resulted in a strongly suppurating abscess, but this led to his recovery. Inoculations with scabies and other skin eruptions also belong to this group.

Fourth Species: Dietetic stimulants

These include wine, coffee, cocoa, malt-rich beers, a meat diet. Further: keeping awake rather than sleeping, exercise rather than rest; for once life has lost the spur of activity, it falls prey to inertia and then to apathy, and sinks ever deeper into the abyss of indecision, which is its death. Such life can be reawakened only by removing the burdens of excessive sleep and idleness.

Fifth Species: Psychic stimuli or means of excitation

A large number of such stimuli were proposed by Reil, but not all of them are feasible. Cf. Rhapsodien, pp. 168 ff. Of these we shall select the following, and add a few of our own: 1. Stimuli of the senses, for the eyes and for the ears, insofar as the patient if sensitive thereto: flowers, natural produce, brightly colored toys (kalei-doscope), sounds in general, such as the sound of bells, trickling water, and most of all, music. (Reil's suggestions for the sense of touch are too hazardous.) 2. For the spirit: occupation suited to the individual patient: mechanical work, artistic work, conversation, games, especially open-air games (bowling, etc.). 3. For the disposition: social conversation, again music, rewards and punishments for those who have retained their self- respect; stimulation of interests of the heart. 4. For the will: compulsion to activity and to an orderly life, again rewards and punishments, severe and mild ones.

§ 345. Fourth Genus: Revivifying Agents

These are applied where the vital force, particularly the vital force of the psyche, is weakened. Insofar as excitement alone increases the weakened vital force and strengthens it through renewed exercise, all medicaments of the third genus belong to this group; but some of them are classed in this group also because they in fact contain the necessary revivifying principle, namely: 1. Elemental stimuli: the air, not only because of its stimulating effect, but because pure, oxygen-rich air is a true pabulum vitae. Sunlight as light is only a stimulant, but its warmth really revivifies, as does any other kind of warmth, especially in the case of cold, half-dead natures. Cold revivifies only negatively, either by stimulating or by withdrawing excessive, burdensome warmth or heat. In the experience of the author, applying electricity to the patient on an insulated chair did not result in true revivification, even though he is convinced that the electricity bound in atmospheric air is a truly revivifying principle. Finally, vital magnetism, if it should fulfill expectations, is a revivifying principle, as can be seen from its name alone. 2. Naphthenes are pharmaceutical stimulants which are revivifying. 3. Dietetic stimulants include all the foods mentioned above as revivifying materials. 4. Of the psychic stimulants only those acting on the disposition are revivifying agents if they have a pleasant effect on the disposition.

The following must be mentioned as especially strong revivifying agents: 1. In the dietetic series: a healthy diet in general, that is, truly nutritive food, in as far as the organism is really receptive to it: the power of bread, and starchy foods in general, as well as starchy fruits; milk, especially if it is fresh enough to have retained the animal warmth, which has its own strength of vitality; eggs, especially the yolk; broths made of snails, crayfish, turtles, poultry, and meat in general; meat itself, roast meat in preference to boiled meat. 2. Of the pharmaceutical series: tonics proper, namely, cinchona; the ginseng root of the Chinese; and iron. 3. It was mentioned in § 295, obviously only as a hypothesis, that transfusion of the blood of young, healthy, strong animals may be employed for the revivification of idiots (and of melancholics with so-called keneangie), but experience has shown that the vitality produced was so high that it resulted in mania. If all vitality has left the patient, there is no danger in such a strong measure of excitement, and there is hope that fresh vitality will be supplied to the brain and to the nerves by the new blood streaming in; at least the physician will not bear responsibility for possible failure of such an experiment if everything seems to be lost. 4. Revivifying stimulants of the psyche include good luck, such as the saving of one's possessions, sudden riches, appointment to a no longer hoped-for position, a formerly rejected but eventually accepted suit. Straton-ike healed the love-sick son of King Antiochus who had sunk into total apathy. A young merchant was saved from Melancholia attonita by being assured that his beloved, whom he thought he had lost, wanted to belong to him; and a woman who had become melancholic due to the absence of her husband re-covered on his return. Joy is the vital element of man.

Chapter Three

SECOND CLASS: MEANS OF FORMAL TREATMENT

§ 346. First Genus: Means against Disturbances of the Disposition or Means Producing a Change in the Disposition

Since disturbances of the disposition are of two opposite kinds, the medicaments are also of two opposite kinds (§ 302), viz, calmatives and stimulating agents.

First Species: Calmatives

Insanity in its various forms, in which the unfree, exalted disposition manifests itself, and consequently the imagination which is excited thereby, must be calmed. But it is easier to achieve this indirectly by psychological means than directly; it is easier to do it negatively than positively. However, the positive way is not impossible, at least in some cases. We shall introduce the concept of a direct effect, insofar as the imagination can thereby be affected directly through the senses. The remedies are the following:

A. Means of calming directly

1. The presence of objects, in cases where the deprivation or loss of these objects has so affected the disposition that insanity results. A well- known voice, the nearness of a beloved person, will do wonders; so will the recovery of a jewel case with its contents.

2. Music. It acts like a real charm on an ear which is used to it. Obviously, the kind of music must be suited to the individuality of the patient. David calmed Saul in this way; Orpheus led Eurydice out of the land of melancholia by the magic power of his lyre. In modern times and modern writers there are examples of such effects produced by even the simplest instruments, except drums.

3. Religious objects. The proximity of holy places and holy objects, the execution of holy rituals with all their pomp and glory, have their effect on dispositions for whom the formality of religion is an object of faith. Hence, the miraculous calming effects and recoveries produced in places of worship, by holy pictures, etc. in antiquity, the Middle Ages, and our own times.

4. Terror-inspiring objects, and effects which they produce.

B. Means of calming indirectly

1. Stillness, solitude, darkness. Cold, applied by means of water. Showers; pouring of cold water over the head, cold compresses on the shorn head, evaporation of naphthene on the head. Vital magnetism: the calming method.

2. Emetics and purgatives; the nausea treatment; calomel, niter; camphor with vinegar and niter, mineral acids; digitalis; aqueous extract of cherry laurel; narcotics in general, in the absence of contraindications.

3. External deflecting means, namely, blistering plaster. Leeches, bloodletting, if the circumstances permit.

4. Very light, cooling diet: frequent drinks of water, much juicy, acidulous, water-containing fruit: strawberries, raspberries, red currants, grapes, etc., the lightest vegetables, which do not produce wind, served as a thin broth without meat, light fish, white bread only, generally frugal meals, even hunger cures, sleep and everything which produces natural sleep.

Second Species: Means of enlivenment

Only the melancholic needs enlivenment of all kinds, and all degrees at all times. These means are:

1. Light and air, warm baths; douche, electric and galvanic shocks, and the excitation method of vital magnetism.

2. Here, too, at least at the beginning and according to the advice of the ancients, also in later stages intermittently: emetics and purgatives: hellebore, Mutzel's medicament; ptisans [tisanes] of saponacea; decoctions of grass roots and dandelion, honey, barley water with oxymel, the loosening and purging, and also mineral waters containing carbon dioxide and iron; iron in general, cinchona, sage, saffron (which, taken in excess, was reported to make the patient laugh himself to death; Weikardt, Phil. Arzt, IV, p. 220). Small doses of opium, vanilla, coffee, cardamon, anise, fennel, cinnamon, calamus, naphthene. Musk has also been recommended.

3. Externally irritating and deflecting medicaments which produce redness of the skin and blistering: rubbing the body with the hand, a flannel cloth, etc.; massages where applicable, rubbing tartar emetic ointment into the shorn scalp; scalp scarifications, scalp cuppings, and maintenance of the irritation thus produced by application of cantharides powder; moderate movements of the swing machine; after a suppressed tendency to hemorrhoids: leeches in the anus; after suppressed skin eruptions, dried ulcers: return of the same or similar skin irritations, artificial ulcers, etc.

4. Light, but nevertheless strengthening diet: wine posset, warm donkey milk or goat milk straight from the animal, light, stimulating beer, good quality old wine (Rhenish wine), light roast meat dishes. Much exercise in the fresh air, work, play, travel, exertion, healthy sleep, all these are the best tonics.

5. Everything producing excitement of the psyche: lively, merry companions, music, walks, again work and play; awakening of lively affections and passions; the exciting effect of fear, fright and, if possible, joy.

§ 347. Second Genus: Means against Disturbances of the Spirit, or ( §3C12) Means of Correction

We have said ( §337) that this genus can be divided into two species: the loosening medicaments (against the bonds of dementia), and the binding medicaments (against the diffusion of idiocy). They are:

First Species: Loosening medicaments

Deflecting medicaments of all kinds (cf. deflecting medicaments, § 343), especially: the hunger cure, the nausea cure, the douche, the swing machine, physical labor: gardening, wood sawing, wood cutting; distractions such as running errands, copying letters, copying in general, proofreading (for those who can and want to do it); counting and sorting of coins; putting together maps cut up into pieces, doing jigsaw puzzles, etc., amusements, music, reading, light conversation, striking reasoning through witticisms, through deduction ad absurdum (Pinel). Games which occupy the mind: cards, chess, "toccatille"; occupation with favorite objects: painting, drawing, drawing maps, copper etchings; natural history specimens, such as stones, plants, in-sects, etc. There is no limit to this kind of inventiveness, as was conclusively proved by Reil.

Second Species: Binding medicaments

This species includes anything which can convert bodily and mental apathy into firmness, indifference into excitability and receptivity, and idleness into activity.

These include, accordingly: apart from a good diet, baths, aromatic, iron-containing mineral waters, cinchona, the so-called nervines, skin irrigations maintained, where necessary: healthy air and healthy surroundings, staying and exercising in the fresh air, getting used to some activity, even if only a mechanical one, orderliness, cleanliness, but most of all: excitation and exercise of spiritual energies; exercise of the reason and of the will by a series of exercises of various kinds and degrees, schooling, discipline: arranging mixed objects, such as sorting dried fruits and pulse vegetables according to their kinds, sorting money, etc.; counting, measuring, computing, reading, writing, memorizing and recitation of texts, catechism, exercises of the mind even when playing, briefly, education, resembling that of a child, the exercises being adapted to the sex of the patient. Punishments and rewards, adapted to the receptivity and tendencies of the patients must not be forgotten.

§ 348. Third Genus: Means against Disturbances of the Will or ( §3O2) Means of Direction

These also (§ 377) can be divided into two species: means of restraint (against rage) and means of encouragement (against apathy and timidity).

First Species: Means of restraint

These include means of limitation, as described above, namely: deprivations of all kinds, restricted diet, exhausting labor, punishments, various kinds and degrees of physical restraint, moral punishments, and, where nothing else is of any use: the rotating machine.

Second Species: Means of encouragement

Revivifying, fortifying medicaments, good diet, warm baths, stay in the open, in pleasant surroundings, friendly, mild, humane treatment, excitation of natural tendencies and activities by games, and attractive objects: music, theater, travel; in general: small but increasingly more difficult trials to reawaken the self-confidence and the capacity for self-determination.

§ 349. Subspecies of formal medicaments

Since, in accordance with §299 and §337, a direct influence cannot always be produced on the three main psychic energies, this must be achieved in a roundabout way, through the intermediate effect of other energies. Hence the subspecies of means of calming and means of stimulation, means of loosening and binding, means of restraint and encouragement. All these are taken from the sphere of the psyche.

1. Indirect means of calming. The exalted disposition of the patient and the imagination which is excited thereby are affected through his spirit and his will. Here the recommendations of Reil (Rhapsodien, pp. 168 ff.) are suitable where the imagination falls captive to ideas, for example, the glowing iron instrument, with which the author of this textbook was able on one occasion to bring a patient completely to his senses, even though this improvement was not lasting; simulated lightning and thunder; a perfectly dark, perfectly still cellar; or else a deafening noise in a dark place, as in the depths of a fountain; sounds of squibs, pistol shots, etc. We may add our advice, namely electric shocks from a galvanic battery given to the patient in the dark. Another remedy is Reil's theater, about which the reader is invited to read for himself. Everything must be tried. The will is guided by ideas and affects the disposition. A quiet child obviously should not be frightened, but a refractory child, who is determined to have his own way in some particular matter, will be quietened by frightening impressions.

2. Indirect means of enlivenment. The depressed disposition of the patient is affected through his mind and his will. Ideas which depress an exalted disposition, awaken a depressed disposition. It is possible, accordingly, to use the means just discussed for opposite reasons and opposite ends, for uplifting the spirit of the patient. But it is also possible to awaken and enliven the disposition by gay objects, pictures, surroundings, ideas. Thus, it is said, the ancient Egyptians cured melancholics by using everything which could stimulate the eye and the imagination.

3. Indirect means of loosening. The spirit of the patient which is directed in the wrong way is affected by his disposition and his will. The susceptibility of the disposition should be awakened by means of objects and impressions dear to the heart of the patient, and he will be nearer to regaining his senses, since his inclination, his will, is then directed mainly to a natural, that is, a true relationship.

4. Indirect means of binding. Here, too, the feelings, the inclinations, the aspirations of the patient must be awakened and his fallen spirit thus stimulated. Let the physician show a pear, an apple, a piece of cake to an idiot and thus make him get up, come nearer, stretch out his hand, make a spoken request, etc. The author has seen such efforts crowned by success if they are continued for a sufficient period of time and are suitably intensified.

5. Indirect means of restraint. The will is affected by the spirit and the disposition. Treatment which affects the self-respect of the patient, shaming the patient, humiliating him; intimidation by the presence of the physician, by the threat of punishment, especially if the patient has been punished before; also loving, mild persuasion, and music, which are the very opposite means.

6. Indirect means of encouragement: again by influencing the intellect and the disposition: display of goodwill, amusing games, social merrymaking.

Chapter Four

THIRD CLASS: MEANS OF INDIVIDUAL TREATMENT (cf. §303 and §338)

§ 350. First Genus: Procedures Related to Sex

It has been known for a long time and has been repeatedly noted that in the male sex, pride, ambition, greed, and excesses of all kinds (in games, sexual desire, drink, etc.) are the elements of disturbances of the soul to which men are prone, whereas the elements of the soul disturbances affecting women are usually love, jealousy, and vanity. The sexual elements of soul disturbances are thus characteristic, and must be treated in accordance with their character. However, here, as everywhere else, everything depends on the susceptibility of the individual; accordingly, the medicaments which must be employed will be mildly exciting or strongly exciting, either case depending on whether the patient has a gentle or rough nature.

First Species: Mildly exciting medicaments

A. For the male sex

Such medicaments should be used on the proud and the ambitious, as they are the most vulnerable. These patients wish to be treated with decency. They do not like being contradicted; and since they should not be humored unconditionally, they must be treated with great caution and deliberation. Thus, they must not be allowed to converse with persons who might easily offend them. Insults make them fly into a rage. Their individuality must be respected, but their folly should not be tolerated. The best way to fight pride is through a greater pride, which does not annoy, does not give rise to indignation, but routs these actions.

B. For the female sex

This sex is kat exokhen, that is, "the delicate, vulnerable sex"; and were it not for the fact that yielding to their wishes aggravates the patients' disease, humoring them would be good medicament. Accordingly, for the most excitable patients, sympathy must be enough. But it is the most vain and the most jealous patients who are also the most excitable; and the best treatment for this excitability is contempt. Contempt does not annoy and does not excite; it depresses. But those who have gone insane for love (le pazze per amore) need sympathy first and foremost.

Second Species: Strongly exciting medicaments for both male and female patients

Privation, labor, compulsion, punishments. Whoever cannot be stimulated otherwise and does not respond to any other treatment must be brought back to the right path by these means. But here, too: "the same is not meet for all."

§ 351. Second Genus: Procedures in Relation to Age

The application of a more weakly or more strongly stimulating treatment should be guided by the fact that excitability is stronger in youth and declines in middle age and in old age. But there are so many competing circumstances that no general rules can be laid down on this subject. Fortunately, neither very young people nor the very old need such a treatment: the former because as a rule mental disturbances do not occur in very young individuals (the case of a boy who was born raging, reported by Lorry, is very exceptional, and the diseases of development prior to puberty, which are more allied to sleepwalking, will not be discussed here), while the latter need no treatment, since therapeutic treatment would be useless. Thus, strongly and mildly exciting means should be applied with due regard to age, but these must be modified according to a large number of other circumstances. However, we would mention the following as an illustration of the specific differences in the different ages and their susceptibilities:

First Species: Mild means of excitement

A. For the youthful: everything related to the homely way of life; for this age is as yet little attached to this mode of life.

B. For a more advanced age: everything related to the objects of imagination and the display of vital force; for a man advanced in years is no longer strongly attached to them.

Second Species: Strong means of excitement

A. For the youthful: everything which engages the imagination and sensual enjoyment, namely: love in general; romantic life, far-away lands; enjoyment of ambition, freedom, art, nature, etc.

B. For advanced age: everything concerning the security of life, existence and possessions, such as: riches, status, family, respect shown by others, official recognition, etc.

§ 352. Third Genus: Modes of Treatment with Reference to Constitution

There are constitutions which can stand the roughest psychic and somatic treatment, while others are upset by the mildest of treatments. It is accordingly necessary to study the effect of all classes of medicaments on different constitutions, without paying attention to the strong or delicate physical aspect of the patient, since this is often misleading; but attention must be paid to the manner in which the affections are borne. Thus, the gentle or the vigorous treatment, the strongly or mildly exciting medicaments, also determine the species in this genus, in accordance with a strong or a delicate constitution.

First Species: Mildly exciting constitutional medicaments

The elementary medicaments include: moderate warmth, moderate light, very gentle zoomagnetic contact. The pharmaceutical medicaments include gentle purgatives, such as: neutral salts of ipecacuanha, rather than stronger medicaments which are difficult to digest, such as cinchona, or iron; at least the latter should not be applied in large doses, but as rather weak bark extracts, weak tinctures of iron. Calmatives include few narcotics or none at all, but rather medicaments of the antiphlogistic group: small doses of niter, mineral acids, Haller's acid, in general, nervina in small doses; calomel may be cautiously administered as a means of deflection. Surgical medicaments should include only those with a weak irritating effect on the skin: gentle friction, stroking with nettles, mustard compresses; no bloodletting, no swing machine; the dietetic medicaments should include only moderate deprivation of food; the food should be nourishing, but not too heavy or too difficult to digest; only a little weak wine or strong wine mixed with water; nourishing broths, light meat dishes, delicate vegetables. Finally, no exacting physical labor, but mild exercise, which should not be prolonged, but rather taken often after periods of rest. The psychic medicaments should all be mild.

Second Species: Strongly exciting constitutional medicaments

The elementary medicaments should include cold, and electric and galvanic shocks. The pharmaceutical medicaments should include drastic emetics and purgatives: Helleborus, Gratiola; tonics are seldom necessary; narcotics and calomel, where prescribed, can be given in large doses. The surgical medicaments include strong irritants: moxa, glowing iron, scarifications, the swing machine, severe punishments administered with the aid of the so-called horsewhip. The dietetic medicaments include hunger cures where necessary; for necessary nourishment, strong, coarse food should be given and the patient should be made to do strenuous physical labor for long periods of time. Moderate or interrupted sleep. The psychic medicaments should include seriousness and severity if necessary.

§353. Fourth Genus: Medicaments Related to Temperament

Here too, there are temperaments which can stand only mildly exciting medicaments and others strongly exciting ones. Hence, again, there are two species of medicaments.

First species: sanguine and choleric temperaments are more responsive to elementary medicaments such as cold and darkness and to calming zoomagnetic treatment; pharmaceutically, they are more responsive to antiphlogistic calmatives and deflecting medicaments: digitalis, niter, mineral acids, calomel; surgically to bloodletting and leeches, cuppings, rubefacients, and vesicants; dietetically, to light, moderate, cooling diets, moderate exercise, abundant sleep; psychologically, to severe, serious treatment. Generally speaking, the medicaments which are suitable for these temperaments are limiting, moderating, and calming.

Second species: phlegmatic and melancholic temperaments respond elementally to warmth, light, electricity, galvanism, zoomagnetic stimulation; pharmaceutically to all the strongly exciting medicaments: Helleborus, large doses of narcotics, phosphorus, etc.; surgically, to the strongest excitants: the so-called cauteria, actualia, and potentialia; the swing machine; dietetically, strong food and drink, wine, moderate sleep, vigorous exercise for long periods of time; psychologically, all the means of encouragement. Generally speaking, the medicaments used on patients of these temperaments must he exciting ones.

§354. Fifth Genus: Medicaments with Reference to Personality

We consider personality to be something distinct from constitution, temperament, age, and sex, even though all these influence the personality. The personality of a man is his innermost, own being, which is determined by his inner activity and energy or inactivity and inertia; thus (§308) it is his character, his intellect, and the sum total of his inclinations and habits. The treatment in general has been described in § 308. The means can be sub-divided into mildly exciting and strongly exciting medicaments. Thus:

First Species: Mildly exciting medicaments with reference to personality

1. Amiable conversation, friendly coaxing, a mild, friendly attitude in general, granting of favors, pleasant surprises, rewards, evidence of respect. These are fitting for soft, pliable, friendly natures. 2. Intellectual conversation, light, amusing reading, intellect-exercising games, music, theater, trips to places noted for their natural beauty and their art exhibits. This is treatment suitable for educated people, for intellectuals. 3. As regards inclinations and habits: society, enjoyment of art and nature, games, light, varied occupations, walks, etc.

Second Species: Strongly exciting medicaments

1. Seriousness and severity, restrictions, punishments of all kinds. Such treatment is suitable for rough, refractory, vicious persons. 2. Imposition of orderly habits in getting up, washing, dressing, eating; strenuous, prolonged physical labor. Such treatment is suitable for inert, disordered, neglected, spiritless personalities. 3. Again severity, threats, restrictions, punishment of pernicious habits: the habits of cursing, inflicting blows, personal uncleanliness, resistance to orders, etc.

§ 355. Sixth Genus: Medicaments with Reference to the Individual Situation

Quite obviously, the individual situation is something very different from the individuality. The individual situation (§ 309) includes the external condition of the patient, with reference to his office or business, good luck or bad luck, respect or lack of respect, helpfulness or helplessness, residence in his own country or abroad, happy or unhappy family relationships, and his economic situation. Here, too, the medicaments to be applied can be divided into mildly exciting and strongly exciting. Thus:

First Species: Mildly exciting medicaments

Hope despite frustration of efforts aimed at the acquisition of an office, or business; consolation, explanations, encouragement in cases of bad luck and loss of the respect of others; hopeful prospects as regards assistance or return to his own country; advice and mediation in family relationships; advice and assistance in economic problems.

Second Species: Strongly exciting medicaments

Serious, severe admonishment and stimulation if business or office duties are constantly neglected (signs of approaching mental disturbance); privations, pain, hardship if a stroke of good luck produces undesirable reactions, for a man can sometimes bear bad luck better than good luck; vigorous stimulation of the self-respect of patients who are not respected by others, especially if this lack of respect is undeserved; rousing courage, resistance, and manly strength by vigorous persuasion, by shaming the patient, by displaying contempt if the patient is cowardly or inactive in his family relationships. We have already said that these measures should be applied to cases of incipient mental disturbances rather than to those already developed.

Chapter Five

FOURTH CLASS: AUXILIARY SOMATIC MEDICAMENTS

§ 356. The importance and the purpose of auxiliary somatic treatment have been explained at length from a general point of view in § 310, § 311, and § 312, and subdivided into groups (§313—§ 318) which are related to the regulation of the main functions of the bodily organism, if these are disturbed to a greater or lesser extent in diseased conditions of the psyche. We shall define the genera of this class in accordance with the suggested sequence.

First Species: Medicaments calming the excitation of the blood

In cases of general turgidity of the vascular system, hypersthenic tension and true plethora: bloodletting, cooling drinks, niter, cream of tartar, tartaric acid in general, oxymel, acids of raspberry juice, and red-currant juice containing additions of dilute mineral acids, light vegetables, cooling fruit such as strawberries and melon. The patient should stay in cool places, wash his body with cold water, and take cold baths; all excitation of the disposition should be avoided. If there is a tendency to hemorrhoids and to swelling of hemorrhoidal vessels with all the accompanying symptoms, the bloodletting should be replaced by leeches applied to the anus or by moderate bloodletting at the foot; the tension should be relaxed by mucilaginous, softening, cooling enemas; opening of the bowels should be maintained by acidic, mildly stimulating medicaments, such as tamarinds, Cremor tart., tart. tartans, etc.

Second Species: Medicaments calming irritation of the nerves

If the origin of this irritation lies in the nervous system itself, in the erethism of this system, in unnatural irritability, that is, in the reduction of the potency thereof, everything should be tried to remove this condition: light, but nourishing food, good broths, light meat dishes, old wine in small, but frequently administered doses (white wines: white Rhenish wine, French wine, Hungarian wine, since these affect first and foremost the nervous system, while red wines act more strongly on the vascular system), tepid baths, washing the body, especially the head, with wine and other spiritous medicaments if these can be borne by the patient; silence, or, in order to bind the diffuse susceptibility of the nerves, music, if the patient can bear this, or a monotonous noise, such as trickling water, etc.; darkness and quiet in general. Among medicaments, the nonheating nervoina; but the idiosyncrasies of the patient must be taken into consideration.

Third Species: Medicaments which soothe irritations of the skin

§ 357. First Genus: Means against Insomnia

These include various species which depend on the origin of this morbid condition.

Dryness and heat produced by dryness, the itching and pain in the skin originating from visible skin eruptions or from internal irritations such as irritation of the vessels or the intestines must first be counteracted directly by tepid baths, cooling drinks, avoidance of spicy foods and condiments, but chiefly by taking proper care of the intestinal tract: enemas, cooling laxatives. If the vascular system needs care, the patient should be cupped. The use of mild diaphoretics, such as: vinegar, Minderer's spirit, niter, camphor, etc., is often useful, especially after the condition of the intestinal tract has been cured.

Fourth Species: Medicaments which calm intestinal irritation

These include more or less mild or drastic purges and enemas, and careful attention to diet.

Fifth Species: Medicaments which soothe irritation of local affections

These affections may be of very different kinds, and thus are treated by all available means of somatic therapy, including both surgical medicaments and medicaments proper. If the sleep of the patient is disturbed by the pain caused by wounds, injuries, ulcers, bedsores, which often remain unnoticed if the bedridden patient does not speak of his own condition, we must attempt to relieve the patient by surgery, namely, by careful dressing of wounds, washing, cleaning, and application of cooling, soothing, pain-relieving external medicines. Local internal pains: rheumatism, gout, pains originating from syphilis, inflammations, gastritis, etc., must be counteracted as much as possible by counterstimulants, deflecting, narcotic, antiphlogistic, purgative medicines, proper care being taken to ensure a suitable diet and avoidance of all irritations of the disposition,

Sixth species: sleeplessness due to lack of exercise and insufficient expenditure of energy can be eliminated only by suitable physical activity, preferably in the open air.

Seventh species: sleeplessness which is due to restlessness of the mind must be counteracted by pain-producing, attention-fixing medicaments, or else by the soothing and revivifying force of music, or by elimination of the sources of the restlessness, which is obviously possible only in rare cases; or by giving narcotics.

§358. Second Genus: Means against Constipation

A few remarks relevant to this important subject will be found above

(§314). Constipation can be successfully cured if the tone of the intestinal tract is restored. This tone may be upset for several reasons, the most important of which are: retention of an abundance of hard, dry excrements; torpor of the entire intestinal tract; rheumatic inflammation of the tract; a morbid condition of other parts of the body, which are particularly close consensually with the intestinal tract. Due to the different causes of the malfunction, the various medicaments must be subdivided into several groups, as follows.

First species: medicaments acting against a large, dry, hard mass of excrements. Nothing can be more harmful in this condition than the administration of purgatives, be they mildly or severely irritating; for due to the high sensitivity of the intestinal tract, only watery humors are attracted and evacuated. The result is general weakness and an inflamed condition produced, in particular, by the drastic medicaments, whereas the pressing hard mass of excrements is neither dissolved nor evacuated. Only mucilaginous, oily medicaments, containing cooling neutral salts, mainly mucilaginous enemas which should be given often, but in small doses, are helpful. This must often be accompanied by baths and bloodletting. The diet must obviously be moderate, light, cooling, and softening. Drinking large quantities of fresh spring water is necessary and healthful.

Second species: medicaments acting against torpor of the intestinal tract. These include medicaments which have a generally fortifying, revivifying, stimulating effect on the organism: fortifying baths; nourishing, but easily digestible food; avoidance of insipid, cold-producing foods and of coarse, gas-producing foods; wine; moderate exercise; enlivening of the disposition; and also special medical treatment of the intestinal tract by bitter, aromatic, astringent medicaments, according to the sensitivity of the tract: cinchona, iron, iron-containing mineral waters, friction, aromatic, strengthening cataplasms or plasters, such as empl. aromaticum, de cumino, and similar medicaments; local application of zoomagnetism, all these may be necessary.

Third species: medicaments acting against constipation brought about by rheumatic or inflammatory tension of the intestinal tract. In the former case the following should be applied: tepid baths; rubefacients and vesicants on the skin; light diaphoretics; fomentations on the abdomen; enemas of enveloping, softening substances; bloodletting if the condition is sthenic. In the latter case: unconditional strong bloodletting, repeated if necessary; leeches, fomentations, softening enemas, cooling mucilaginous drinks; no irritation of intestinal tract by medicaments; and in particular, elimination of the reason for the inflammation such as strangulated hernia or an ingested poison.

Fourth species: medicaments for constipation due to the morbid condition of consensual parts. In such cases we are told by somatic therapy to eliminate stoppages in the portal venous system, or morbid conditions of the4iver, spleen, pancreas, kidneys, bladder, uterus in women, urethra and prostate in men. Leeches, calomel, tamarinds, neutral salts, mercury -friction, cicuta and aconite, opium, softening injections, etc., may be administered, in accordance with each individual case.

§ 359. Third Genus: Means of Revivification of the Skin

The procedures to be applied have been described earlier (§ 315). We shall supplement this account by recommending sea baths as a powerful means of stimulation and revivification of the skin, and also dietetic and pharmaceutical remedies. Since the main reason for the parchment-like dryness and lack of sensitivity and vitality of the skin is a torpid system of blood vessels, which depends on the slackness or paralysis of the so-called organs of reproduction, it follows that all medicaments which are able to strongly stimulate and revive this system and these organs will be suitable. Thus: light but strongly stimulating and nourishing food and drink: young, well-prepared vegetables; juicy fruits such as cherries, strawberries, raspberries, red currants; and especially grapes and whey; buttermilk, juice pressed out of young plants, plenty of water; sparse, light, meat dishes. Suitable medicaments include typical soapy extracts, neutral salts, mineral acids, bitter extracts; direct action on the skin of niter, camphor, and antimony preparations.

§360. Fourth Genus: Means of elimination of so-called Congestion

Both the name and the concept of congestions will be retained, but the reader is reminded of the discussion in § 316. This genus contains a large number of medicaments, grouped according to the different origins of the congestions; hence the different species.

First species: medicaments for congestions originating from the organs in the abdomen.

Firstly, the blockages in the stomach and intestinal tract and various impurities must be removed by loosening emetics and purgatives, including anthelmintica; secondly, blockages in the liver and portal vein system must be eliminated by neutral salts, soaplike agents, loosening resins, loosening mineral waters, and mainly by the persistent application of Kampf's enemas; thirdly, infarcts affecting the pancreatic system, and those otherwise responsible for hemorrhages or morbus niger Hippocratis should be almost exclusively treated by acid laxatives such as tamarinds and cream of tartar.

Second species: medicaments for congestions in the vascular system. Bloodletting from arm and foot; leeches; scarifications on various parts of the head, cool, diluent drinks, niter, digitalis, antiphlogistic remedies in general.

Third species: medicaments for congestions originating from excessive excitability of the nervous system. The source of irritation may reside in the cerebral or ganglionic system, for which narcotica such as belladonna, hyoscyamus, opium, aqua laurocerasi, and other remedies are applied indirectly or directly, as depressants and equalizers; this is accompanied by the application of skin irritants such as vesicant plaster, mustard plaster to the back of the neck and lower limbs; stimulating foot baths with cold compresses on the head.

§ 361. Fifth Genus: Means against Convulsions and Paralysis

Both affections, although of opposite kinds, usually originate from the same, albeit various, causes. Hence the different medicaments which must be applied.

First species: medicaments for convulsions and paralyses originating in the abdomen. Firstly, purgatives and emetics in general; secondly, and in particular, anthelmintica; thirdly, medicaments to counteract various kinds of poisoning; fourthly, lithontriptica; fifthly, antihysterica, if the disease is caused by physical irritations, mucous acidity,* or local congestions in the circulation.

Second species: medicaments for convulsions and paralyses of the vascular system. In orgasm: bloodletting, niter, digitalis; in torpor: narcotica. Third species: medicaments for convulsions and paralyses idiopathically originating in the nervous system: cold or warm baths, according to circumstances; the douche, the shock bath; narcotica in cases of erethism, nervina in cases of torpor. In accordance with the circumstances, the patient should be given a mildly or strongly stimulating, nourishing diet; electricity, galvanism, vital magnetism. If Wolfart's amazing experiments can be confirmed (Jahrb. fur den Lebensmagn., Vol. 1, No. 1, pp. 141 ff.) the best possible medicine against this evil has at last been found.

* [In German: "SchleimschMfe", meaning unclear.]

For special treatment of specific organic abnormalities the reader is referred to somatic therapy. in small quantities but at frequent intervals; but their food must still have a nourishing, revivifying force: broths, soups, tender meat, tender vegetables, light wine, chocolate.*

Second Species: Palliative treatment with reference to exercise and rest

APPENDIX

§ 362. Palliative Medicaments

The meaning of the concept of palliative medicaments and the relationships concerned therewith have been described above (§ 319—§ 323) in some detail, with reference both to the treatment of the patients in accordance with their individual natures, and the nature of the disease and the welfare of the patient. But diet, in the broadest meaning of the word, must also be considered to be part of the palliative treatment; below, a contribution to the problem discussed in § 340 will be given. This must be subdivided into three particular kinds of treatment.

First Species: Palliative treatment with reference to food and drink

We must feed the patients to keep them as healthy as possible and to prevent them from sinking deeper into their morbid condition. In this respect the patients can be classified in various classes and grades: to the first class belong those who require the most nourishing kinds of foods in order to subsist. Nourishing, wholemeal, well-baked bread; fresh, pickled, or smoked meat; nourishing vegetables such as legumes (peas, lentils); drinks should include well-fermented, malt-rich beer at least once a day. This need may be recognized by the constitution of the patients, their desires, and their work. The second class includes those needing a medium diet. These are no weaklings, but they are used to milder treatment. More white than wholemeal bread; more tender vegetables and more tender meat, a large glass of old wine, coffee in the morning, soups in the evening. Their needs may be recognized by their constitution, their manners, their education, and their habits. The third class of pâtients must be given the most delicate, mildest diet, such as is really suitable for children. They can stand nothing, because they can do nothing; they should be given only the mildest foods and drinks,

Here, too, we have three classes. The first includes individuals who need the most intense exercise and must make the most strenuous physical effort to feel well. These have athletic constitutions, and would soon abuse their superior force if this were not constantly used up by permanent physical occupation. The second class includes those who need exercise but no physical effort; therefore walking, etc., is most suitable for this group. The third class includes those incapable of motion, who must be moved in an artificial manner by riding in vehicles or on horseback, sailing in a boat, rocking in a swing, being carried about in chairs, etc., in order to satisfy to some extent the law of physical stimulation. Such patients would never move from one spot in the absence of such means. While the shortest periods of rest, including sleep, are sufficient for those in the first class, constant rest is still not sufficient for those in the third. They have not the necessary susceptibility to the soothing force of rest and sleep.

Third Species: Palliative treatment with reference to the mode of occupation and recreation

It is well known that the mode of occupation and recreation of a man is not a matter of indifference. Here again we must remember that "one thing is not meet for all." Even in a morbid condition, even when all hope of recovery has been lost, the farmer, the day laborer, and the artisan must be differently occupied and differently encouraged than the artist, the scientist, or the intellectual in general. The right mode of occupation and recreation is very important. Accordingly, everyone should be occupied and distracted in his own accustomed manner, provided that this does not intefere with others. This is the transition between the palliative and the individual treatments, which have been discussed in their proper place.

* It should be obvious that all recommendations of this kind given in this book concern only the needs of the patient, but not the possibility of satisfying them. As regards the latter, let the State take care of this.

III. THE SCIENCE OF CURE

Chapter One

THE ORGANON OF THE SCIENCE OF CURE

§ 363. The science of cure has the task of laying down the mode of treatment of specific cases of diseases of the psyche, as they appear in the lists drawn up according to the science of forms. But the different forms cannot be treated except in accordance with the general rules of heuristics; however, the particular rule to be applied and the connection in which it is to be applied must be deduced from each case. Thus, every heuristic moment is immediately associated with the appropriate means of treatment, since the science of medicaments is closely related to heuristics. The only question is how are we to recognize and to find the heuristic moments belonging to any particular case of the given form of disease. It is the task of the organon of the science of cure to set out the general features of this procedure and the common model thereof.

§ 364. The most immediate question which arises in any specific case is: should this case be treated in a special manner, and is such a treatment possible? The answer to this question will depend, first, on whether the case is at all curable, and second, on whether the physician has the necessary means at his disposal. For it is just as pointless to act when even the strongest force is of no avail as it is to try to overcome a large burden with a disproportionately small force. In fact, however, we see that these conditions are not properly appreciated by practicing physicians, or even by those who study the theory behind the practice. For how often do we read of cases which have resisted all treatment and proved incurable! And do we not find in our best and most modern compendia of chronic affections of the somatic organism, in which mental disturbances are arbitrarily included, modes and means of treatment for every single mental disturbance? It is indeed a pleasure to observe with what faith in the medical art, medicaments supposedly suited to every possible case and every moment of every case are reported. Thus, for example: "In order to heal melancholia, we must first try to eliminate the reasons behind it and render them harmless. If the melancholia is found to be the result of violent passions, we try to restrain these passions and to keep them within bounds," etc. Now disregard of our first condition, namely, whether the case is curable at all, is less to be deplored than disregard of the second, namely, that the force must be commensurate with the burden; though it might be objected that neither the incurability of certain cases nor the inadequacy of certain means of cure can be so completely demonstrated that there is no need to act, or to apply various medicaments, even if there is no certainty of success. But if this is admitted, the work of the physician must remain merely empirical, and the results obtained thereby can never be assembled into a law prescribing a regular treatment. Since we cannot agree with this view, we shall try to fulfill the above-mentioned first task of the organon of the science of cure.

§ 365. We must first remind the reader that we are speaking here only of what we have called the indirect psychic method; for the healing art or the gift of healing which works directly through the believing will is ex hypothesi not bound by the limitations of the curability of a particular disturbance of the psyche nor by the inadequacy of the ordinary medicaments. Thus, if we disregard the direct method, we must come to the conclusion, which is based on experience and careful observation, that no therapy should be attempted against morbid conditions of the psyche with which the patient was born, or which have lasted for a very long time, or where the patient is very old. This will generally be accepted as obvious, but our conclusion drawn from this will be found less acceptable, namely, that all cases which show the form of the three conditions just mentioned, without properly being one of them, must be treated in the same way, that is, must be left untreated. For we are relying on the truth of physiognomies, which both pathologically and physiologically is an externally changed expression of an internally changed condition. Accordingly, wherever we encounter forms of diseases similar to those with which the patient was born, in victims of a long sickness, or in the very old, we must conclude that they are incurable and are best left untreated. This is our first poirt Next: how do we know if the medicaments at our disposal are adequate or not? Here, too, experience and accurate observation should be our reliable teachers and guides. It is generally known that certain recommended medicaments work wonders in certain cases and in the hands of certain physicians, but are quite useless in other cases and in other hands. This alone should make us doubt the efficacy of medicaments, or at least trust them only conditionally; for we are speaking of the so-called specifica against melancholia and mania, including camphor, musk, opium, helleborus, belladonna, digitalis, extract of cherry laurel, etc. Such individual medicaments and treatments always satisfy only a specific indication; if this is absent, or, as is mostly the case, if many indications appear together, successful results are not obtained, which is hardly surprising. The heuristic which was set out above, and the science of medicaments which is based on it, afford a positive proof that as a general rule every such individual treatment is inadequate, and if medicaments against the combined indications are lacking, it is better to leave the individual medicaments untried, for each unsuccessful attack on the enemy only enhances his forces. Accordingly, a careful investigation and listing of the moments to be eliminated in each case is the best, indeed the only, procedure which will tell us whether or not we are capable of dealing with the case. For if we know exactly what is required, we shall also know whether or not such a treatment is in our power. But we cannot even know what is required if we do not observe the case and have no clear idea of the nature of the morbid condition before us. This leads us to the first rule for the second condition (§ 364) with which we are now dealing: do not act in ignorance. But even if we are familiar with the nature of the case, there are another two rules which forbid the administration of special treatments and which are valid in all cases: first, be master of the situation; second, be master of the patient. But how often is the physician master of neither, and how often does this lead to failure! Accordingly, the second rule is that no special treatment should be attempted unless the physician can control the external surroundings, relationships, and influences on the patient. For all these factors together, and each one by itself, may disrupt and destroy in a moment everything that the physician has been trying to achieve with much effort and much patience. Indeed, the physician must not act unless he is also certain that all the factors that lie beyond his power are favorable. And the third rule is: the physician must not apply any specific treatment unless he is master of the patient, and this he can only become if he is spiritually superior to him. Unless this superiority is established, all treatment will be in vain. All observant physicians of the psyche recognize this rule and make it the prior condition of any treatment. But the other two rules are no less important, and the combination of all three gives the answer to the second part of the question before us.

§ 366. The next question which the organon of the science of cure must answer is this: if there are no objections to a specific treatment, is there a first, main aspect of such a treatment? It is obviously assumed that each such case has been properly investigated and identified, that all the conditions have been determined, the true state of things properly recognized, and that the physician has realized how far he will be assisted by the forces of nature and of natural growth. Now that we are concerned with the direction of treatment for a definite purpose, we must ask ourselves: of what kind should such a treatment be? Since we are not speaking of negative or palliative treatments, but only of the four heuristic moments of gradual, formal, individual, or somatic treatment, we can choose from among only these four if we are allowed to choose at all. But how are we to choose among methods which are all equally necessary and equally urgent? We cannot do everything at once; accordingly, we shall apply the treatment which at the moment appears to be the most urgent and the most necessary: somatic aid, if this appears to be the most urgent; gradual treatment, if exaltation or depression require prompt treatment, or if these two are still in the background a formal or an individual treatment must be applied as needed. There are all too many possible individual cases. This means that there is no first, stereotypic aspect of the treatment but that the treatment should be decided in accordance with the characteristic features of the case being treated. This must be left to the skill of the physician, his tact, which is the result of experience and careful observation; here indeed is the beginning of true medical art.

§ 367. In these circumstances we are in a position to follow the heuristic sequence in our further discussion of the tasks of the organon of the science of cure. The following question must be asked for each one of the four moments to be observed: what claims does it have for particular consideration? First, with reference to the moment of gradual treatment; according to heuristics (§288—§ 296), a state of exaltation usually calls for means of restriction and deflection, whereas a state of depression requires means of stimulation and revivification. We must now describe these conditions in more detail, insofar as they require these kinds of treatment. Either exaltation or depression must be the predominant feature of the disease of the psyche. If this is the case, it follows, first, that exaltation is not a mere somatic accessory symptom but is the main affection of the psyche; the muscular motion, the play of imagination, and the accompanying thoughts are each overtense, not because of some bodily stimulus, but because the disposition and the will are affected, deeply stirred, and inflamed by the psychic stimulus. The prominently degenerate features are consciousness, inclination, thoughts, and for this reason it is these which must be tamed and restrained by means of a powerful counteraction directed at the disposition and will. The depressing gradual treatment is indispensable; it strikes at the nucleus, at the very being of the morbid condition, whether the actual form is mania, insanity, or dementia. Just as indispensable and just as urgent is the stimulating and revivifying treatment in all those cases in which the main features of the disease are a deep suffering of the disposition and grave impotence of the will, as well as a spirit which is empty of all convictions and all ideas. There is then nothing more immediate, nothing more urgent than to straighten the bent disposition and infuse life into the extinct will; and all means which produce stimulation and revivification listed by the science of medicaments must be utilized for the purpose. Such a course of treatment will thus be required, first and foremost, in all forms of melancholia, spiritual emptiness, and impotence of will. As regards, second, the moment of formal treatment, we have already (§ 299) noted that this is to be preferentially applied to cases in which the form has not yet fully developed, or there is a trend to recovery, or if there are periodic lucid intervals. Here all other treatment must take second place, and all means producing change in disposition, means of correction, and means of direction must be immediately and preferentially applied. Accordingly, formal treatment is preferentially indicated whenever mania, insanity, dementia, melancholia, spritual emptiness, and apathy of will are only nascent or are fortunately receding. Third, as regards the moment of individual treatment, such treatment should be given at all times and under all conditions, since an individual never ceases to be an individual, with all his qualities and relationships. And even if individual treatment does not result in complete recovery, neglect of such a treatment will not only nullify the effects of all other treatment, but the treatment itself will remain significantly incomplete with reference to requirements of sex, age, constitution, temperament, personality, and the individual situation of the patient. There is thus no need to list any special forms of disease in which this moment is to be considered, since this moment applies to all cases without exception; and the physician must not presume to administer any treatment at all to any individual without paying constant attention to the rules and means of individual treatment. Finally, and fourth, as regards the moment of somatic auxiliary treatment, this need not be applied to all cases (in contrast to the third moment), but whenever it is necessary it will insist on its own rights. The relevant cases have been listed and described in sufficient detail in §312—§318; they are those in which the main systems and organs of somatic organism are clearly affected in some way and disturbed in their activities; but it must be stressed that these affections and these disturbances must be so prominent and so influential in the maintenance of the morbid process that no proper treatment would be possible before these affections are eliminated. Examples are mania with an obviously inflammatory or nervous character, insanity accompanied by affection of the vascular system or of some important organ, dementia or melancholia accompanied by affections of the abdomen; finally, idiocy and apathy accompanied by total exhaustion of physical strength. All these conditions must receive urgent somatic auxiliary treatment pursued with vigor and persistence.

§ 368. But it is the task of an organon of the science of cure, which deals with medical treatment, not merely to clarify the identity of the disease, the forms of disease in general, the possibility of their treatment, and the kind of treatment, but also to clarify the necessary qualities and the subjective procedures undertaken by the physician himself; for it is the physician himself, first and foremost, who forms part of the cure, and not only the disease to be treated or the medicaments to be utilized. The concept of the physician of the psyche has been outlined in the preliminary chapter of this book (§ 60—§ 64), but this was only the most general notion, according to which the physician of the psyche must be a man of reason. This concept indicates everything but says nothing specific about the actual activity of the physician. This will now be described. The first quality of a physician of the psyche must be true independence and freedom of spirit; this and everything else follows from living in the true life element of man, which is reason. The physician of the psyche, in fact, any physician at all, must not be merely a plaything of his surroundings or of the patient he is treating. He must stand on his own feet, see with his own eyes, and act with his own strength. He must not let any crooked, one-sided persuasion, any irrational resistance influence him, make him hesitate, or cause him to stray from his path. Whatever he has clearly recognized as right he must try to put into practice with a firm, unflinching will. But he must first come to a definite conclusion, and his mind must be clear; and this quality of his inner being can only be the result of spiritual freedom which is given by reason alone; for this is the freedom of the spirit itself which lives in the element of all truth. Thus, he is limited by no one-sided views, he is oppressed by no preconceived ideas; he always stands in the center of his field of vision and everything appears to him in its true proportions. Such clarity is given only by a life trained in the school of reason; and the same is true of the certainty and independence of his existence and activities. But these two properties imply all the others: for the result of spiritual freedom and independence is self-possession, which must not leave the physician of the psyche, or indeed any physician at all, for even a single moment; nay, this self-control is itself the living expression of spiritual freedom and independence. But this also implies an unshakable calm; for without it the physician falls prey to passions that trouble the clarity of his vision and shake his firmness, and to which he should be totally immune. This is a difficult demand, and one which can be met only by persistence in reason. The physician, in our case of the psyche, must remain perfectly free of bias, and he will remain so if he has maintained spiritual freedom and independence, which is the element of this impartiality. But such impartiality is incompatible with coldness, hardness, and lack of sympathy; for these qualities are displayed by those living for themselves alone, that is, by those who are enslaved by themselves. In general, the inner strength — and there is no greater inner strength than that of spiritual independence and freedom — has the power and the will to impart of itself, namely, to show sympathy to objects which have lost their freedom and independence, namely, to unfree individuals who need this sympathy. Thus, mildness, nay, love, which may be likened to the blessedness of sunrays, is both a necessary attribute and the finest adornment of the physician of the psyche, besides being the most secure proof that he has reached the acme of human strength; for nothing is more difficult than to love in the sense in which we are now using this word. But love requires patience and consideration, which no physician can dispense with, no matter how earnest, how firm, and how consistent he may be. Thus, it is only the physician who in fact possesses the character traits outlined here who is a true physician. The elements of a true physician have already been stated (§273) to be insight and tact: for it is only the man who can clearly grasp the interrelations of things who can have the necessary insight, and only a man who can readily imagine the condition of others can show the proper tact. Moreover, it should be obvious that the physician must not be estranged from the world around him, that he must be familiar with men and their relationships, and with the properties and influence of natural objects such as were outlined above, and must have an adequate historical knowledge, as well as a knowledge of anything else that is worth knowing on earth of medical art and science, and that he must be an educated man, due to exercise of his abilities. How could it be otherwise, since freedom and independence, which are the fundamental attributes of psychic-medical existence, can only be acquired through living, through leading a life rich in training, trials, experience, even faults and mistakes, the final product of which is truth.

§ 369. The procedure to be adopted by the physician, insofar as this can be dictated by the science of cure, will now be described. Since the physician of the psyche appears to the patient as helper and savior, as father and benefactor, as a sympathetic friend, as a friendly teacher, but also as a judge who weighs the evidence, passes judgment, and executes the sentence, and at the same time seems to be the visible God to the patient, it follows that the component parts of the procedure he adopts must be, according to conditions, mildness and friendliness, gentleness, calmness, patience, consideration, sympathy, and a measure of condescension, but also earnestness, firmness, impressive though restrained authority, and the exercise of a just, consistent, firm discipline. But, like a monarch, the physician does not do all this directly by himself. He must accordingly find suitable assistants who do not hinder, but on the contrary, promote his plans and intentions: faithful, honest, humane, hard-working, skillful individuals, such as may be found among the servant class, though not in large numbers, and whom anyone with a knowledge of human nature can identify without any trouble. Such individuals are no mere machines; they also have their insight, often a better one than the physician himself if he is unequal to his task. They also have their own procedures, which are not acquired but natural, and are adapted to the patient and to the circumstances. They soon become friendly with the patients, who in turn become attached to them. The helpers have only to utter a single word, a request, or even a threat, for the patients to obey them implicitly in everything they should or should not do. The patients would never thus obey a stranger who is unfamiliar with their individuality, whom they dislike, and whose authority they reject. The physician needs such helpers, who assist him in his task and promote it, just as unskillful, unwilling, basely motivated men hinder it. If surrounded by men of goodwill, the patient lives in a healthy atmosphere, whereas if he is among people who treat him unnaturally, he breathes poison. The behavior, the example, the habits of the hospital orderlies affect the patients to a greater extent than is usually believed; this is even more true of the influence of the behavior of the physician on his assistants who are to serve his purpose. The attentive, careful, conscientious, punctual, unceasingly active, sympathetic, steadfast physician is quietly observed by his helpers who model themselves on him. Thus, the physician must spend some time with each one of his patients every day. If he is the head of an institution, he must visit it at least once a day so as not to overlook anything, but to remain its motive force at all times, and by his presence to keep others active and on the alert. He may have to deal with patients who have been ill for a long time, whom he knows well, and whom he has already treated, or else with newcomers whom he does not know and whose individualities are as yet unfamiliar to him. In the former case the purpose of his visit is further observation, further progress in the treatment, greater familiarity with the condition of the patient, and a deeper insight into and a more powerful influence on him. In the second case, the physician must familiarize himself as much as possible with the case history and personal relationships of the patient; this must be followed by a careful examination of the present condition of the patient. This first examination leads to the most general instructions and rules. Whether the patient is to be left solitary or should remain among others, whether he should be left free, be constrained somewhat, or be fully restrained, whether he is to be immediately treated mildly or first with severity, whether or not he should be deprived of sounds, light, food, and sleep, whether or not some surgical or pharmaceutical treatment is immediately necessary, all this will be indicated by this first examination, which, though detailed, is still provisional and does not initiate any protracted treatment. The latter can only be the result of a longer acquaintance between doctor with patient, permanent or periodic, depending on the circumstances. But, unlike the outward behavior of the physician, which must in each case be suited to the nature of the disease and to the individuality of the patient, the mood of the physician must never change.' The physician must never visit the patient while he is in a bad temper, cross, excited, tired, distracted, or laboring under strong emotions. He must appear strong, cheerful, and lively, but at the same time restrained and moderate, and must always be ready to communicate or to take all manner of action which his clear thinking tells him is necessary. If he has not the required equanimity, it is preferable that his task be postponed to a more propitious occasion. The physician of the psyche must have a faithful medical and if possible also a surgical assistant, on whose skill, accuracy, and conscientiousness he can rely. To these assistants he can leave the recording of the course of the disease and of the different treatments prescribed under his supervision. For the physician must keep a free mind — strict training is necessary only for the apprentice, while the master must develop beyond it.

§ 370. Finally, with reference to the organization of the science of cure, this must follow the development of forms set out in the science of forms, so that its main subjects are the various genera of the three orders, taken in succession, together with the simple species within each genus, whereas in the treatment complex forms and subspecies are referred back to the simple forms. But the science of cure takes notice not only of the sequence of forms, such as is found in the science of forms, but also of the description of these forms, their development, cultivation, interconversion, and mainly of their nature and their elements, which guide us in analyzing the moments of the cure; thus, the science of cure will include: the treatment of the forms of disease of the first, second, and third orders, with their successive genera and species, so that, as has already been mentioned, only the simple species are dealt with in detail, while the others are merely mentioned. Finally, we note that every time we describe a definite treatment and specific medicaments we find ourselves obliged to refer the reader to the corresponding sections of the science of medicaments as established by heuristics, contrary to the usual, more convenient practice. This is because such a procedure is organically dictated by our development of technique, and because in the following the author assumes that the reader is familiar with everything that has already been stated.

Chapter Two

TREATMENT OF FORMS OF THE FIRST ORDER (EXALTATIONS, HYPERSTHENIAE)

First Segment

Treatment of Forms of the Genus Insanity (cf. Vol. I, p. 149, §197)

§ 371. Treatment of pure insanity (ecstasis simplex).

We have defined the nature of insanity (Pt. I, § 254 and § 256) as being torn out of oneself, as a withdrawal of the disposition from itself and its escape into the visions and phantoms of the imagination. The inclination of the disposition toward the object that attracts it, and the imaginary aspect of this object itself as seen by the disposition, constitute the elements of this mental disturbance, the union of which produces the enrapture of the disposition (ecstasis), the dream life, insanity itself. This product may appear (Science of Forms, § 197) under a definite form. The treatment of this form must differ, depending on whether the form is in the generation stage (§198), is fully developed (§ 199), or is in the extinction stage (§ 200); the moments of the treatment must be suited to the stage of the disease. We have, accordingly:

First moment of treatment. As soon as we notice the precursors of pure insanity (§198), we must take vigorous steps to prevent the disease from developing to its full intensity. The violent passions, the restlessness which persists day and night, must be calmed. To start with, we have the gradual treatment (§ 342, species 5, No. 4), which is to be followed by formal treatment (§ 346, species 1). However, here as everywhere, due allowance must be made for the circumstances, and it should be remembered in particular that at this stage the patient still retains consciousness, knows who he is, and is still able to restrain himself if necessary. He must be treated gently but firmly. The forgetfulness, the neglect of all the usual tasks including the calls of nature, distraction, thoughtlessness, total absentmind-edness, finally indifference or aversion to everything usually considered as worthy of interest, all these must be treated formally and individually, by application of stimulating medicaments (§ 346, species 2, No. 4 and No. 5), and those producing mild or strong excitation of the personality (§ 354, species 1 and 2). If these are the indications, the patient's preferences must not be considered: severity will do more good than mildness. The main symptom, namely, sleeplessness, must be dealt with by somatic auxiliary treatment (§357, species 7); the same applies to constipation (§358), if present.

Second moment of treatment. If the disease could not be halted and has fully developed, or else if the physician has taken over only at this stage (§199), the latter must first select restraining and deflecting means of gradual treatment (§342, species 1 and 4; § 343, species 3, No. 2), if the calming medicaments of the formal treatment (§ 346, species 1) have proved inadequate.* We recommend in this connection the mildest irritants of the skin and of the general disposition, namely, vesicants and mustard paste. In the second stage we must tear the patient away from his dream world, and this need becomes most urgent. While the medicaments indicated above are useful, they are inadequate by themselves, and the gradual treatment must proceed up to the stage of mechanical-surgical restraint (§342, species 3), of which we shall only mention the confining chair (pp. 292 ff.) which, in the experience of the author, produced a return of consciousness after the patient had been bound to it for a brief period of time in a dark, quiet place. (Quiet and darkness alone, without total fettering of the patient, do not bring about this result, while partial fettering is worse than none at all.) If even this is of no avail, there remains the rotating machine, which must be applied if we do not desire the morbid condition of the patient to take deep root. In addition, powerful deflecting and counterstimulating pharmaceutical and surgical medicaments must also be administered (§ 343, species 2 and 3), since the conversion of the somatic organism has now gained in volume, power, and persistence and forms a clear imprint of the state of the psyche, the morbid condition of which it supports and maintains. The means specially recommended are: of the pharmaceutical medicaments: emetics (pp. 300 ff.), counterstimulants in the narrow meaning of the word: tartar emetic to create nausea; calomel (p. 303); surgical means include: vigorous irritants of the skin and of the general feeling: douches and setons on parts of the body far removed from the head; a powerful tartar emetic ointment rubbed into the shorn scalp; moxa; showers; as a final resort the threshing machine, which, however, must be applied cautiously (p. 306). Briefly, this is the crucial stage, and if the enemy is allowed to win, it will be difficult to overcome him in the later stages. In the third stage (§ 199, p. 150), if there is a third stage, which follows a longer or a shorter second stage, when truly lucid intervals appear, the treatment must be changed; it must be aimed at the bright spots of the consciousness. As lucid moments appear, everything painful, repugnant, and frightening and horrifying to the patient must be put aside. Here, individual treatment should be preferen-tially applied; the means of affecting personality will be almost exclusively required (§ 354, species 1), namely: the friendly presence of normally cherished objects, of long-absent friends, of beloved children, etc.; a happy trip to the country if the weather permits; and in this manner we shall pave the way for the transition to the third moment of the treatment.

What is really obvious, but will be repeated here superfluously for the last time: that definite medicaments which are recommended in special cases should never be applied indiscriminately but always in accordance with the special circumstances and relationships. It is not possible, however, to describe the very special features of the cases or of the medicaments in an account of the science of cure, neither would it be desirable; the final discriminations to be applied in actual practice must be left to the physician, to the medicus oculatus (in the words of Stoll).

Third moment of treatment. If consciousness returns, even if only sporadically at first, but weakness of thought and susceptibility of the imagination remain (§ 200), the patient must be helped to return to life, but this must be done with the greatest caution. If such action is precipitate, if the patient is too suddenly exposed to vital stimuli, an immediate relapse may be the result. The author himself saw an insane patient whose consciousness had returned, and who had been prematurely thrust into the society of men from his dark, quiet place of abode, and had become so excited by the unaccustomed surroundings that he relapsed into his former state within a few hours. Later, a more cautious procedure was adopted, whereupon his consciousness remained, and complete recovery eventually ensued. Here, the recommended procedure is a cautious alternation of mildly exciting (p. 319) and calming means ( § 346, species 1). Special attention must be paid to temperament ( §353) and, most important, no errors must be made in the dietetic treatment (Appendix, § 362). If, however, the insanity does not come to such a fortunate end, if an idee fixe lingers, that is, if the patient remains demented to a certain extent and in a certain manner, or if he sinks into melancholia, the medicaments found under the headings of dementia and melancholia must be applied. But if both these conditions become combined and eventually fuse into general confusion and idiocy, there is little hope of any successful treatment, and the patient must usually be given up. However, Haase reported an extraordinary case which he had himself treated with a very happy outcome (Die chronischen Krankheiten, Vol. 2, under the heading "Idiocy"): a village magistrate had gradually sunk into the deepest depth of idiocy as a result of being affected by the unhappy events of the year 1806 and those of the years which followed, and was completely cured by the application of a seton to the back of the neck. This cure was, actually effected twice, since after the patient had recovered sufficiently so that he could go about his business in the normal manner, he failed to continue with the seton, whereupon the disease returned. He was permanently cured by renewed application of the seton, until he fell victim to typhus contagiosus.

The treatment of the disease as a whole must be pursued in accordance with (§201) the semiotic, diagnostic, and prognostic moments, which must always be kept in mind, and to which the reader is referred.

§372. Treatment of complex insanity.

Each complication of insanity renders the treatment more difficult and the prognosis less hopeful. Each complication is a sign that the morbid affection of the psyche is deeply rooted and that the activity of the vital forces themselves, aimed at the restoration of health, is feebler. The medical effort must accordingly be intensified, but the physician must take care to distinguish between the individual complications, for each individual complication indicates a specific condition of the psyche of the patient, that is, it indicates the need for a different treatment. The form is an expression of the nature of the disease. We shall accordingly again follow the sequence given in the science of forms, and shall be guided partly by the course of the disease and partly by semiotic, diagnostic, and prognostic moments.

1. Insanity with dementia (Ecstasis paranoia) (according to § 202). Both the course of the disease and the semiotic moments in the widest sense of the word indicate that, besides the need for attention to the insanity itself, a main part of the treatment without which nothing can be accomplished is consideration of the individuality of the patient generally, and also of his individual situation and of the medicaments pertaining thereto (§355, species 2), and those pertaining to the formal treatment of the spirit and the means of such a treatment (§347, species 1). Of means of the first kind, we must stress the need for serious, severe admonishments and stimulation when the disease is in its initial stage, and the need for deprivation and pain if the patient is already deep in his forgetfulness of self. For means of the second kind, we must apply the hunger cure, nausea cure, douche, swing machine; if weaker stimulations have no deflecting effect, the above medicaments become more necessary as the ideas of the patient become more alienated from natural concepts and relationships. But if the patient has been rendered milder and more receptive and is thus cooperating to a certain extent, more or less exacting physical and mental labors, or revivifying, distracting occupations must gradually be introduced (pp. 313 and 314). In the worst cases, all the means of constraint, in so far as applicable (§ 342, species 1 and 5), must be employed. 'This complete milder or rougher treatment should be strongly supported by deflecting medicaments (§ 343, species 2, 3, and 4), some of which are used for other indications.

2. Insanity with rage (Ecstasis maniaca) (according to § 203). Here we must note, first and foremost, whether or not an orgasm of the vascular system indicates the need for local or general bloodletting, and whether or not depressant pharmaceutical agents (§342, species 2) should be employed as auxiliary means. If the disease is new, either this case occurs, or else a nervous superexcitation must be allayed, in which the former procedure would obviously by quite unsuitable, but the means given in § 342, species 2A and 2B would have to be employed. But if the origin of the disease does not lie in somatic conditions, but in a degeneration of will, then it must be obvious that the methods of limitation and constraint are to be applied energetically (§ 342, species 1, 3, 4, 5), from which the ones most suited to the conditions must be selected. It is only after the rage has been subdued and the patient has become mild and submissive, that it is possible to pro-ceed to the treatment of the insanity itself. It will be found, however, that this has been well prepared by the former treatment, or has even been started, so that often half the work has been accomplished.

3. Insanity with dementia and rage (Ecstasis catholica) (according to § 204). If treatment of this doubly complicated condition is justified by a favorable prognosis, which is the case if neither the patient nor the disease is too old, the first step is to eliminate the rage by restraining means (§ 342), if a conspicuous irritability of the nervous system or an orgasm of the blood vessels make it imperative to use means of the second kind; but if these symptoms are absent or have already been dealt with, we need only use means of constraint (§ 348, species 1, cf. § 342) as necessary. At the same time, and also after rage has been overcome, means of deflection (§343) against dementia should be applied; through all of which the insanity itself is also overcome to a certain extent and can be specifically treated at a later stage, if this proves necessary. The author had occasion to treat one such complicated case, which fortunately was able to be cured in the way just indicated. This case is described in Nasse's Zeitschrift fiir psychische Aerzte, Vol. I, No. 1 as the second case history. We have already said that, as a rule, the complicated cases of any form are more frequent than the simple ones.

§ 373. Subspecies and variations of insanity (§ 206)

A. Eratomania. If the disease consists merely of insanity caused by love, that is, it is purely psychic, without showing any features of nymphomania or satyriasis, or is a pure form of either of these two, in which case the well-known somatic treatment must be applied, the treatment should be formal (§346, species 1 or 2) and individual (§§ 350, 352, 353, 354, and 355) and must be more or less strongly exciting, according to the circumstances.

B. Daemonomania. Here somatic auxiliary treatment is indispensable. We may have here many kinds of affections of the abdominal organs (including the sex organs), of the vascular system, and especially ganglionic affections, which must be removed. Accordingly, the medicaments mentioned in §§357, 358, 360, and 361 should be applied, separately or in combination as required. But neither must the gradual, formal, and individual treatment be forgotten: here, the necessary medicaments may be those of restraint and deflection (§342, species 1, 2, and 5 and §343, species 1 and 2), or those changing the disposition or corrective medicaments (§ 346 and § 347), and also their subspecies ( § 349); the individual means (§ 354) are also needed, due regard being paid to age, sex, temperament, and indi-vidual situation (§355).

C. Melancholia metamorphosis. Whatever the form in which this subspecies of insanity appears, it cannot be treated in the first stage except by auxiliary somatic medicaments as described above. In the following stages the formal treatment, with its corrective medicaments (§347), also becomes necessary.

D. Metroniania (not to be confused with mother rage) is more a state within insanity itself than a special form of insanity. In the experience of the author, especially women speak in rhymes or in verses for hours and days on end, adapting their metric nonsense to familiar tunes or inventing their own tunes. The author has also noted that this condition, this symptom of insanity in women, is connected with an irritation of their sexual system; this must be considered insofar as we are dealing with women, and the actual treatment for this disease is a suitable auxiliary somatic treatment, namely, antiphlogistica, antihysterica, anthelmintica, etc; suitable deflecting means must also not be forgotten.

Second Segment

Treatment of Forms of the Genus Dementia (paranoia)

(cf. Vol. I, p. 168, §§ 207 ff.)

§ 374. We have said (§ 207) that the essence of dementia is thinking imprisoned in perverted concepts. Thus, the lack of freedom or of the ability to liberate oneself from certain concepts, judgments, and views is one element of dementia, the other element thereof being the principle which binds and paralyzes the intellect, or the object of dementia, which was the object of interest at all times, but which now appears as an irritant of the thought and engages the entire thought pattern. Just as the moth keeps circling the flame, which fascinates, singes, and kills it, so, too, does the sick spirit, attracted and fettered by the object of its error, move around this object erratically or in confused flight. The form taken by dementia shows us only this perverted behavior of the sick spirit, but we cannot see the magnet by which this spirit is attracted, for it lies in the disposition, it is the interest of the disposition; but it is not the disposition which appears to be sick, in fact, it is not sick; it is the intellect fettered by this interest that is sick. Our task is to free the intellect from these fetters; this can be accomplished only by direct destruction of the talisman which fetters it, or else by countering this compulsive attraction with another compulsion, powerful enough to overcome the first. The former can only be successful in rare cases, even though examples of such cases are quotet, in ancient and modern literature; the latter is more feasible and we shall concentrate our attention on it. The kind of counterstimulation or counterweight will differ according to the different courses taken by the dementia, or rather, according to the different forms assumed by it. Pure dementia may appear in three different forms, namely, folly, craziness, and foolishness, and we must therefore determine the proper treatment for each.

§ 375. Treatment of the first species of pure dementia, or folly (ecnoia) (according to § 208).

If treatment is possible according to the age of the patient and the disease, and also other conditions and relationships, the first point to which attention must be paid is the period in which the disease is present at the moment of treatment. We may be fortunate enough to encounter the disease in the precursor stage, as was described in § 208, No. 2.

First moment of treatment. Here treatment is the most simple and help is easiest. Distraction and deflection away from the objects which occupy the candidate for the disease to the exclusion of all else; awakening of a new interest; stimulation of affections and passions which are opposite to those to which the patient is victim; briefly, everything mentioned in § 346 and § 347. Suitable means in such cases are social activities and social occasions, repeated visits to the theater, trips to the country, and rural occupations and amusements such as hunting, fishing, etc., short journeys, occupations of the senses and of the spirit which take the patient out of himself. Not infrequently, a pair of pretty eyes is all that is needed to effect a cure at this stage. Generally, what is needed is life with all its attractions, not forgetting good, wholesome food and a cheering glass of wine. But the paramount need is a sympathetic, cheerful, friendly soul who watches over the patient like a guardian angel. Friendship, and where possible love, work wonders. At the same time auxiliary somatic treatment, if necessary, should not be forgotten: for it is only rarely that some abnormality is not present in the system of abdominal organs, or in the circulatory or nervous system, which requires somatic therapy. Briefly, neither the physician nor the friend must spare the utmost efforts; for the patient is standing at the edge of the abyss, and, once he has been allowed to topple, he can be fully saved only rarely, and always with only the utmost difficulty.

Second moment of treatment. If the disease has fully developed (§ 208, No. 3), the treatment will depend on what stage of the disease the patient is in when he is entrusted to the care of the physician. In the first stage it is necessary, according to the conditions, to impose a suitable constraint and to calm the excited condition. Accordingly, medicaments of the first genus and the first class (§ 342, species 1) are suitable: quiet, silence, darkness, cold, etc., restraint of all unnatural activity of the patient, even if this can only be achieved by mechanical means (species 3). Some application of deflecting medicaments (§343, species 2) is also advisable, for these have a calming effect on the patient, at least indirectly. On the whole, what is most urgently needed at this stage is the negative treatment, including the means just given and, most of all, quiet and patience. As is commonly said, nothing much can be done at this stage, and evasive tactics are indicated, since the disease has now broken out and is in its first, most violent stage. This is why any mistake in the treatment must be carefully avoided, but what is most harmful is excessive compliance with the peculiarities of the patient. The patient must be fixed, that is, must be brought into complete dependence on the physician in every respect. The patient who is left to himself, who is allowed to do as he pleases, is as good as lost. Only recently, the author has seen a case, over which he had no influence, which was lost this way, but various considerations prevent him from publishing the details. We on our part shall follow the rules which are applicable in such cases. The patients must be brought from their accustomed surroundings to another milieu, more suited to the circumstances. They must remain in silent solitude, no unauthorized person must have any contact with them, no weak, inexpedient conversation, coaxing, or quarreling must be allowed. Silence is to be preferred to idle talk. But they must remain exposed to the magnetic charm of the physician's power (not violence), against which they are powerless. Their will, their arbitrariness must be disarmed by silent seriousness. Thus, after a few restless days and nights, the patients learn to bow to the inevitable, which is the first step in their return to sanity. Nov they may enjoy the friendly presence of one or more persons who have influence on them. Men, accustomed to being busy and active, find it hard to suffer prolonged idleness. They will welcome small occupations and minor distractions. Suitable means may be selected from § 347, species 1. Briefly, we should not forget calmants, not least, dietetic means (§346, species 1), and at later stages means of encouragement, again including dietetic means (§346, species 1). And thus it may be possible that the patient may recover. This is the procedure in the second stage. But if the third stage (§ 208, No. 3 to the end) has set in, all that remains to do is to ensure that the patient has the proper care (§362), and the recommended treatment is manum de tabula.

As regards the subspecies of folly (§209), folly combined with insanity (ecnoia ecstatica) offers greater hope of recovery than does pure folly, for it indicates a greater vitality of the individual, and thus also a stronger tendency to recover. The complication with insanity gives the immediate indication for treatment, and the rules enumerated under insanity remain valid here as well. As the complication increases, the fundamental evil itself may frequently disappear; alternatively, if it remains behind, it must be treated as pure folly (ecnoia inaniaca), the situation becomes worse; the same applies if all provinces of the psyche are affected (ecnoia catholica). If such complications are not brought about by incorrect treatment, as is not infrequently the case, when only an immediate return to the abandoned path of correct treatment can repair the damage caused, the original malignity of the disease (§ 209) leaves little room for hope, however careful the medical treatment may be. This treatment, if undertaken, must aim mainly at treating the component of rage according to the rules which will be given below, and thus return the complicated case to a simple condition.*

§ 375 [sic]. Treatment of the second main form of dementia or craziness. (paraphrosyne; § 219).

First moment of treatment. As in the case of folly, or any other mental disturbance, much depends on whether the disease can be recognized in its precursor stage; for if this is so, the work of the physician is easiest and the chances of a happy outcome are greatest. The immediate, most urgent step is to divert the man becoming crazy from the objects which obsess his mind and which threaten to deprive him of all his freedom. The best help which can be given is to occupy his senses and his reason, and to drag him back to the activities of everyday life, no matter how difficult this may be. The patient must not be left to himself and must not be abandoned to his melancholic thoughts, his broodings, and his phantastic inclinations; he must be led away from the whirlpool, in a more or less severe manner, by means of all the psychic-deflecting, encouraging, stimulating treatments offered (§ 343, species 4; § 344, species 5; § 346, species 2; § 347, species 1; § 354, species 1 and especially species 2), for otherwise this whirlpool will swallow him up, and usually there will be no salvation.

Second moment of treatment. If, nevertheless, craziness has broken out in all its strength ( §210, 3), the first stage must be treated like an acute disease or, more specifically, like insanity in its first stage. The patient needs rest, quiet, darkness, and calming, deflecting medicaments (§ 342, species 1; § 346, species 1; medicaments selected from those mentioned in § 343). If the excitation is directly favored by overexcitation of the nervous system, recourse must be had to the medicaments listed in § 242, species 2, case 1; in case of an orgasm of the circulatory system, those listed under case 2 in the same section must be employed. However, often neither of these two treatments is adequate or even possible to administer if, as is frequently the case with such patients, the system of abdominal organs is overloaded with foreign, spoiled materials and is deprived of its natural energy on account of a sedentary way of life, coarse, tough, indigestible foods, and enervating, lymph-destroying and blood-destroying beverages. In such cases auxiliary somatic treatment according to §§ 358, 360, and 361 must be applied. In the second stage we must have recourse to the entire variety and strength of deflecting medicaments (§ 343) in order to overcome the insane ideas of craziness. The longer this stage has lasted, and the older the disease, the more need there is for exciting treatment according to § 344, § 345, and § 347, species 2. Here mesmerism would be a suitable treatment (if it in fact achieves what it claims), in order to supply new life to the brain activity which has become paralyzed by the persistent overtension of the imagination; for nothing is more harmful to the essence of the creative force than the preoccupations of craziness. In the third stage, in which the patient has already adjusted to himself and has again attained a kind of permanent, self-conscious activity, except for his particular imaginings concerning supernatural objects, the best course is to withhold any medical treatment, in accordance with § 210, 4.

When he is talking about the tasks of the art and the rules of the art, the author often imagines that he is being accused of inconsistency by his readers. "How is this to be reconciled," they may ask, "with what the author said in § 73, namely, that the physician need not have any plan of treatment at all, and that the idea of such a plan is itself to be condemned?" We think that the two are in no way inconsistent. For it is one thing to prepare in advance a scheme of treatment of conditions which are not yet present, which may or may not appear, while quite different, unexpected ones may appear instead, and quite another to proceed in a given case in accordance with the requirements and circumstances of the moment. Any plan of treatment designed in advance constrains the physician, robs him of the spiritual independence which should not leave him even for a moment. The result is that he is forced, if he wishes to remain true to himself, to follow his plan against nature (which not infrequently happens). Alternatively, he must very soon give up his design when he has noted that there is a contradiction between the real object and his idea of it, namely, that he was mistaken. Why should he then perform this unnecessary labor? So much for the answer to this quite reasonable objection.

If (according to § 211) the craziness is accompanied by insanity or rage, these two modifications of the disease, even though really different in form, must be considered for the purposes of treatment as merely an intensified degree of the main disease; the rules of depression and constraint (§ 342, all species, and § 346, species 1) must be applied in a special manner. If the evil has advanced thus far, and the whole force and mechanism of the living existence has been so much confused, hope of recovery is slight.

§376. Treatment of the third main form of dementia: foolishness (moria) (according to § 212)

First moment of treatment. Since the advent of foolishness can be seen well ahead (§ 212, 2), haste must be made to counteract the disease, for to cure one suffering from foolishness is as proverbially difficult as it is to wash a blackamoor. But even the treatment of the precursors of foolishness is difficult. The seeds of foolishness are sown in early youth and should be extirpated early. Foolishness is a weed, which becomes more and more deeply rooted in the human soul, and thus cannot be pulled up early enough. If this is done later, the treatment, even if successful, is exceedingly painful. There are two main sources of foolishness: pride and vanity. Just as the character of these two is different, so, too, their offspring are different and must be treated in different ways. The main feature of vanity is flaccid weakness, and vigorous, severe, strong treatment is needed in order to eradicate it and to replace it with strength of character. The recommended medicaments are those of the fifth and sixth genus of the third class (§354, species 2; § 355, species 2). The proud can be bent only by humiliation, and particularly by being despised, or else they may be guided by someone who gives them his unreserved trust. The approach to them is more difficult than the approach to the vain, but once contact has been established, the proud possess sufficient energy to perform even the most difficult tasks in order to attain recovery. It is necessary to make use of their pride in order to cure them of it; the vain, too, must be handled through their vanity. But the cure is laborious, since it really consists in complete reeducation.

Second moment of treatment. If the disease has broken out, and both kinds can affect both sexes, the vain fool must receive a different treatment from the proud one, since the sanguine temperament differs from the choleric; for vanity is characteristic of the sanguine, just as pride is characteristic of the choleric. The most immediate treatment must thus be directed according to the temperament, and must be constantly and vigorously pursued according to § 353. In this case individual treatment is more itnportant than any other, provided that the first, acute stage of the disease is already over. For this first stage, which is always a stage of excitation, must be treated according to the particular circumstances, by the administration of depressants for excessive excitation of the first genus of the first class. But once this first tumult has abated, individual treatment comes into its own, and all groups of medicaments of the third class may be used in some way in one connection or another. But formal treatment must not be neglected either. The recommended medicaments for proud foolishness are what we call releasing medicaments ( §347, species 1), while vain foolishness must be treated with binding medicaments (§ 347, species 2), but the selection made within these species must obviously be suited to the individual and to the degree of his sickness. This treatment may be applied only in cases of foolishness which originated as such, and not in cases of foolishness originating from melancholia (§212, 3 to the end), for the latter will probably resist all treatments. Even the former may well prove incurable, and a combination of foolishness with rage or with insanity is even more difficult (§ 213). However, if it is nevertheless decided to treat such cases, the physician should begin by trying to eliminate the complications by medicaments indicated in their proper place; should this attempt be crowned with success, the seed of the main evil may have been destroyed as well. Treatment of general dementia (paranoia catholica) (according to § 214).

Since this evil cannot appear in the absence of a high degree of bodily and mental decline, since it is mostly encountered in old people, and since a whole lifetime has usually prepared the ground for it, it is readily seen that most of these cases will prove resistant to treatment. In cases in which the conditions still offer some hope of recovery, the treatment, apart from that of the auxiliary somatic type in accordance with definite indications found in § 357—§ 361, should be chiefly individual (§ 350—§ 354) depending on the circumstances, mainly formal treatment insofar as applicable (§ 347, species 1), and should be seriously and persistently followed. Nevertheless, it will be difficult to restore such patients to more than some kind of a mechanical daily routine.

Third Segment

Treatment of the Genus Rage (mania)

§ 376. Treatment of the first species: pure rage (mania simplex) (according to §215).

This form is the simplest, and because of its simplicity, also the rarest; but it is almost the hardest to treat and offers the least hope of recovery. For its nature is deeply rooted in a will which has been persistently ruined from youth, and its elements have their sources in the depths of neglected human morals, no matter how much it may evidence itself in bodily ills (§215, No. 2, 3). "Neglected upbringing, wrong upbringing, weakness and an indulgent attitude of the parents, together with a contrary, unyielding character of the child, who is goaded into rage by any resistance to his own supreme will, so that he destroys everything that he can master," all these give rise to the first element of the disease, namely, the tendency; but the second element, the stimulus, is based on the resistance offered by the outside world to the unrestrained desire at every moment. It is accordingly only natural, indeed it would be strange if it were otherwise, that in the course of time, owing to the irregular way of life, gluttony, intemperance, etc., the bodily organism, namely, the functioning of the vascular system, the liver, the ganglia, gradually become abnormal also, like the psyche. This is the origin of the grave condition of the patient, which is difficult to treat and offers little hope of recovery; the condition becomes even more serious if the disease which has already appeared has lasted for a long time, or rather, if the patient has suffered repeated attacks of the disease, each attack being of short duration. This is dangerous, since the disease (§215, No. 3) has a strong tendency to assume a periodic character. This does riot mean, however, that every case is hopeless, especially if both the patient and the disease are young. Accordingly, the science of cure must indicate the treatment which is required in such cases. The treatment will be listed according to its moments.

First moment of treatment. During the precursor stage (§ 215, 2) and when the fit is in its first violence (§ 215,3), nothing can be done except to confine the patient and fetter him so that he can injure neither himself nor others. Thus, we must immediately proceed to the means of constraint and restraint (§ 342, species 3). It is not advisable to simply lock up the patient, since his excitement only mounts as a result of the permitted free movement, and he may attempt to ram his head against the walls of his cell; such cases have repeatedly been described by Auenbrugger and are known to occur in any institution in which patients thus affected are accommo-dated. Mild fettering, such as a straitjacket, is just as useless; the patient soon frees himself and becomes even wilder. The best, safest, and least harmful means of restraint, in which all points of the patient's body are held fast, while no harm can come to any part, and which does not prevent the patient from sleeping (if healing sleep follows his first wild fits), which does not even hinder natural evacuation, is the confining chair ( § 342, species 3, No. 4) on which the patient is placed in a lonely, quiet, dark place. It has been found by experience that the patients do not become even wilder, but on the contrary become quiet, even though not immediately, without any organic harm being caused by the restrained frenzy. Initially such patients seek compensation in screaming, but they will soon give this up after a few applications of the pear combined with Autenrieth's mask (§ 342, species 3, No. 6 and 7). Under certain conditions, copious bloodletting, even if prolonged until unconsciousness results, and application of leeches all around the scalp are to be recommended. The only condition is that all signs of a true, dangerous orgasm of the system of blood vessels must be evident. The scalp should be shorn and cold compresses (§ 342, species 1) constantly applied. If the patient does not object to drinking, any amount of fresh water, pure or with niter, vinegar, etc., may be given. There is no need to forcibly bring about sleep, but if constipation is present, there is no choice except to cause bowel movement by administering large doses of tartar emetic in the drink. This simple treatment should be continued until the first fit has abated.

Second moment of treatment. Once the unrestrained, wild frenzy has abated, which may last a few days, even a week, and the patient merely sits brooding while staring straight ahead, nothing is less indicated than to release him from his imprisonment, not even if he decides to beg for his release and to promise obedience, as long as his expression still betrays his inner excitement. This would be contrary to the recommendations of Celsus (De Medic., libr. III. cap. XVIII.), "Neque credendum est, si vinctus aliquis, dum leuari vinculis cupit, sanum iam se fingat; quamvis prudenter et miserabiliter loquatur, quoniam is dolus insanientis est." First, we must remove the somatic irritations which maintain the sick condition; these can be of many kinds, and must therefore be carefully investigated. Thus, we must first apply the auxiliary somatic treatment with its various genera (§357—§ 361) according to the circumstances, until the patient becomes naturally peaceful. We must consider here, very particularly, sleeplessness which, if it still persists, is a certain indication of internal morbid stimuli which are still active; next, we must consider constipation, and finally the so-called congestions, and remove each of these morbid conditions as prescribed in §§ 357, 358, and 360, in accordance with the different prevailing organic disturbances. It is only after the patient has become genuinely quiet that he can be released from the confining chair, for in no other case is the desire of the patient to injure others and himself as strong and as typical of this disease. If the savage passion for destruction has abated, the illness is over or is broken for this time, and there is nothing to be done except to ensure that the disease does not return, if this is possible. Thus, an after treatment is required, and this is actually the main task of the physician, that is, how to produce a complete cure if this is at all feasible.

Third moment of treatment. Here we have to deal with various considerations which concern partly the somatic and partly the psychic condition of the patient. We shall take the somatic moments first. If it is found, after an exhaustive examination, that abdominal infarcts give rise to irritation of the ganglionic system (§ 215, No. 2) and head congestions, which affections are further intensified by a special erethism of the blood vessels and a morbidly excessive plasticity of the blood (which are all consequences of an upset bodily organism brought about by a perverted way of life), these anomalies must be dealt with according to the rules of somatic therapy. For infarcts, we recommend persistent application of Kampf's enemas; a faulty vascular system and its contents should be counteracted by administration of digitalis or cherry laurel extract, until the normal condition is reestablished. But the most important thing is that the medical treatment be assisted by a diet adapted to these conditions. The food should be exclusively of vegetable origin: green vegetables, lettuce, fresh and dried fruit, more of the juicy than of the starchy varieties, no indigestible bread, no legumes or raw starchy foods, no condiments or heat-producing substances in general. The same applies to liquids. Nothing must be given to the patient which produces heat, no alcoholic beverages, no blood-thickening drinks. Liquids which should be plentifully served include fresh spring water, whey, buttermilk, couch-grass root broth, etc. The patient should be made to do heavy, prolonged, physical labor in the garden and field, in the house and yard. He should be allowed little sleep. If these recommendations are persistently and faithfully followed, there will be a beneficial effect on the body in the first instance, but indirectly also on the disposition of the psyche. An unblocked abdomen, purified blood, a body which is brought to perspiration and exhaustion by daily labor, allow no room for gloomy, oppressive feelings and ideas; the unruly, goading passion will be restrained and blunted, thus laying the foundation for a quiet, lucid life of the psyche, which now must itself be assisted with all the means at the physician's disposal. Even the usual daily activities will do much good in these cases. However, the entire way of life of the patient should also be transformed. This can be achieved by a proper cultivation of his intellect and habits, by a daily exercise in self-control, by letting him enjoy the company of gentle, good, friendly people, and by the inoculation of a truly religious frame of mind. However, special attention must be paid to the tendency of such apparently cured patients to suffer periodic relapses, insofar as such relapses are favored by atmospheric and cosmic influences, by natural disposition or even by hereditary tendencies, such as a tendency to hemorrhoids. In such cases it is advantageous to impose a stricter diet from time to time, to prevent any excitation of the psyche by anger, fury, etc., and if there is evidence of traces of orgasm in the vascular system, the patient should be bled, or leeches should be applied to the anus, digitalis should again be administered, etc. All this must be persisted in until every trace of the disease and of a tendency thereto has been extirpated. If the physician is successful, he will have given a model example of the treatment of this condition, which is so terrible and so difficult to cure.

§ 379. Treatment of the second species: insane rage (mania ecstatica) (according to § 216).

Whether the disease has a direct psychic origin or is due to a perverted functioning of the organism brought about by a perverted mental life, the immediate treatment must invariably consist in restraint and depression of excessive excitement (§ 342), including: quiet, darkness, solitude, fettering of the patient. The next step is the treatment of any somatic irritation in any system or organ (cf. auxiliary somatic treatment, §357—§361, and § 342, species 2, case 1 or 2). Once the frenzy has abated, deflecting treatment (§343) must be applied at once, insofar as circumstances make this permissible or desirable; in particular, all potential psychic irritants should be removed. If the temperature of the patient is depressed, there will be need for means which change the disposition (§346), either those bordering on the previous treatment, namely, calmants (species 1) or the means of encouragement (species 2) if any consequences of depression, deflection, or apathy appear: prolonged stay in the open air, reasonable occupation, amusement, and distraction. If everything goes well, the last stage in the cure is the admission of the patient into a community of men of good will, who are made happy by their natural activities, and whose example is itself the best medicament.

§ 380. Treatment of the third species: rage combined with folly (mania ecnoia) (according to § 217)

Just as folly is deeper rooted and harder to cure than insanity, rage combined with folly is harder to cure than insane rage. A tendency to suffer from this form of disease is usually displayed by individuals of a more advanced age and a more stable temperament. In the first period, the disease must be treated as pure rage, with very careful attention to constitution and temperament. For even though it is the choleric temperament which is most often affected by this form, the constitution of the patient may well preclude the use of all excessive depressants such as bloodletting, too drastic deflection by means of emetics, drastic purges, etc. Hence, individual treatment ( §350—§ 355) is very important in the very first stage of the disease, and becomes even more important in its later stages. For after the first violence has abated, the second stage ensues (§ 217, No. 2); here, the deflecting treatment ( § 243, with selection) and the appropriate formal treatment ( § 347, species 1) must be continued, and in addition special attention must be paid to the sex, age, constitution, and temperament (§350—§ 353) of the patient, particularly to his personality and individual situation; both these will dictate the application of the weakly stimulating or the strongly stimulating treatments (§354 and § 355, species 1 and 2). It is only if the disease has not lasted long, if the patient is not too old, and if the disease has not yet assumed its periodic character that there can be hope of recovery.

§ 381. Treatment of the fourth species: general rage (mania catholica) (according to § 218).

It is here that the most vigorous restraining and constraining treatment is most urgently recommended. Bloodletting, if necessary until unconsciousness ensues, repetition thereof, leeches all around the scalp, cold water poured over the patient, douche on the shorn scalp, scarifications and application of powdered cantharides on the wounds, emetic ointment rubbed in, internal administration of belladonna, aqueous extract of cherry laurel, gratiola, hellebore, in accordance with the circumstances. If the patient cannot be restrained even after being bled and after application of other means of restraint, a specific remedy is the swing machine, at least judging by the happy results produced by it in desperate cases of this kind reported by Cox. If all these do not help, nothing will. Once the patient has been restrained, he has become receptive to formal and individual treatment, and the means in the second and third class for the complication of insanity and dementia, in accordance with the procedures there described, are to be applied. The main moment of the treatment must still be restraint; if the patient can be restrained, other means of treatment have a good chance of success. If perhaps, by good fortune, this form of disease has been overcome, the after treatment is subject to the same rules as for pure rage, to which the reader is referred.

§ 382. Treatment of subspecies, varieties, etc., of rage (according to § 220). 1. Mania continua acuta. This disease often cures itself, and needs only a negative treatment, including the usual means of restraint (§ 348) and cal-mants (§346, species 1).

2. Mania continua chronica. The name itself indicates that a radical treatment does not exist. However, palliative treatment must be applied as widely as possible.

3. Mania periodica. This is merely a general appellation for most of the species heretofore discussed, which tend to become periodic.

4. Metromania or furor uterinus or nymphomania needs mainly immediate auxiliary somatic treatment, as prescribed by somatic therapy; but at a later stage, when the violence of the disease has abated, the physician must also consider the recovery of the psyche, that is, moral treatment and guidance of feelings and passions. Another factor which is very important is diet in the widest sense of the word, characterized by the least possible irritation by outside agents, much exacting physical labor, and distracting activity of the mind. Cf. formal treatment and its subspecies, including a suitable selection of means (§346—§349).

5. Satyriasis. Except for the sex of the patient, everything that has been said under metromania applies to satyriasis.

6. Melancholia saltans. This is most probably the old plague, known as

the Black Death, which only a few centuries ago swept not only through Germany but through the whole European continent, and this particular species of mania was one of its accompanying symptoms. It is to be hoped that this visitation on mankind will not recur; in any case, it would be no task for the physician of the psyche.

Chapter Three

TREATMENT OF FORMS OF THE SECOND ORDER (DEPRESSIONS, ASTHENIAE)

First Segment

Treatment of Forms of the Genus Melancholia

(cf. Vol. I, § 194 and § 255)

§ 383. Treatment of pure melancholia (M. simplex) (according to § 221). "Whoever lives entirely on himself," says Zimmermann, "gnaws at his own brain and feeds on his own heart." This is the true description of melancholia, which can also be found in this book (§ 194). The ancients justly named this disease insania tristis; Aretaeus gave a strikingly true definition of its nature in De causs. et sign. morb. diuturn., libr. I. cap. 5: "esti de athymie epi mie phantasie." This definition gives the most distinct expression of both elements of melancholia: the first, athymie, is the depression, the lack of inner resistance, the decay of the disposition into itself and the gnawing pain produced thereby; the second is mie phantasie, the so-called idee fixe, the nature and the significance of which have been discussed in detail (§ 221, No. 3), and which does not determine the nature of the disease, but since it continually irritates, or rather gnaws at the disposition, it is the second element of the disease which helps to create and maintain the morbid condition itself. If it is desired to cure the melancholia,* it is necessary to separate and to remove its elements, and since the ideas of a man change with a changing condition of his disposition, the latter must be changed if this is only possible. This is the principle of the cure; the cure itself can be broken down into the following moments.

* We have used the word "cure," since the term is suitable, even though we have already discussed its limitations on more than one occasion. The term "cure" is based on a false assumption concerning what the physician is able to do; the physician is in fact credited with the achievement of the diseased but still independent soul.

First moment of treatment. The physician of the psyche is fortunate if he can identify and halt the disease in its nascent stage. Once the precursors and the first traces of melancholia have appeared (§ 221, No. 2), the "quiet, reserved, withdrawn behavior" must be overcome by friendly sympathy and persuasion, by searching for the sources of the disease, such as a great loss or the fear of such a loss; and then, if possible, by deflection of these sources (according to § 355, species 1), not all at once and not through one medicament, but by persistence and by repeated efforts. If the patient cannot be compensated for his loss by some substitute, and if the fear which is dominating his disposition cannot be dispelled by any reasonable argument or by any encouraging prospect, the patient must be forcibly withdrawn from his situation, his disposition must be violently stimulated, some new interest must be awakened, and he must be removed from his situation and his environment, if possible by a journey to a far distant place, which involves much excitement, much discomfort, and much activity. For such patients, traveling is a universal medicine. This is also the best means of giving back to the patient "the lost appetite and the lost sleep," of chasing away his "fearfulness and timidity, and his gloomy brooding," and of leading him back to the "society and business activities from which he has escaped." If this purpose cannot be attained by traveling, since this is precluded by the situation and means of the patient, the lack of this powerful remedy must be compensated for as much as possible by distractions of all kinds taken near home, physical exertion, general activity, and occupations imposed on the patient, through which he is torn out of his preoccupation with himself.

Second moment of treatment. If the physician is unable to check the disease in the nascent stage, or if he is unfortunate in his efforts and the disease has become established, the disease which is already present calls for another kind of treatment. In the first stage, if the patient appears excited (§ 221, No. 3), he must first be calmed; thus, the elimination of noises which disturb the patient instead of helping him, and needlessly excite him; if necessary, restraint by a straitjacket, etc., until the first restlessness has abated. But patients whose disease begins with a kind of apathy or rigidity immediately require powerful means of excitement; and since psychological influence and formal and individual treatment are ineffective, the means of excitement forming the main genera of the first class must be applied (§344, species 1 and 3). Not infrequently, it is fortunately still possible in this initial stage to make the psyche active and susceptible to further treatment by such physical stimulants as, for example, strong skin irritants. Thus, Chiarugi claims to have completed the cure of melancholia with vesicants as almost the only treatment. Even if not much is gained by the application of such means, since the treatment of any specific organic sphere can only affect one aspect of the disease, something will have been achieved if we can render the patient receptive, at least to some extent. For this receptivity is the first thing which we must attempt to awaken and to maintain at all costs, in view of the patient's tendency to withdraw into himself. For if the force of gravity is allowed to dominate the patient at this period, all hope for the future is lost, unless spontaneous, organic revolutions intervene; which must never be relied upon, since it is a very good excuse for inactivity. Thus, if stimulation and psychic receptivity cannot be awakened by milder stimulants, more powerful means (§ 344, species 3) must be resorted to, up to and including the swing machine. But even then the pharmaceutical and dietetic stimulation ( § 344, species 2 and 4) must not be neglected. If all the suitable means of encouragement ( § 346, species 2) (which we can call the sum total or the selection of medicaments listed above) have in fact restored the receptivity of the patient's psyche, the patient must be speedily brought back to life and accustomed thereto by bodily and spiritual occupation and distraction, with due regard to his individuality (§ 35O—§ 355). Thus it may be possible to overcome the disease in its second stage (§ 221, No. 3) if this was not done in the first, before it has assumed its extreme form.

Third moment of treatment. If the first and the second moments of treatment have proved ineffective, the disease has taken firm roots not only in the psyche but also in the somatic nature of the patient, in fact, the general condition of the psyche has passed over into his bodily nature ( § 221, No. 4). If anything at all helpful can be done by the physician at this stage, and neither ancient nor modern physicians consider all cases of this kind to be hopeless, it is first and foremost somatic auxiliary treatment. We could apply here the helleborism of the ancients, if we had it, and if it were in fact the powerful remedy which it is generally claimed to be. Since the method is not available, we can at least use the drugs themselves: both black and white hellebore, and related medicaments such as Gratiola, briefly, speczfica which have been recommended in cases of melancholia; these are mainly to be found among the deflecting medicaments ( § 343, species 2); they will probably not effect a complete cure, but where a cure is still possible, they will prepare for it. In this deeply fallen condition, this extinction of all response to stimuli, this apparent death of the mental faculties, the ancients recommended warm baths, fomentations, and frictions. The diet should include wine and all nourishing, restorative foods. If neither the disease nor the patient are too old, and the physician's efforts to reawaken mental and bodily responses to stimuli have finally been successful, so that he is now freer in his choice of further treatment, all species of means of encouragement (§ 346, species 2) should be applied, with consideration for and together with individual treatment ( § 350—§ 355) in the right place.

§ 384. Treatment of the second species: melancholia with idiocy (M. anoa) (according to § 222).

Idiocy which accompanies melancholia can be recognized by general dullness; and this is the first moment of the treatment which must be considered here, if a final cure of the disease is at all possible, which is rarely the case since the patients are generally weaklings, without any inborn strength ( § 222, No. 2). We believe that there is little hope of a radical cure, but it is not possible to prove that such a cure can never be achieved. The first moment must accordingly be very carefully considered, and the condition of apathy or idiocy (in the experience of the author, it is mostly female individuals who suffer from this form of the disease) must be overcome at all costs. The recommended medicaments are a good, nourishing, restorative diet, friendly treatment, long periods of time spent in the fresh air in cheerful surroundings, encouraging the patient to carry out small tasks, compulsion and severity if necessary; also appropriate medicaments which stimulate and generally excite through both internal and external deflection ( § 343 and § 344). After this treatment has been continued for some time, the prospects for improvement should become clearer. If the dullness recedes, the enemy may be considered as beaten; for these medicaments are just as suitable for treating melancholia itself as described in the preceding section, and the lack of receptivity is the main hindrance to recovery.

§ 385. Treatment of the third species: melancholia with apathy (M. aboyle) (according to § 223).

Authors have described the first period of this form of melancholia as a special form of disease, called Melancholia attonita. Even though this is in fact no special form, it nevertheless requires its own moment of treatment, which is given here as the first.

First moment of treatment. The general procedure, which is prescribed by somatic therapy in cases of tetanus and catalepsy, is to be recommended in this case as well, since the condition of the patient is usually a kind of rigidity or rather catalepsy, except that its duration is longer than that of cataleptic fits, and there are examples when the patient remains conscious in this condition. The most immediate task is that of auxiliary somatic treatment (§ 361, species 3). The most recommended means are warm baths, pouring cold water over the head, frictions, brushings, application of nettles, vesicants, and mustard plasters; for sthenic constitutions, copious bloodletting is the most important. If the condition of the patient does not improve, strong electric or galvanic shocks should be administered. It is possible that vital magnetism is able to remove this condition like magic. Cases are known in which the patient has awakened from a somnambulistic condition with his eyelids spasmodically closed, and had this condition instantly removed by a light stroke of the mesmerizer. In general, the condition we are discussing in many respects resembles certain cases of somnambulism. However, mesmerism has not yet been tried as treatment for M. attonita, since this condition is very rare. Finally, the first attack of the disease passes, whether it is treated or not, and the patient awakens from his comatose condition, but not to return to a new, fresh life but to fall victim to the second stage of the disease.

Second moment of treatment. This moment appears in the second stage of the disease, and just as this second stage has nothing in common with the first except the lack of active force, that is, of will, so does the second moment resemble the first only as concerns the stimulating treatment, which, however, covers a wider range and is more important. If apathy can be overcome, the foundation of melancholia, as it appears in this case or in this particular form, has been shattered. It is, however, difficult to restore the will of the patient, since he lacks the joy of life and thus also the vital instinct. If this joy and this instinct can be reawakened, we may be sure that life has gained a victory over death. The science of medicaments offers the revivifying ( § 345), the enlivening ( § 346, species 2), and the encouraging (§ 348, species 2) means to meet such cases, as well as the subspecies of means of formal treatment (§ 349). The only purpose is to impart to the patient a new interest in life, and this must be done by way of somatic treatment producing a tonic effect. No medicament which permanently stimulates the vascular and the nervous systems should be neglected; and the strength of genuine wine is particularly important, for it flows from the lap of nature to bring joy to the heart of man. In particular, individual treatment with reference to the individual situation of the patient (§ 355) must not be lacking. For a long time the author treated a patient suffering from this form of disease in the manner just described, without being able to awaken in him any interest in life; the patient retained his full mental capacities, was physically fit, but was indifferent to everything, seemed to feel best when sunk in his gloomy broodings, and, at least at first, it cost him a great deal of effort just to lift a hand or a foot. There was no way of bringing him to make any decision or to undertake any sort of action; he was unaffected by any hopes held out to him; and it was merely because of this apathy and inertia that he allowed himself to be released to enjoy home freedom, since the circumstances were favorable for such a step, after a long time of deprivation of freedom due to his serious condition. The author's last hope was that the restoration of freedom might have a favorable effect; and lo and behold, this stimulation alone caused the patient to recover; he again became cheerful and active.

§ 386. Treatment of the fourth species: general melancholia (M. catholica) (according to § 224)

Any treatment must be carried out at the very beginning of the disease, and must include everything that is available in the category of exciting (§344), revivifying (§345), and encouraging (§ 346, species 2) medicaments. Nevertheless, in most cases, since the disease is deep rooted and is both somatic and psychic in nature, all efforts are fruitless.

§ 387. Treatment of subspecies, varieties, etc., of melancholia (according to § 225).

1. Home-sickness (nostalgia). The best treatment for this disease, and indeed the only one which produces radical recovery, is to send the patient back to his own country. Nevertheless, even if this is not done, not every patient will die of the disease; whatever cannot be overcome by the unfree reason of the patient or by the limited art of the physician is often achieved by nature itself. Nature makes the sick patient even sicker by adding high fever or a prolonged slow fever to the suffering of his psyche, until the self-destructive force has become exhausted. This is the decisive moment, and young age and strong constitutions are not infrequently victorious. The sting of the pain has become blunted or even destroyed by the disease. If the patient awakens to a new life following a period of apathy, which may be of varying length, he has become immune to any future relapse. The physician can from first to last only assist and stimulate the natural forces.

2. Religious melancholia. This is a scandalum medicorum, as the four-day fever used to be at one time. Nothing helps in such cases: reasonable persuasion, consolation, hope, or any other balm or spiritual life. The faith has gone; what can be put in its place? The most important thing is for the physician to have a thorough knowledge of human nature. True religious feeling never results in religious melancholia; on the contrary, it offers a protection from it and from all other morbid conditions of the psyche. However, if this feeling is not there, it cannot help. It is therefore quite useless, not to say foolish, to attempt to cure a so-called religious melancholic by way of a divine speech on religion. The patient is deaf to it, and it is indeed his very lack of religion that has made him sick in the first place. It may sound paradoxical, nevertheless, the way to the recognition and cure of this evil lies in a different way of healing. Worldly life, worldly errors, sinking in its quagmire, and the finally awakened voice of conscience, which arouses terror in the degenerated spirit and disposition, are the moments of religious melancholia. A life consisting of excesses, vital forces which have become exhausted, devotion to passions of all kinds, a crime or a number of serious offenses, this is the swampy pond, the sediment of which is now sent to the surface by the storm, these are the terrors of the deep which are now exposed to daylight. Religious melancholia is caused by a disturbed soul dwelling in a disturbed body; this is why it is so difficult to cure and why it often cannot be cured at all. Nobody should be deceived by its appearances; the air of religious sensations is spurious. They are in fact not religious sensations at all but are upheavals of the tortured imagination of an impure heart sunk into worldly life and into self-life. Who can look into the human heart? The apparently innocent life is often but a sin retained in the innermost soul and cloaked by a veil of exterior shame so that it might pose as innocence. There are such things as "whitewashed sepulchres." Why are we saying all this? In order to reject any attempt at a moralizing or religious treatment. The immediate business of the physician is deflection by counterstimulation and relief of oppressive feeling by a counterpressure; while his next task is to strengthen the fallen, excite and revive the petrified, dead spiritual and somatic life. This is done through two moments.

First moment of treatment. All appropriate medicaments of the deflecting genus (§343) must be employed: douching the shorn scalp, the nausea cure, rubbing tartar emetic ointment into the head, moxa, the swing machine. The exterior pain calms the inner pain; fear and anxiety directed at the outside make the patient forget his inner fears. Since the suffering of the disposition is broken in this manner again and again, day after day, there eventually appear prolonged intervals in the internal pain of the soul, that is, moments arise which can be utilized to bring the patient back to his senses. Let no one call this method cruel, for if so, all surgery is cruelty; nevertheless, it remains true that

. . . immedicabile vulnus

ense recidendum est, ne pars sincera trahatur.

Second moment of treatment. This includes suitable foods such as good, nourishing broths, chocolate, light meat dishes, soft, well-prepared vegetables, but above all genuine wine if the patient can stand this; also suitable pharmaceutical medicaments, nervina and roborantia, with occasional narcotics, alone or in combination with the former medicines, for example, cinchona with opium. Furthermore, exercise in the open air, warm baths, frictions, the charm of music; on the whole, everything recommended in § 344, § 345, and § 346, species 1 and 2, chosen in accordance with the individual nature of the patient, if continued, can so far improve the condition of the patient that moral treatment proper can be considered.

Second Segment

Treatment of Forms of the Genus Idiocy (anoia)

(cf. Vol. I, § 194 and § 262)

§ 388. In the science of forms (§ 226) it was postulated that idiocy cannot be considered to be a mental disturbance unless there was a previous development of consciousness and the possibility of freedom. The same must now be postulated for the medical treatment of idiocy. For this reason, congenital idiocy, which originates from the immature development of the higher vital system (cerebral system and sensory system), that is, idiocy of organic origin, and cretinism, as well as senile idiocy, that is, gradual necrosis of the noble organs (amentia senilis), rightly do not form the subject of medical treatment of the psyche. It is only idiocy generated at a subsequent stage (and not even this in all cases, but only in conformity with the postulates of the organon of the science of cure, § 364 and § 365) which can be treated by the medicine of the psyche. We shall accordingly omit pure idiocy (§ 226), which is the first form of the disease, and shall immediately turn to the second.

§ 389. Treatment of the second form: idiocy with melancholia (anoia melancholica) (according to § 227).

It is only if the approach of the disease is noted in the precursor stage or in its first stage and only if the disease has not become too deeply rooted and has not lasted for too long that medical treatment has a chance of success and there is hope of a cure. The medical treatment, both in the precursor stage and when the disease has broken out, comprises two moments: that of the symptoms of idiocy and that of the symptoms of the accompanying melancholia.

First moment of treatment. The recommended medicaments are the exciting and revivifying kind (§344, § 345, and § 347, species 2); fresh air, especially country air, bathing in a river, appropriate application of robo- rantia and nervina in combination or alternately; nourishing foods, milk fresh from the cow, good, nourishing beer, and above all good, old wine if it agrees with the patient; the appropriate stimulants of the psyche should also not be forgotten. The progress which can be achieved by making the patient do suitable physical labor in the fresh air and forcing him to be occupied against his morbid inertia has to be seen to be believed. However, such efforts must be persisted in, especially with reference to § 347, species 2.

Second moment of treatment. The medicaments prescribed for the first moment are also suitable for the second moment and help to establish it. Suitable medicaments of § 346, species 1 and 2, as well as individual treatment (§ 354, species 1 and 2 and § 355, species 1 and 2), in accordance with the circumstances, should be added; distractions and cheerful occupations of all kinds, friendly coaxing and earnest admonishment, maintenance of hope, favorable prospects, offering pleasurable impressions in general and everything which can reawaken and maintain the joy of living. The author (§ 227, No. 3) was successful in fully averting an approaching outbreak of the disease in this manner. The patient thus cured is at present an active and cheerful individual, and a useful member of the community.

§ 390. Treatment of the third form: idiocy with apathy (anoia aboyle) (according to § 228).

It is only if this form is not the after effect of a disease (§ 228, No. 2) that treatment can be successful, though a few exceptions to this rule are known. The treatment really consists in educating the patient to rise above his animal-like condition. The author has seen one such case in which the efforts to do this were not unsuccessful. Strengthening, stimulation, revivification of the bodily organism in accordance with the indications given in the preceding section, as well as external stimulants which excite the general disposition through the skin system: inoculation with materials producing skin eruptions after such eruptions have been suppressed, vesicants, setons, or stroking with nettles, birching with twigs, all severe, harsh measures directed against the depression of the patient, compulsion to activity. But also encouragement, tempting the patients by means of objects he is known to desire, rewarding the patient if he proves obedient; in particular, accustoming him to orderliness, cleanliness, requiring him to concentrate, all these lead to improvement. In the case just mentioned, which was also described earlier in this book, the author had the opportunity to observe a young female patient whose disease was so far advanced that it had reduced her to a condition which was fully that of an animal. She was apathetic, dirty, and kept squatting in one place, greedily swallowing the food given to her, without emitting a single articulate sound. The application of the entire procedure just described, in conjunction with complete reeducation, brought her back to the stage of being able to speak, to do certain feminine tasks such as knitting and sewing. In fact, she could be taught to read and write, and even to do simple calculations; thus, she fully mastered the multiplication table, even when questions were put to her at random.

§391. Treatment of the fourth form: general idiocy (anoia catholica) (according to § 229).

Here again a cure is only conditionally possible. Thus, for example, senile idiocy (amentia senilis) (mentioned in § 388) does not respond to treatment. The disease is cured more readily if it was caused by fright; it is more difficult if it is the result of debauchery such as onanism, especially when accompanied by epilepsy. In accordance with the variety of reasons responsible for its outbreak, the disease must also be treated by different means; and nowhere is it more true than here that the causative moments of the disease are a part of the therapy and must serve as the main guide to the treatment. If the morbid condition has been brought about by fright, the cure, if at all possible, must be produced by the aid of stimulation (§ 344, species 1, 2, and 3); this must be done in such a manner that, if the sensitivity is low and the entire nervous system is paralyzed, the most violent and deeply penetrating stimulants must be administered, until the freshly awakened sensitivity makes it necessary to proceed more cautiously. If the evil is due to debauchery, such as onanism, the application of violent stimulants is deadly to the mere spark of life which still remains, and only revivifying medicaments can be administered (§345). The same applies to cases in which the source of the disease is the abuse of medicaments, such as mercuriales or narcotica; here, somatic therapy with its specifica must be allowed to help.

§ 392. In view of the discussion in the science of forms (§ 230) on the subspecies of idiocy, etc., we must state that these, as well as the related conditions of weakness of intellect and power of judgment, etc., are not outside the scope of all medical treatment, but since they are not mental disturbances in the proper sense of the word, they are the task of general medical treatment, but not of the medicine of the psyche as we understand it. Nevertheless, the nomothetic part of our technique must deal with these conditions from another aspect, namely, insofar as they are investigated by the police and the courts as being related to unfree condition, and insofar as nomothetics has to pronounce the decisive verdict on them. But this will be discussed in its appropriate place, when our present remark will be referred to.

Third Segment

Treatment of Forms of the Third Genus: Apathy (abulia)

(cf. Vol. I, § 194 and § 265)

§ 393. Treatment of the first form: pure apathy (abulia simplex) (according to § 231).

The cure of this disease may be attempted in two ways: by compulsion or by temptation; both these paths merge into one, when the two methods must be applied alternately. However, it is just as difficult to force the patient as it is to tempt him; it is difficult to force him, because compulsion tends to make him stubborn and obstinate; it is difficult to tempt him, because the depression, which is brought about by apathy, is always accompanied by a lack of sensitivity to stimuli. The physician must accordingly study the individual character of the patient, beginning with methods which affect him in a mild and friendly manner, and alternating these with severity and force (§ 350—§ 355). It requires extraordinary skill to treat the patient according to his individual character; and even more to work on this and thus, even if not immediately, at least gradually, to produce an improvement; to convert dullness to excitability, inertia to activity, apathy to new independent willpower and an inclination to exercise it. This can be achieved only in the above way; anything else is of no avail.

§ 394. Treatment of the second form: apathy with depression (abulia melancholica) (according to § 232).

Even though it is apathy which is the major feature in this form of disease, it can only be cured by treating the associated depression. The patient is not properly and completely melancholic; but his will is paralyzed (which is the main symptom here) because he is depressed. Fresh water of life must be poured over these sensitive, drooping dispositions and they will be healed. If it is not in the power of the physician to lift up such a disposition, the will remains cast down, and with it all vital force and vital activity. This is why it is so difficult to establish any contact with such patients. Violence and compulsion have no effect; a friendly approach, mildness, and sympathy are more suitable. The patients must be offered hope and shown encouraging prospects, and in this way they will be cured. It is therefore the task of the physician to appear as a true humanitarian and as a wise man, and to spare no effort to look for the sources through which the evil might flow to the patient. This is a special gift, with which not every physician is endowed.

§ 395. Treatment of the third form: apathy with idiocy (abulia anoia) (according to § 233)

Since this disease is solely caused by a weakening of the sex organs, the immediate business of the physician is to extirpate the results of this evil. But he must apply not only somatic but also psychological therapy, with all due consideration of individual treatment. The patient is not merely extremely weakened bodily, and thus also deprived of his psychic energy, but he is also demoralized to the highest degree and his entire disease has as its origin his moral corruption and his fall from innocence. His susceptibility to physically fortifying agents is just as much lost as his susceptibility to morally strengthening treatment. This is why it is so difficult to cure this disease. The first and last need of such a patient is an understanding, faithful, sympathetic friend who watches over him and who has full sway over him. This friend must be perfectly familiar with the somatic measures and must also be sufficiently gifted and fortunate as to miss no chance of affecting the patient psychologically, if the patient is at all responsive to such an influence. The physician can do nothing except give his instructions to this benefactor, since if help is possible at all, it must consist in a permanent presence and supervision. However, if successful, such an effort is well worthwhile.

§ 396. Treatment of the fourth form: apathy with general depression of the psyche (abulia catholica) (according to § 234).

The pure picture of this form was stated elsewhere to be melancholia attonita: but this is only the permanent moment of this evil. If a man has suffered a great misfortune, if he is overcome by fear and terror and cannot be contacted anymore, if he has lost all consciousness and all thoughts, if he gives everything up because he is no longer able to act, since he is no longer able to will, then the prominent feature of the disease is indeed apathy with all its consequences, but his disposition and his spirit are on the same level as his will, that is, on the level of total depression. How can we help under such circumstances? If his house, which has been burnt down, can be rebuilt, or if he can be assured that it can be rebuilt, if the value of a shipwrecked cargo together with the ship can be restored, briefly, if in each individual case more help is given than can usually be given by an individual, the patient will be saved. These patients are not always incurable, however terrible their disease. But such patients are not found in mental institutions, and when they eventually arrive there, they are too deeply sunk in their misery and its consequences for a cure to be possible. It is only all-powerful nature that can offer some hope of cure through the healing power of time and the organic changes which may occur in the course of time; the best thing the physician can do here is to adopt an attitude of "wait and see."

 

Chapter Four

TREATMENT OF FORMS OF THE THIRD ORDER (MIXTURES, HYPERASTHENIAE)

First Segment

Treatment of the Forms of Mixed Mental Disturbances (animi morbi complicate) (cf. Vol. I, §194 and §235)

§ 397. The remark made in § 235 from the theoretical point of view is repeated here for the sake not only of the technique in general but also of the science of cure in particular. Just as the complicated diseases of the psyche are composed of the simpler forms and occur more frequently than the simple forms but can be recognized only if the physician is familiar with the simple forms, so can the cure of the complicated forms be clear, certain, and easy only if the physician is familiar with the simpler forms and with their treatment. But this is also why there is no need for the science of cure of the complicated forms grouped as genera of the third order to be very detailed; just as these forms themselves were only outlined in general in the science of forms, since the details had already been described for the simple forms and only needed to be summarized, so now, in this last chapter of the science of cure, we can and shall only follow the same method of presenting the treatment of these forms. Accordingly, since we shall now meet complex treatment procedures which correspond to the forms themselves, we shall only give their composition, since the component parts have already formed the subject of our considerations.

§ 398. Treatment of the first form: quiet insanity (ecstasis melancholica) (according to § 236).

Even though the disease seems simple at first sight, it is in fact composed of opposite elements, and its treatment must be adapted to this fact. Everything depends on the stage of the disease when the patient was entrusted to the physician for treatment. On the whole, the first stage requires mainly calmants (§346, species 1), while in the second the encouraging treatment is more suitable (§ 346, species 2). Whatever treatment is administered, either mainly or possibly alternately, the individual treatment with all its particular features (§350—§ 355) must at no time be lost sight of. The physician must penetrate into the innermost soul of the patient and be perfectly familiar with it if he is to be of any use at all. The more advanced the disease, the more need will there be for stimulating and revivifying treatments (§344 and § 345); but the more need there is for such a treatment, the less hope there is for the recovery of the patient.

§ 399. Treatment of the second form: melancholia with foolishness (melancholia moria) (according to § 237).

This form, which may appear as the result of any aspect of the disease, necessarily requires the counterstimulating, deflecting treatment (§ 343) with its many gradations, according to the circumstances. If the physician is fortunate enough to have brought about a momentary restoration of equilibrium, or a mere glimpse of returning consciousness, he must apply the individual ( §350—§ 355) and the formal (§346, species 2, and § 347, species 1 or 2) treatments. This procedure will be successful only if neither the patient nor the disease is too old. Otherwise, the physician's efforts are usually fruitless.

§ 400. Treatment of the third form: quiet rage (after Auenbrugger) (melancholia furens; the nosologists' mania melancholica) (according to § 238).

This form of disease occurs often, but its cure is much less frequent. Even Auenbrugger, who devoted much time to its treatment, frequently had to admit failure; it must, however, be remarked that his procedure is wanting in several respects and is generally one-sided. The objectionable feature of his method is his neglect of both restraining and individual treatment, whereas both these kinds of treatment are necessary, though not both at the same time. The main feature of Auenbrugger's method, the auxiliary somatic treatment, is admittedly not to be neglected; but the immediate task is to restrain the patient in all ways that the conditions allow, followed by the application of the various medicaments described in § 342, species 1-5. It is only when the physician has totally mastered the patient, which certainly requires more than one somatic treatment, that he can administer the specific somatic treatment directed at the patient's diseased condition of the body, approximately as we have described it under the heading of pure rage. In addition, such a procedure can form only one of the aspects of the treatment, since the other aspect must be the reeducation of the psyche of the patient. If this is not successfully carried out the patient will never be safe from a relapse, as confirmed by similar cases described by Auenbrugger in his paper mentioned above. The treatment aimed at this reeducation is the same as that described for pure rage.

§ 401. Treatment of the fourth form: melancholia with dementia, insanity, and rage (melancholia mixta catholica) (according to § 239).

In treating this form it is more than ever necessary when considering all the individual affections involved not to lose sight of the basis on which they all rest. Here the principle must be: divide, et imperabis. The physician must be particularly careful not to go to extremes. For he may easily drive the patient to extreme depression by treating temporary fits of rage, or, alternatively, he may overexcite the patient whose prevailing mood is melancholic. One extreme inevitably produces another: an excessively depressing treatment causes the melancholia to strike deeper roots, and a ruthless excitation feeds the tendency to rage which is associated with the disease. Nevertheless, both excitation and depression are necessary, though not at the same time. The depressed disposition cannot remain totally without support, neither can the excited rage remain totally unrestrained. Whatever state happens to be dominant at the moment must be appropriately treated, with moderation, until the efforts of the physician are finally assisted by time, or rather by the organic laws which are always in search of equilibrium, as long as life itself is not extinct. Alternating rage and melancholia resemble the waves of a stormy sea flung upwards one moment, cast into the abyss the next. The soul itself is not unlike a heaving wave. Even after the storm has abated, it is still turbid, and it is not surprising that it may relapse into insane images and perverted notions. If only these two evils are to be dealt with, the treatment is simpler, and, in fortunate cases, insanity can be overcome by a calming treatment, while dementia may yield to what we have designated as releasing medicaments ( §346, species 1, and § 347, species 1, suitably chosen). Even though this form of disease is of frequent occurrence, its cure is rare owing to its very nature (§ 239, species 2). But very often this complication (which outwardly resembles pure chaos and tempts a superficial observer to conclude that morbid conditions of the psyche have no form and no order at all) is brought about by the harmful effect of the conditions, of the persons surrounding the patient, or even of the physician and his assistants themselves; the author has witnessed this more than once.

§ 402. Treatment of subspecies and varieties of this genus (according to § 240).

1. Melancholia metamorphosis, with its modifications. These forms are very seldom heard of nowadays but were frequent in antiquity. If they were to occur in our own days, they would be treated in the manner of the ancients, by bloodletting and helleborism, and by moral reeducation. They may attack zoomagnetic conditions; if so, they would also have to be zoomagnetically treated.

2. Daemonomania. This condition is related to the one just discussed, and its treatment is the same.

3. Melancholia errabunda or silvestris, which was described in detail by Greek physicians, would require the treatment described by these; it would generally be treated as under No. 1.

4. Melancholia misanthropica or antipathica is merely a modification of Auenbrugger's so-called quiet rage, and is treated in the same manner.

5. Melancholia taedium vitae or anglica would be cured mainly by hunger and by compulsion to work, since its source, according to the most faithful observers, is luxurious living and idleness.

Second Segment

Treatment of Forms of the Second Genus:

Mixed Disturbances of the Spirit (morbi mentis mixti) (cf. §241—§244)

403. The prospects of a successful treatment become progressively dimmer the more complicated is the mental disturbance which has taken root in the spirit. All the forms listed elsewhere in this book under this section are of a nature which permits almost nothing except palliative treatment; and such a treatment can produce nothing more than the return of the patient to some mechanical routine. All these forms, listed in the science of forms, are almost without exception residua or capita mortua of previously suffered mental disturbances, and are thus incurable and yield to no treatment. [Lunatic asylums, that is, institutions intended for custody, are full of patients of this kind, and also (as we note in passing) of patients of the kind to be described in the following last section.] Only when silliness ( § 241), confusion in the narrow sense (§242), confusion with frenzy (§ 243), and general confusion (§ 244) are not secondary morbid conditions and not definite forms of disease (for they can represent only secondary forms of disease) but are mere beginnings of definite forms of disease, can they be treated in accordance with the condition of the patient and the nature of the disease which they forecast. The following summary has been compiled from this point of view.

§ 404. Treatment of the forms of this section as mere precursors and symptoms of definite forms of disease.

1. Stupidity. This is the precursor and symptom of foolishness. It is a sign of a depressed but at the same time irritable nervous system, of general slackness induced by an effeminate way of life, miseducation, and general lack of cultivation of the intellect or will. If any help is still possible, and an outbreak of foolishness can still be prevented, severe and harsh somatic and psychic discipline, as well as reeducation, can be the only treatment.

2. Confusion in the narrow sense. This is a precursor of most morbid conditions of the psyche about to assume a definite form: of melancholia as well as rage, of dementia as well as insanity. This is why the physician is so often misled into looking for the nature of these forms in a disease of the intellect, since it is the intellect which falls victim to preliminary confusion in almost all such cases. It would perhaps sometimes be possible to prevent the outbreak of the true form of disease if this precursor, this symptom of inner ferment, were immediately kept under constant observation and treated by stimulation or by depression, in accordance with the circumstances. However, this requires a highly trained eye, and a measure of luck in seizing the right moment.

3. Confusion with frenzy. Hot-tempered men are prone to this disease, especially when under the influence of drugs; if the disease has lasted for a long time, or if the outside stimulus is particularly strong, it very readily becomes true mania, whose precursor this condition may be said to be. The disease may be nipped in the bud by rapid removal of the patient to a quiet, dark place, by administration of calming medicaments of all kinds, and by restraining the patient to a reasonable extent.

4. General confusion. This not infrequently occurs following a violent fright or a sudden shock and is the precursor of melancholia. Its consequences can be counteracted by removing or at least moderating the depressed emotional states through stimulating, revivifying, and deflecting medicaments.

Third Segment

Treatment of Forms of the Third Genus

Mixed Disturbances of Will (morbi voluntatis mixti) (cf. §245—§248)

§405. This is again a passing parade of various morbid conditions against which little can be done; some of them have been alluded to under mixed disturbances of the disposition ( § 402), but their proper place in the table of the science of forms is doubtful. Insofar as these forms are accompanied by timidity, or if timidity is their main feature, they must be treated under the present heading. But, wherever their place, this treatment is always problematic, for they are invariably deeply rooted in the total life of the individual and originate from a degeneration which has lasted for many years. It is only if these forms are just beginning to manifest themselves as an indistinct outline and before they have fully ripened or become overripe that a very cautious, penetrating, careful treatment may offer some hope, but somatic treatment must be administered along with the treatment of the psyche, since neither must be given without the other. For it is necessary to equilibrate the defects of the system of digestive organs, of the system of blood vessels, and of the nervous system, in particular of the ganglionic system which supervises the vegetative life; the physician must at one time stimulate and excite, and at another depress and deflect. Then again he has to enliven and encourage the patient whenever timidity is dominant. Briefly, the gradual treatment goes with the auxiliary, and the individual with the formal, either together, or in succession; all depending on the nature of the prominent morbid phenomena. But these phenomena indicate more or less simple principles of these complex conditions. We hope that we have given a detailed description of these simple principles as well as of their appropriate treatment, so that the task of the physician, even in these complicated phenomena, invariably involves a simple solution.

I. POLITICAL SCIENCE

FOREWORD

All the conditions, whose concepts were introduced in Basic Concepts under the name of mental disturbances, whose treatment was critically followed through the history of mankind, whose elements, forms, and nature were discussed in the theoretical part, and were the subject of a rational psychomedical treatment under Technique, can also be considered from another point of view, namely that of political science insofar as they concern the judiciary and police (§ 84). In this case the physician of the psyche must render services which are not medical but legal. His duties are not restricted to mental disturbances proper but to all states of mind which, like mental disturbances, are unfree, without manifesting themselves as true forms of diseases of the psyche, and are therefore not directly subject to medical treatment of the psyche (§392). Since the legal aspect introduces a large number of new subjects into the scope of activity of the physician of the psyche, and the nature of these activities is altogether different from his medical activity, and since, finally, he must communicate with the authorities in a manner altogether different from the theoretical and technical procedure, so, too, will this part of our book take an altogether different course from that followed in its previous parts, and will therefore represent one whole in itself, both in the form and in the contents, even though it is still an integrated part in the organism of the psyche. Accordingly, for the sake of the efficiency of the physician as a citizen and as a servant of the law, we have now adopted a point of view which is different from the previously chosen freedom of ideas, namely,, that of civics and of the law, and shall follow this path to attain our ends. All this must be stated at the outset, in order to avoid the accusation of a different treatment of our subject matter in this part of the book, up to and including quotations of the relevant literature.

INTRODUCTION

§ 406. Everyday experience teaches us that man is a creature able to determine his actions in accordance with his ends, which he has himself considered and selected. This is his natural bent. The condition of a man following his bent is known as freedom, while the union of a large number of such individuals in order to maintain each other in this condition is known as the state. All members of such a union are known as citizens. The contributions required of each citizen in order to ensure the survival of the state are his duties, while the privileges granted to him by the state are his rights. The determination of these rights and duties is the task of the law; anyone empowered to pass laws is a legislator, while he who administers the law is the judge.

§ 407. It follows that the purpose of the law is to ensure the freedom of its citizens and at the same time the security of the state, and the judge, insofar as his verdicts are based on the law, is a sovereign person and needs no help from outside. However, he frequently does need help with reference to the objects of his decisions; and if these are within the scope of activities of the physician, then the physician, in his capacity of assistant to the judge, becomes an official, and his science, insofar as it furnishes the data required for the administration of the law, is called forensic medicine (M. forensis).

§ 408. The objects of forensic medicine may be living persons, with reference to the determination of age, procreative power, cohabitation, pregnancy and birth, doubtful diseases, past injuries, and use of corporal constraint or corporal punishment. They may also be corpses, whose cause of death is to be determined, or simply materials whose effect on the objects of medical examination is to be found.

§ 409. A very special branch of forensic medicine consists in the examination of and giving opinions on the mental state of certain individuals, partly owing to the importance and difficulty of this task, and partly because of the great variety of species and degrees of mental disturbances, the differentiation and exact determination of which are most important in all branches of legal activities. Since the medicine of the psyche is a special branch of medicine in general, and since it requires special studies, its application to legal fields can justifiably be named Medicina psychica forensis, and this task must be entrusted to specially selected physicians of the psyche, whenever these are available.

§ 410. But the legislator, too, needs medical assistance. Since laws aimed at ensuring the continued existence and welfare of the state must necessarily ensure the physical welfare of its citizens, and since the legislator cannot dispense with the aid of the physician in ensuring the care of public health through the intermediary of various organizations, those duties of the police or of the welfare authorities of the state which are intended to ensure the physical wellbeing of its citizens must be named medical police work, or public health, while the science which teaches how to apply the dietetic and medical principles for the advancement, maintenance, and restoration of public health is known as medical police science.

§ 411. The subjects dealt with by medical police and medical police science are measures against air pollution and the ensurance of healthy living accommodation, safe use and enjoyment of food and drink, clothing, means of livelihood, amusements, healthy propagation of the species, physical education, public care of the sick, precautionary measures against certain dangers and accidents, contagious diseases and cattle diseases; and finally, the care of medical conditions and medical personnel.*

§ 412. The most important duties of medical police work include dealing with dangers and accidents, as well as public care of the sick. Both these considerations are seen to be very relevant to the establishment and administration of lunatic asylums for the custody, care, and healing of mentally disturbed patients who are useless to the community at large or are a public nuisance or a public menace, and must be taken care of by the state in a very special manner. But this again is the exclusive duty of the physician of the psyche; and the proposals and rules for the custody, care and healing of these unhappy individuals form the task of the police part of the medicine of the psyche (Medicina psychica politica).

§ 413. Both Med. psych. forensis and Med. psych. politica are accordingly to be regarded as integral parts of law and political economy, and are justifiably included in the medicine of the psyche as applications of the principles of this science to general relationships between citizens. But it is the task of the legislator and of the judge to instruct the physician about these relationships, and to state the points on which they require information from the physician.

* See Dr. C. B. G. Hebenstreit's Lehrsiitze der medizinischen Policeywissenschaft. Leipzig, 1791; Introduction, p. 16.

§ 414. In the administration of law, there are many civil, criminal, and police cases in which the judge requires the assistance of the physician in order to determine whether the state of the psyche of certain individuals is natural or if it runs counter to nature. The civil judge, who determines the rights and duties of citizens, is often unable to decide without the aid of the physician whether a particular individual is or is not able to enjoy his rights or assume his duties. The criminal judge, who determines the kinds and degrees of crimes and metes out sentences, is often unable to decide, for the same reason, whether, how, and to what extent a given individual is to be punished. The policy judge, who has to judge cases involving the security and the welfare of the state, is often unable, again for the same reason, to decide if a given individual is or is not fit to go on living in perfect freedom among his fellow citizens. For each of these authorities the physician must determine the cases they are uncertain about, and state the points on which a medical opinion will decide the case. The lawyer is assisted in such cases by a special branch of his science known as medical jurisprudence (see G. Kopp's Jahrb., Vol. IV, pp. 120 ff.).

§415. The points on which all legal authorities in common must be informed by the examining physician are: 1) whether, in a given case, the individual in question is in a natural or unnatural condition of the psyche (vulgo: disposition), or whether he was in a natural or unnatural condition of the psyche at a certain time, and if so, whether the disease was natural or artefact (Morbus factitius), that is, if it was the individual's own fault or not; 2) if an unnatural condition of the psyche is simply feigned (Morbus simulatus) out of fear of punishment, unwillingness to fulfill a citizen's duties, to carry out a certain plan, or even only to evoke pity; 3) whether such a disease was in fact present but denied and kept secret by the patient himself or by his relatives (Morbus celatus) out of ignorance, pride, shame, personal advantage, or fear of punishment; all such cases occur in matters concerning inheritance, promises of marriage, divorces, nomination to an office, or dismissal from office; 4) if such a disease has been falsely imputed to the individual (Morbus imputatus) in order to offend his honor, deprive him of advantages, put him at a disadvantage, invalidate a will, or bring about a divorce.

§ 416. Individual judiciary authorities must know the condition of the psyche of certain individuals in the following cases: 1) the civil judge must know if the signature of the individual on a document is legally valid, or whether an action performed by such an individual has in fact the implications laid down by the law; thus, for example, whether the individual is able to bear witness, sign a contract, marry, assume office, make a will, accept an inheritance, and administer his own property, or if this task should be entrusted to a guardian; 2) the criminal judge must know if the individual is to be blamed for acting contrary to the law, and to what extent, and if the legal consequences of such action are to be abolished, restricted, or altogether changed; 3) the police judge must know if the individual is to be allowed to remain free, can be left under private supervision, or is to be sent to a public asylum or hospital.

§ 417. It is thus seen that the respective judges hand over the individual himself, or his files or both, to the examining physician, not so that he can decide in civil cases whether the individual in question is fit to enjoy his rights and to carry out his duties, or in criminal cases whether and how he is to be punished, or in police cases whether he can remain free; for such decisions are always the task of the judge, and it is the judge who answers such questions as soon as he knows if the individual in question is free, that is, sui compos, or was free at a definite time in the past. The only point of contact between the judge and the physician is the question of the free or unfree condition of the individual, that is, whether the individual is the master of his own mind and will, or was master at a certain time, and if not, why not? The task of the physician is restricted to answering these questions, and the judge must not expect the physician to say any more, and the physician must not offer to say anything more. A judge who requires more, surrenders his rights and is untrue to his job, while a physician who passes judgment, exceeds his competence and interferes with the business of the judge. Thus, the physician needs no further legal knowledge but only knowledge in his own field.

§ 418. The judge cannot and must not interfere with the task of the physician any more than the physician with the task of the judge. Forensic medicine is the task of the physician, and the judge cannot make medical decisions unless he himself is a qualified physician; and who would expect a judge to be one? He is therefore not required to study forensic medicine but only medical jurisprudence in order to be able to decide the cases in which he is obliged to consult the physician.

§ 419. Secondly, with reference to individuals with a sick psyche entrusted to the care of the police, and the keeping of such individuals in public institutions for purposes of custody or cure, the physician must necessarily be involved in the task of the police official, not to take it over, but so that his opinions and suggestions will guide the official in the organization and administration of such institutions. This is the task of the police branch of the medicine of the psyche (Medicina psychica politica). It has to lay down the principles for the organization of institutions established in order to cure psychologically sick persons or to take care of those whose disease cannot be cured, including the internal organization of such institutions (house police). It has to give the signs by which curability or incurability can be recognized in order to choose the proper place for any given individual, the methods of preparation and treatment in general, diets, occupations, rewards, punishments, institutions for the preservation of bodily health and for curing specific bodily ills of such individuals; briefly, the medicine of the psyche supplies the legal norms for this branch of the duties of the police.

§420. In ordinary compendia and other writings of both doctors and lawyers on Medicina forensis and politica, their large number notwithstanding, the chapters on the recognition and treatment of morbid states of the psyche are superficial and incomplete, or else this information is scattered throughout the book and is not dealt with in its proper context. Thus, the literature of the legal and police branches of psychological medicine is as yet very deficient. This makes the need for the compilation and arrangement of the available literature even more urgent. It consists of special writings on the subject, of isolated contributions published in scientific periodicals and in other treatises, and of academic papers dealing with special aspects of this subject. The following list is arranged accordingly.

I. Writings concerning the legal part

of the medicine of the psyche

A. Special writings on the subject

I. E. Hebenstreit. Anthropologia forensis. Lipsiae, 1753.

C. G. Schaumann. Ideen zu einer Criminal-Psychologie (Ideas on the Subject of the Criminal Mind). Halle, 1792.

J. E. Hoffbauer. Die Psychologie in ihren Hauptanwendungen auf die Rechtspflege nach den allgemeinen Gesichtspunkten der Gesetzgebung, oder: Die gerichtliche Arzneywissenschaft nach ihrem psychologischen Theile (Main Applications of Psychology in the Administration of Law

from the General Point of View of the Legislation, or: The Psychological Aspect of Forensic Medicine). Halle, 1808.

Elvert. Uber drztliche Untersuchung des Gemuthszustandes (Medical Examination of the State of the Disposition). Tubingen, 1810.

B. Isolated contributions

J. J. Schmidt (in: Versuch fiber die psychologische Behandlungsart der Krankheiten des Organs der Seele. Hamburg, 1797) (In: Experiments on the Psychological Treatment of Diseases of the Soul. Hamburg. 1797): Ueber die Verstellung und ihre Ausmittelung (Recognition of Malingering), pp. 64 ff.; Regeln zum psychologisch-prtifenden Verfahren uberhaupt (Rules of Procedure for General Psychological Examination), p. 135.

Peter Frank's System einer vollstdndigen medizinischen Policey (Peter Frank's System of a Complete Medical Police). Mannheim, 1779-1788 ff.

Mason Cox. Remarks On the Derangement of the Spirit: Drawing Up of Certificates and Verdicts in Cases of Insanity. German translation. Halle, 1811.

Pyl's (und Unden's) Magazin fur die gerichtl. Arzneyk. Stendal 1782-85; Neues Magazin fur die ger. Arzneyk. 1785-88, 2 vols.; Repertorium fur die Offentliche und gerichtl. Arzneywissenschaft (Handbook of Public and Legal Medicine). Berlin, 1789-93, 3 vols.; Aufsdtze und Beobachtungen aus der gerichtl. AW (Essays and Observations on Forensic Medicine). Berlin, 1783-91, eight collections.

W. H. S. Buchholz. Beytrdge zur gerichtl. Arzneyw. und med. Policey (Contributions to Forensic Medicine and Medical Police). 4 vols., Weimar, 1782-92.

C. F. Uden. Magazin fur die gerichtl. Arzneyk. 2 vols., Stendal, 1782-84.

Augustin's Repertorium fur die bffentl. und gerichtl. Arzneyw. (Handbook of Public and Forensic Medicine). Berlin, 1810; Archiv der Staatsarzneyk. (Archives of State Medicine). Berlin, 1803-4.

Kopp's Jahrbuch der Staatsarzneyk. (Yearbook of State Medicine). 1800 ff. Knappe's kritische Annalen der Staatsarzneyk. (Knappe's Critical Annals of State Medicine). Berlin, 1804-5.

Henke. Abhandlungen aus dem Gebiete der gerichtlichen Medizin (Proceedings of Forensic Medicine). Vols. 1 and 2.

Kausch [Memorabilien der Heilkunde, Staatsarzneywiss. u.s.w. (Notes on Medical Science, State of Medicine, etc.) Vol. 2. 18181: Ueber die

Untersuchung des GemUthszustandes zu gerichtlichen und policeylichen Zwecken (Examination of the Mental State for the Judiciary and the Police). pp. 1-53.

Isolated contributions of jurists

Quistorp. Grundsãtze des deutschen peinl. Rechts (Principles of the German Penal Law), §§38 ff.

Meister. Praxis iur. crimin. 8. Gottingen, 1789.

Westphal. Criminalrecht (Criminal Law), Note IX.

Klein. Annalen der Gesetzgebung (Annals of Legislature), Vols. 1-5. Berlin,

1788-90.

Koch. Institut. iur. crim. § 35 and § 37.

Bochmer. Element. iur. crim., p. 25.

Leyser meditat. p. 430 (quousque imbecillitas mentis homicidam excuset.) iurisprud. med. Vol. II, p. 301 and Vol. IV, p. 526.

C. Academic publications

Wallich pr. Friderici. De mania ex philtro. Jen. 1670.

I. G. Neumann. De simulatione morbi. Viteb. 1688.

I. A. Kochlau. pr. H. Bodinus. De iure circa ebrietatem. Hal. 1697. I. B. Friesen. De delictis dormientium. Jen. 1701.

C. G. Pietschmann, pr. BOrttner. An et quatenus Somnia hominibus imputentur. Lips. 1703.

M. Scheffer. De phantasia eiusque effectibus cum applicatione ad fanat cos.

Lips. 1706.

I. C. Westphal. Pathologia Daemoniaca. Gryph. 1707.

G. Detharding. De obsessions. Rost. 1724.

I. C. Hebenstreit. De homicida delirante eiusque criteriis et poena. Lips.

1723.

C. W. Strecker. De testamentis mente captorum invalidis. Erf. 1725. C. F. Luther. De morbis simulatis et dissimulatis. Kil. 1728.

I. Z. Platner. De morbis, eveovapaovrt;5v xat, evepyou pem7.w. Lips. 1732. C. L. Crell. De probationibus sanae mentis. Viteb. 1737.

I. M. Witt. De obsessis falsis ac veris. Erf. 1739.

F. G. Pitschmann, pr. Stolze. In wie fern die Schwachheit der Vernunft ein Verbrcchen entschuldige (How Far Does Feeblemindedness Excuse a Crime? ). Lips. 1743.

G. W. Alberti . De imputatione Somnii. GOttig. 1745. G. H. Kannegisser. De morbis dissimulatis et fictis. Kils. 1759.

I. H. Heckenberg, pr. R. H. Vogel. De insania longa. GOtt. 1763.

Ch. Wildfogel, pr. Stryke. De effatis agonizantium. Francf. 1766. R. A. Vogel. De morbis simulatis. Giitt. 1769.

E. G. Baldinger. De morbis simulatis. GOtt. 1774,

Deutrich, pr. Bose. De morbis mentis delicta excusantibus. Lips. 1774.

C. G. Gruner. De causis melancholiac et maniac dubiis in medicina forensi caute admittendis. Jen. 1783.

C. G. Gruner. De fontibus melancholiac et maniac forensibus. Jen, 1784. A. Vogel. De fatuitate. Jen. 1794.

E. Platner. Quaestiones medicinae forensis. Particulac I-XXX1I. Lips. 1787-1811.

II. Writings on the police aspect of psychological medicine

Reil. (In den Rhapsodien tiber die Anwendung der psychischen Curmethode auf Geisteszerrtitt) (Applications of Psychological Healing Methods to Derangements of the Mind). §§ 23-27.

Reil. (Anhang zu M. Cox. Bemerkungen tiber Geisteszerruttung): Ueber die Organisation der Versorgungsanstalten fur unheilbar Irrende (Supple-ment to M. Cox's Remarks on the Derangement of the Mind: Organiz-ation of Asylums for Incurable Mental Patients). Halle, 1811.

Pinel. Sur l'alienation mentale (Mental Alienation). German translation by Wagner. Vienna, 1801, and Supplements.

Wagnitz. Ueber die Zucht- und Irrenhauser (Prisons and Lunatic Asylums). Vol. III, Halle, 1791-94. Appendix: Expedient Organization of Prisons and Lunatic Asylums.

Giinz. Ueber die Einrichtung des Irrenhauses zu Waldheim (Organization of the Lunatic Asylum at Waldheim), in Pyl's Magazin.

Rolloff's Beytra:ge zur Errichtung eines Irrenhauses (Rolloff's Contribution towards the Establishment of a Lunatic Asylum) in Uden's Magazin, Vol. 2.

Communication Received from the Hospital and Asylum at Sonnenstein near Pirna. Dresden, 1817.

Subdivision Ia

PSYCHIC-LEGAL NOMOTHETICS (medicina psychica forensis)

§ 421. The legal part of the medicine of the psyche has a threefold task, according to the moments which determine the activities of the physician of the psyche in law courts. Since he is required to give his opinion on the mental condition of the individuals concerned, it must be assumed, first: that he is familiar with all the possible unnatural conditions of the psyche; second, that he is skillful enough to identify such conditions; third, that he is able to give the judge an opinion, with all the details necessary for the judge to make a decision. Forensic medicine of the psyche must therefore, first, teach the symptoms of the unfree condition in general, and their kinds and degrees in particular; second, explain completely and clearly the aids and methods for the study of such conditions; third, lay down, definitely and completely, the procedure to be followed when delivering legal opinions on the psyche. It thus consists of three parts: the characterization (semiotis forensis), the art of examination (ars exploratoria), and the method for delivering legal opinion (ars instrumentaria).

Chapter One

CHARACTERIZATION OF THE UNFREE CONDITION

§ 422. Just as the free (normal) psychic state is indicated by a natural, undisturbed activity of reason and willpower in word and deed, or else by definite manifestations of the will, which is well known and is assumed for each individual, so lack of freedom is shown in the opposite manner, because the reason and the will are not free. But the reasons for the unfree condition and its particular features may be very different and varied, or, in other words, there are many different states of loss of freedom, which are recognized by correspondingly different signs.

§423. For the free will can be suppressed partly by the state of the body, partly by the state of the soul, and partly by the state of both. The first instance occurs when the individual is sleeping or dreaming, in the magnetic state of somnambulism, suffering from a sickness primarily affecting the brain, such as inflammation of the brain, under the influence of drugs, or in a similar state. The second state occurs under conditions of confusion and of uncontrolled passion. The last case occurs in all soul disturbances proper, ranging from rage to idiocy. All these states are either transient or permanent, and for this reason they themselves and their signs and consequences must be sharply differentiated. All the states in the first and second category are transient, those in the third are permanent. This difference has a great influence on the verdict of the judge and must therefore always be borne in mind.

§ 424. The fact that free will is not manifested does not necessarily mean, however, that it has been abolished, that is, that the man is in an unfree condition. Stubborn malice and callousness may refrain from all manifestations of will, while deceitful ruse and craftiness may even simulate an unfree state; finally, in a true impotence, for example, when the organs of speech or motion have been paralyzed, free will cannot be manifested even though this condition is not truly unfree. All such cases are apparently unfree states, and the physician must never be deceived into pronouncing such states as truly unfree.

§ 425. There are also states which are not completely unfree, but only to some extent, or partially, because in such states the free will is not fully restricted but only partly and to some extent. Since a normal manifestation of free will, that is, a psychologically normal or free state, includes the sum total and the full strength of the forces of the will, the state of the will cannot be fully free if something is missing in the sum total or if the energy is weakened. Such states accordingly include weakness of the mind or of the soul, which are not really unfree conditions, but are less than completely free, or are free to less than the full extent. Thus, they include weakness of memory, intellect, and power of judgment, as well as naturally restricted intellect and lack of cultivation thereof, and also weakness of disposition and weakness of the will.

§ 426. Weakness of memory is the inability to commit to memory much of what should be so committed, either all at once or one thing after the other, and also forgetfulness and inability to remember. Weakness of memory is often a natural deficiency or else originates from lack of exercise; but forgetfulness and inability to remember are often caused by a disease or are an aftereffect thereof. They may result from old age, or often from absentmindedness, or from being pampered. In the former case this is not the fault of the subject, but in the latter, it is. In general, all these weaknesses are very harmful to the proper conduct of business, since they can result in grave omissions and neglect.

§ 427. Weakness of intellect and of power of judgment are shown by the inability to understand many ideas, especially complex ideas, to assemble them, to survey them, to compare them, to order them, and to detect their mutual relationships. It may originate from natural impotence, which is known as dullness, or from lack of education and lack of exercise of mental powers, as in the case of very rough men, who are brought up and educated like domestic animals, or of those born without eyesight or without the power of hearing, especially the latter who are also unable to speak: the deaf- mutes. Feeblemindedness may also be the result of aftereffect of diseases which attack the nervous system in the first place, such as nervous fevers, apoplectic fits, etc. Feeblemindedness prevents the subject from conducting extensive or complicated business and can produce various disturbances.

§ 428. Weakness of disposition or of will also prevents free manifestation of free will. There are persons who are unable to refuse anything which is demanded of them by others or to resist compulsion. In both cases it is the fault of the disposition, which is too soft, too excitable, or too timid. Others have not enough will to make themsel