PSYCHO-PHYSICAL INVESTIGATIONS WITH THE GALVANOMETER AND PNEUMOGRAPH IN NORMAL AND INSANE INDIVIDUALS
CHAPTER 4: THE GALVANOMETRIC AND PNEUMOGRAPHIC CURVES IN DEMENTIA PRĘCOX.
Before recording the results of our experiments in dementia pręcox it is necessary to say something of the psychology of the disorder. The chief characteristic in the mental condition of these patients is a peculiar disturbance of the emotions. In chronic conditions we have, as Kraepelin has clearly shown, an "emotional atrophy." In acute conditions there is a species of "incoordination" or ataxia" between affectivity and concepts, as well demonstrated by Stransky . The emotional disturbance has also been called "inadequate emotional tone." But these phrases represent rather the superficial impression that these patients make upon the physician. As soon as one examines the phenomena analytically and critically, the difficulty of attaining to a common point of view as regards all the morbid emotional symptoms is found to be extraordinary. We see at once that in most cases of dementia pręcox all of the emotions are not changed or destroyed. We find, indeed, on closer analysis that many normal feelings are present. Cases with complete loss of all emotion are exceptional. Elementary affects, such as fright, anxiousness, pleasure, embarrassment, shame, &c., are usually preserved. There is even at times an increased affectivity, or real nervous sensitiveness, present. Furthermore, in cases where one would expect more or less diminution of affectivity from their previous conduct and life the elementary feelings are still maintained. The disorder is then shown in what Janet calls the fonction du rčel5 or the psychological adaptation to environment. It is hardly to be expected that we should find characteristic disturbances in such patients by our experimental method (psycho-galvanic), since they would lie in quantitative differences between the various feeling tones. Even were qualitative changes there they would be too small for recognition.
One of the chief factors in psychological adaptation to environment is attention, which renders possible all the associations necessary to normal existence. In dementia pręcox, especially the katatonic form, there are marked disorders of attention, which are shown by lack of power of voluntary concentration; or, otherwise expressed, objects do not excite in the diseased brain the affective reaction which alone permits of an adequate selection of intellectual associations. This defective reaction to stimuli in the environment is the chief feature of dementia pręcox. But this disorder is not simple and elementary; on the contrary, it is very complicated. What is its origin? There is in the psychology of dementia pręcox still another characteristic which throws light upon the problem. By means of word associations and subsequent analysis we find in these cases among other abnormal manifestations certain thought complexes associated with strong emotional tone, one or several of which are fundamental complexes for the individual and embody as a rule the emotions or experiences which immediately preceded the development of the mental disorder. In suitable cases it is possible without much trouble to discover that the symptoms (delusions, hallucinations, insane ideas) stand in close relation to these psychological antecedents. They, in fact, as Freud has shown, determine the symptoms. Freud applied his method particularly to hysteria, in which he found conscious or unconscious constellations with strong affective tone which may dominate the individual for years, or even the whole life through, by their might exerted upon associations. Such a morbid complex plays the part of an independent being, or soul within a soul, comparable to the ambitious vassal who by intrigue finally grew mightier than the king. This complex acts in a particular way upon the psyche. Janet  has described it in an excellent manner in his book. The complex robs the ego of light and nourishment, just as a cancer robs the body of its vitality. The sequelę of the complex are briefly as follows: Diminution of the entire psychic energy, weakening of the will, loss of objective interest and of power of concentration and of self-control, and the rise of morbid hysterical symptoms. These results can manifest themselves also in associations, so that in the hysterical we find clear manifestations of emotional constellations among their associations. But this is not the only analogy between dementia pręcox and hysteria. There are numerous others which we cannot here describe in detail. One may, however, call attention to the large number of undoubted katatonic processes which were formerly called "degenerative hysterical psychoses." There are many cases, too, of dementia pręcox which for years are not to be distinguished from hysteria. We call attention to the similarity of the two disorders here in order to show that our hypothesis of the relation between psychological adaptation to environment," and an emotional complex is an established fact in the matter of hysteria. If we find in dementia pręcox similar conditions, we are justified in assuming that here, too, the general disturbances of mind may have a close causal relationship with an underlying complex. The complex is naturally not the only cause of dementia pręcox, as little as it is of hysteria. Disposition is also a chief agency, and it is possible that in the disposition to dementia pręcox affectivity brings about certain irreparable organic disturbances, as for instance metabolic toxins.
The difference between dementia pręcox and hysteria lies in certain irreparable sequelę and the more marked psychic disturbances from the former disorder. Profound general disturbances (delirium, severe emotional crises, &c.), exceptional in hysteria, are usual in dementia pręcox. Hysteria is a caricature of the normal, and therefore shows distinct reactions to the stimuli of the environment. In dementia pręcox, on the other hand, there is always defective reactions to external stimuli. There are characteristic differences in relation to the complex. In hysteria with very little trouble the complex may be revealed by analysis, and with a good prospect of therapeutic advantage in the procedure. But in dementia pręcox there is an incapability of being thus influenced. Even if, as is sometimes possible, the complex may be forced to reproduction, there is as a rule no therapeutic result. In dementia pręcox the complex is more independent and more strongly detached, and the patient more profoundly injured by the complex than is the case in hysteria. For this reason the skilled physician is able to affect by suggestion acute hysterical states which are nothing but irradiations from an excited complex, while fails in dementia pręcox where the inner psychic excitement is so much stronger than the stimuli of the environment. This is also the reason why patients in the early stages of dementia possess neither power of critical correction nor insight, which never fail in hysteria even in the severest forms (Raimann .
Convalescence in hysteria is characterised by gradual weakening of the complex till it vanishes entirely. The same is true in the remissions of dementia pręcox, though here there is always some vestige of irreparable injury, which, even if unimportant, may still be revealed by study of the associations.
It is often astonishing bow even the severest symptoms of dementia pręcox may suddenly vanish. This is readily understood from our assumption that the acute conditions of both hysteria and dementia pręcox are the results of irradiations from the complex, which for the time conceal the normal functions that are still present. For example, some strong emotion may throw a hysterical person into a condition of apathy or delirium, which may disappear the next moment through the action of some psychological stimulus. In like manner stuporous conditions may come and go quite suddenly in dementia pręcox. While such patients are under the spell of' the excited complex, they are for the time completely cut off from the outside world, and neither perceive external stimuli nor react to them. When the excitement of the complex has subsided, the power of reaction to the environment gradually returns, first for elementary and later for more complicated psychological stimulation.
Since, according to our hypothesis, dementia pręcox can be localised in some dominating psychological complex, it is to be expected that all elementary emotional reactions will be fully preserved, so long as the patient is not in complete control of the complex. We may, therefore, expect to find patients with dementia pręcox, who show psychological adaptation in elementary matters (eating, drinking, sleeping, dressing, speaking, mechanical occupation, &c.) the presence of some adequate emotional tone. But in all cases, where such psychological adaptation fails, external stimuli will produce no reaction in the disordered brain, and even elementary emotional phenomena will fail of manifestation, because the entire psychic activity is bound up with the morbid complex. That this is an actual fact is shown in the results of our experiments.
The following is a brief résumé in each case of the features that have interest for us here:―
(1) H., male, aged 43, teacher of languages. Insane first ten years ago. Well educated and intelligent. Entered an asylum for a time in1896. Passed through a light period of katatonia, with refusal of food, bizarre demeanor and auditory hallucinations. Later always persecutory ideas. In August, 1906, he murdered one of his supposed persecutors, and since then has been in this asylum. Very precise and correct in his dress and conduct, industrious, independent, but extremely suspicious. Hallucinations not discoverable. Diagnosis― Dementia paranoides.
(2) Miss S., aged 61, dressmaker. Became insane about 1885. Innumerable bizarre delusions, delusions of grandeur, hallucinations of all the senses, neologisms, motor and language stereotypy. Conduct orderly, neat, industrious, but rather querulous. Is on parole and shows considerable independent activity. Diagnosos―Dementia paranoides.
(3) Dr. S., male, aged 35, chemist. Became insane about 1897. Very intelligent and reads numerous scientific books. Has many wants and makes many complaints. Extremely careful in dress, and is extraordinarily neat. Numerous grandiose ideas and hallucinations. No katatonic symptoms. Diagnosis―Dementia paranoides.
(4) Mrs. H. 0., aged 44, farmer's wife. Became insane in 1904 with an attack of hebephrenic depression. Since the end of 1906 in a second attack of similar character. Speaks only in whispers. Somewhat inhibited, anxious, and hears very unpleasant voices. Works industriously and spontaneously. Neat in dress and in care of her room. Diagnosis―Hebephrenic depression.
(5) Mrs. E. S., aged 43, merchant's wife. Became insane in 1901. 0ccasionally light maniacal excitement, never confusion at first, but rapid dementia. Now greatly demented, inactive, and vexes other patients. Unemotional, indifferent and untidy in dress. Without interest in her husband or surroundings. Chatters a great deal, but quite superficially, and it is impossible in any way to rouse in her any of the deeper emotions. Diagnosis―Hebephrenia.
(6) A. V. D., male, aged 39. Entered the asylum in 1897. From the beginning quiet, unemotional, somewhat timid and anxious. Speech fragmentary and indistinct, and talks most of the time to himself. Makes meaningless gestures with the hands. Has to be cared for by the attendant in all matters. Cannot work. Shows neither homesickness nor desire for freedom. Automatism on command and at times catalepsy. Diagnosis―Chronic katatonic stupor.
(7) Sp., male, aged 62, factory worker. Became insane in 1865. In the early stages several attacks of katatonic excitement. Later chronic stupor with occasional raptus. In one attack of raptus tore out one of his testicles with his hand. At another time suddenly kissed the attendant. During a severe physical illness at one time he suddenly became quite clear and approachable. Speaks only spontaneously and at long intervals. Works only mechanically when he is led to it. Stereotyped gestures. Diagnosis―Chronic katatonic stupor.
(8) F., male, aged 50. Became insane in 1881. At first for along period depressed inhibition. Later mutism, with occasional outbursts of abusive language on account of voices and numerous hallucinations. At present constant hallucination though he is speaking only when addressed, and then in a low, short fragmentary manner. Occasionally outbreaks of abuse because of the voices. Works mechanically, and is stupid and docile. Diagnosis―Chronic katatonia.
(9) J. S., male, aged 21. Became insane in 1902. Stupid, stubborn, negativistic, speaks spontaneously not at all or very seldom, wholly without affectivity and apathetic, sits the whole day in one place, wholly disorderly in dress. Once in a while demands release with some irritation. Diagnosis―Mild katatonic stupor.
(10) J., male, aged 21, student of philosophy and very intelligent. Became insane about 1901, when he had a short attack. The second attack came in December last (1906). At times excited, wholly confused, and strikes about him. Incessant hallucinations. Wholly wrapt up in his inner mental processes. In occasional intervals of some lucidity, the patient states quite spontaneously that he has no feeling at all, that he cannot be either glad or unhappy, that everything to him seems wholly indifferent. Diagnosis―Acute katatonic stupor with raptus.
(11) M., male, aged 26, merchant. Became insane in 1902. At first maniacal excitement. Later dull apathy and occasional exhibition. Then gradually increasing stupor, with complete detachment. Now mutacismus, and tears out his beard, but at other times rigid and cataleptic. Diagnosis―Acute katatonic stupor.
The galvanometer curves were in many of the tests with dementia pręcox extraordinary. As in normal individuals we found, where there was reaction at all, a gradual exhausting of the power of the stimulus in repetitions of the same series, so that the waves became smaller in the second, and still smaller, and more rounded in the third series. In some cases, where the waves were small in the first series, they disappeared altogether in the third. In fig. 8 we have a good example of a very labile galvanometer curve from a case of dementia paranoides, in which we have abrupt and high ascents, at times with large bifurcations. This was the second series of this patient, and the curves are smaller than in the first. They may be compared with the labile nominal curve of fig. 6, which was the first series; and also with fig. 10, another case of paranoid dementia, but in which the galvanometer wave is rather unemotional, while the pneumographic curve shows in this instance such marked changes owing to the disposition to whisper. The type of galvanometer curve shown in fig. 8, is also characteristic of curves we have taken in hysteria.
In the hebephrenic type there is nothing especially noteworthy in the curve, either in point of great lability or smallness of wave. In the katatonic forms of' dementia pręcox, especially in the acute forms, we observed, however, extraordinary variations from the normal in the character of the curve. Not only is the latent time longer, but the waves are almost always of gradual ascent, and very small if present at all. Figs. 9A and 9B, from a case of acute katatonic stupor, present illustrations of curves brought about by sudden call of the name. The galvanometer curve is exceedingly slight, the pneumographic curve shows the singular changes previously mentioned.
FIG. 11. Three galvanometer curves for contrast. The first curve is a normal one, with series of mixed stimuli (Miss B., a Canadian). The second curve is that of Sp. (Case No. 7), one of chronic katatonic stupor. Note presence of elementary emotional stimulus The third curve is that of J. (Case No. 10, acute katatonic stupor). No change whatever in the galvanometer curve to any of the mixed stimuli.
In fig. 11 we have three galvanometer curves shown. The upper one is from a normal person, with the series printed in the text. The middle one is that of a case of chronic katatonic stupor (Sp.), which is characterised by almost no reaction to any stimuli until 14 is reached, when the threat of sticking with a needle (and the actual stick where the line crosses the up wave) produced a great rise in the curve. A slighter rise occurred at 15, the threat of fall of weight. This is an example of reaction to an elementary emotion in a chronic case where some emotional tone is still present. The lowest line in fig. 11 represents the galvanometer curve of an acute case of katatonic stupor (J.), and here it is seen that the line is perfectly straight, that not one of the mixed series of stimuli printed in the text had the slightest effect; whistle, drop of weight with loud noise, sudden loud call by name, actual hard pricks with the needle―nothing brought out a response in the galvanometer. The pneumograph could not be applied in this case. Our experience with the six cases of katatonia is that such curves are characteristic for the type, and bear out our idea of the psychology of the disease as recorded above.
Another feature of importance in these cases is the matter of latent time. It will be remembered that latent time, before the rise of the galvanometer wave, was estimated by us to vary in normal persons between two and five seconds. In fact, the normal average is three seconds for the first series, and 3.77 seconds for subsequent series. In the following tables, one relating to latent space on the kymograph, and the other to latent time, only seven of the eleven cases of dementia pręcox appear, for in the others the waves were so slightly marked or so uncertain that the facts could not be satisfactorily determined. One of these patients (Dr. S.) was tested with both the mixed series and a series of word associations.
Latent Time in Millimetres of Distance from Stimulus to Beginning of Ascent of Galvanometer Emotional Wave in Cases of Insanity.
Latent Time in the Same Cases of Insanity as Above Estimated in Seconds
In the first case, a woman with dementia paranoids, the latent time is quite within normal boundaries. In the second case, also dementia paranoides, Dr. S., the normal was overstepped only in the fourth round of the same mixed series, but with the same patient with a word association, the latent time was excessive (6.45) in the first repetition of the same words. In the third case, (Sp.), a case of chronic katatonia, the first series showed a latent time of 3.55 seconds, but there were no waves whatever in the repetitions. The four succeeding patients, all cases of katatonia, show increase of latent time; and the two acute cases of katatonia presented an astonishing interval of space and time between the stimulus and the galvanometer wave.
The following table will better show the differences in latent time between the normal and cases of dementia pręcox, especially in the averages given at the end of the table.
Comparative Table Showing Latent Time in Galvanometer Curve of Normal Cases and of Dementia Pręcox
The average of distribution is obtained by subtracting the ordinary average from the larger numbers in the series, or the smaller numbers from the average. The sum of these differences is divided by the number of items, which gives what is called the average of distribution or the average of differences―a useful method of showing wide fluctuations in pathological conditions.
5. "Acting up to realties."