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thrown into such a state of depression that for hours she remained in her bed refusing food. Then suddenly she jumped off the bed, picked up a poker and attacked her mother, taking her for the wrong offender. While striking her she talked quite incoherently so that she could not be understood. About 20 minutes later the condition disappeared. During a period of four weeks she had frequent outbursts of fury with a desire of attacking far more violent than formerly, although she was always subjected to abnormal impulses.
The following deductions may be drawn from the observations concerning the 15 cases composing the first group: Following some emotional factor the defective mode of thinking, feeling and acting becomes intensified. The usual want of parallelism between the emotional and intellectual elements of the personality becomes accentuated; the inhibiting power of intelligence over the moral personality is reduced to a minimum; impulsive acts may reach their maximum in intensity and frequency; there may be either an increased emotivity with exaltation, during which extreme anger, violence and brutality are conspicuous, or else emotivity with greater depression, during which timidity and shyness are extreme and a tendency to solitude is striking. In all cases, morbid tendencies become more conspicuous. It seems that the cerebral centers, which are the source of ideas and of their association, are further reduced and withdrawn from the chain of mental activities; they now present not merely a deficiency, but utter collapse. The activities which otherwise in defective individuals are the result of a feeble struggle between feeble conscious reasoning and claims of passion are now entirely out of the field of this struggle.
Group II.-Twenty-two individuals constitute this group of defectives. Either following some special etiological factor or without an apparent cause, symptoms characteristic of classical psychoses developed. In the majority (17) the onset of the psychotic manifestations was preceded by some somatic or emotional disorder. Influenza, profuse diarrhoea, measles, mumps, bronchitis, on one hand, sudden fright and slight accidents, on the other, were all present.
The psychoses observed were: Maniacal and depressive states (12), paranoiac states (3) and delirious or confusional states (7). There were more depressive than maniacal cases (9 to 3). This category included all adult cases. In the depressive subgroup the depression was not as profound as is observed in individuals with a former normal mentality. The sad appearance, pale faces with drawn features, expression of humility and deep suffering, complete immobility—this was the habitual picture characteristic of cases with mental depression. At no time were all these symptoms combined in the defectives. Those that were present showed a shallowness, a superficiality. On the other hand, none of the patients presented during the entire period a depression or a state of anxiety, such as are found in painful emotional states; there was no lamentation, no moaning, no exclamation—all of which are observed in cases of agitated depression. Indifference, apathy and indolence were all present, but at no time were there delusions. The latter were absent even in the most pronounced cases of depression, when the patients isolated themselves for days and even refused food. There was no case of true melancholia with unsystematized delusions of self-blame or of unpardonable sin. There was no tendency to suicide in any of the cases. The absence of delusions is to be expected in depressed defectives, if we take into consideration the elements and the underlying psychology of ideas and special interpretation of conceptions which require mental elaboration of complete character.
The maniacal cases presented special features worth mentioning. In one of them was an early violent outburst. A man of 27, who up to that age presented the usual characteristics of mental deficiency, developed suddenly, after a slight accident, a most pronounced maniacal state which lasted six weeks. Restlessness, talkativeness, increased rapidity of thought and verbal expressions, and increased motor activity, were all present, but they all bore the stamp of the previous mental state. Owing to the limited association of ideas there was no characteristic coloring, but there was one feature in my patients which deserves special mention; it was so constant that it may perhaps be considered of some diagnostic significance.
In individuals previously normal during a maniacal period, opposing ideas may be easily brought out because of the easy association of ideas, or else because of the restraint in which such individuals are held. In these cases any opposition to the patients' wishes brings forward an intense feeling of self-esteem, followed by a strenuous protest against the opposition. Moreover, owing to the fact that the thoughts flow in great rapidity, the states of opposition and protest are not lasting and they are quickly substituted by other emotions, pleasurable ones among them. In the defectives, on the contrary, opposing ideas were not readily called up and when they made their appearance they were feeble. On the other hand, if an opposing idea happened to be conspicuous it persisted with great tenacity for some time. It was also observed that the above-mentioned feeling of exaggerated self-esteem as a consequence of enforced opposition was not at all as intense as we find it in non-defectives. Neither did I find the rapidity of transformation of psychic energy into multiplicity of associated ideas such as we observe in non-defectives. Again, owing to the underlying limitation of intelligence in general there was absent the quickness of comprehension, of wit or humor or sarcasm, which is so characteristic of maniacal exaltation. Accordingly, I failed to find here the manner of expressing in especially choice language, or hasty acts ill considered, or especially strong impulses, or special desire or longing for pleasurable emotions, which are all so typical of maniacal individuals. Briefly speaking, the psychomotor side of exalted mental activity was expressed here in a lesser degree than in cases of mania occurring in individuals with a previous moral mentality.
Another interesting symptom is found in the hallucinations. Contrary to the usual absence of hallucinations or to their fleeting character when they are present in maniacal attacks, here in the defectives hallucinations occurred more frequently and were more persistent. Moreover, in two cases the patients acted upon. A girl of 12 in one of the maniacal attacks of an unusual intensity saw “ugly faces ” and was so frightened that she picked up a cup of very hot milk standing on the table and threw it at her sister standing in front of her. The other patient, a girl of 16, saw “ the devil ” and was in such a state of fright that she ran out of the house and while running kept on looking back and screamed as she saw the devil pursuing her. Illusions were constantly present in all the cases.
The depressive and maniacal outbreaks in various individuals did not run a parallel course as to their frequency and the mode of repetition. It was observed, generally speaking, that there were more individual phases of depression than exaltation. Two of the maniacal patients had but one attack of exaltation during a period of several years and only one patient had three attacks during two years. The depressive attacks, on the contrary, were frequent and in some cases very frequent. No patient of the series, however, had alternating attacks of one and of the other form of the manic-depressive psychoses. In the depressive cases there were only periods of depression; in the maniacal ones I observed solely periods of exaltation.
Paranoid states were present in three cases. Here disturbances are no more expected in the emotional and psychomotor spheres, but in the ideational realm. As the latter is originally of an inferior character in defectives any pathological modification of it incidentally occurring must per force be of an unusual composition. The disturbance of critical power, which plays so great a rôle in the formation of the systematized delusions, shows itself naturally in slight reflection and in superficial elaboration of ideas and deductions. For the same reason, the formation of delusions is not so easy or imperative, while in the normal type of paranoia the latter are formed with the greatest facility and readiness. The elements of the delusions which ordinarily develop out of imagination and defective judgment, assisted by errors of logic, are all here fundamentally defective and lead not only to abnormal creations, but are also defective in their abnormality; and accordingly the depression and apprehension which are constantly found in paranoiacs are not and cannot be as profound and as disturbing to the patient as in the habitual cases of paranoia. The characteristic abandonment of the patient without control to the delusional conceptions is not so striking here as in typical paranoia, because the ideational associations are here fundamentally defective. The reactions produced by external impressions are not as profound as in ordinary paranoiacs, as their relation to the originally defective individuals are not only perverted, but are defective in their perversion. The same peculiarity was also observed with regard to hallucinations. When the latter were present they were feebly used by the patients for the elaboration of their delusions, contrary to what we observe in the majority of cases of typical paranoia in which the hallucinatory sphere is greatly implicated and is used for the development of delusions.
The character of delusions and hallucinations in paranoia makes the patient live in a world of errors and deception which are so characteristic of the disease; but by reason of defective ideational associations in mental defectives the errors and selfdeception to which their delusions and hallucinations lead cannot be striking and conspicuous. Herein lies the substantial difference of the morbid states of non-defective and defective paranoiacs. When one considers the evolutional period of life in a future paranoiac, one assists at a gradual change of the per
ity which later becomes a disease. One observes how all perceptions of the external world in early life have a special relation to the individual, inasmuch as he very early commences to consider them as facts which fundamentally concern his own personality. This is intensified by his inherently vivid imagination. As is well known, the paranoiacs belong to the dreamy, romantic and eccentric category of individuals, who with great facility elaborate ideas which at first remain in a latent state, but later develop into delusions. Such characteristic features underlie the real foundation of a future paranoiac. They show a constitutional abnormality of the character. On such a morbid basis, with the gradual growth of the individual, multiple impressions arising with age and accidental occurrences are all apt to create erroneous conceptions of the external world. At first there are only presumptions and suppositions, but later delusions and hallucinations.
When we consider the development of the personality and character in defectives, the observation changes. We fail to find here the special personality with eccentric tendencies; there is no intensity of imagination with regard to external impressions ; there is no special tendency to refer the latter to himself or to herself; there is no rapid formation of imperative ideas ; suspicions to create rapidly erroneous conceptions; hence, delusional ideas are not easily developed and when they do arise they lack in depth and in elaboration. Continuing the analysis of the comparative picture in both classes of paranoiacs we find a further difference. The phase of transformation of personality which is