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usually present in the advanced stage of the fully developed disease is totally absent in the defective cases of paranoia if one has the opportunity to observe the individual during a sufficiently long period of time. The absence of this phase finds its explanation in its very nature. As is well known, it is characterized by excessive development of exalted ideas concerning the patient's own personality. As for the development of this manifestation, which becomes in fact predominant over other ideas, an extraordinary elaboration of ideational processes is essential. As indicated above, the latter cannot be expected in defectives, hence the phase of transformation of personality must correspondingly be totally wanting.
In pursuing further the development of the subject, the final stage of paranoia must be considered. The terminal period of the disease is characterized by a gradual development of mental weakness with gradual fading of the delusions and hallucinations. In the three defective individuals of my series such a phase was not observed. When the hallucinations and delusions began to disappear there was no gradual diminution in the intensity of the faulty beliefs or any change in the interpretation of the ideas or images, but a sudden disappearance of both for a brief period of time and later a reappearance of the same, then again a disappearance and a return. This occurred several times in succession, and then finally a total abolition of both took place. Moreover, there was no genuine diminution of power of reasoning; otherwise speaking, there was no real dementia such as we observe in paranoia. It was therefore no terminal stage, so to speak. The patients merely exhibited the same mental attitude as prior to the outbreaks of the paranoiac state.
If we recall all the characteristic features of the various phases of paranoia, and consider the incompleteness of the most important manifestations with the lack of depth in each of them by virtue of the fundamental defect of ideational processes in defective individuals, we are bound to admit that there is no paranoia in the latter. The disease as an entity cannot develop in them for the above reasons. Delusions and hallucinations of a paranoiac character may occur in defectives, but their development and their relation to the defective personality, the entire attitude of the individual to the external world, the course of the condition and the termination of the latter, are all not of the kind which we observe in the classical psychosis. Not paranoia as a clinical entity, but paranoid states are met with in individuals with mental deficiency.
The last sub-group of my series comprises seven cases with delirious or confusional states. Three individuals were convalescing from influenza, one from typhoid fever, and in three of them a fright had preceded the onset of the mental disorder. Five patients had delirium with confusion, two only confusion.
In confusional states the mental operations are disintegrated. The ego no longer presents a union of individual elements of the mental mechanism. The ideas are consequently vague and ideational association is abnormal, so that a confusional individual uses words without special meaning to him; of his former ideas and conceptions only glimpses are left. He expresses his fragmentary ideas and notions in a demented manner and therefore without all associations, so that purposeful acts are not possible.
When we attempt to find these diagnostic elements in mental defectives we observe that not only they are present, but they are in the most intense and conspicuous form. Irrespective of any superimposed psychosis the mentality of these individuals is characterized essentially by a quantitative and qualitative deviation from normal. Appreciation and meditation are not only superficial, but abnormal. There is a fundamental defect in association of ideas, so that the acts are of a reflex nature. The whole life of defectives, generally speaking, is composed of incidents of an instinctive nature, as judgment and will power are wanting. When a confusional element is added it stands to reason that defective ideas will be still more vague and ideational associations more abnormal. A confused defective's words will have still less meaning to him than in a formerly normal individual. If in ordinary cases remnants of former ideas and conceptions are left, in a defective who is under the influence of a confusional outbreak the sentences uttered and actions executed show an absolute lack of such remnants and give the impression as if the individual were devoid of all thinking power. If in an ordinary case of confusion, the individual acts in a demented manner; a defective individual in such cases behaves like an imbecile or idiot.
In some of my cases to the confusion was added a delirious element. As is well known, in the latter there is a deep involvement of the sensorium, especially in the form of hallucinations and the suppression of the faculties of attention and reflection. The disturbed sensorium creates delusions. In the five defective individuals of the series there was confusion with a delirious state. The attitude of these individuals, such as appearance, motions with the hands, sudden and repeated turning of the head, suggested the existence of auditory and visual hallucinations. As to the delirium itself it was throughout in all the cases of a muttering character and at no time in the form of anxious excitement. Since the faculty of reflection based on association of ideas is rudimentary in defectives, and an involvement of the sensorium cannot be deep in these individuals, the elaboration of delusions and hallucinations cannot, fundamentally, be strong and conspicuous. Thus the muttering and not the excitement with anxiety of the delirium in ordinary cases was to be expected. The muttering was unintelligible, fragments of words could be heard occasionally; the patient preserved a uniformly quiet and undisturbed attitude throughout the delirious states, which in some cases occurred several times.
One of the most interesting phenomena in the last group of cases was that the mental state of each individual suffered considerably following each attack of confusion or delirium. The individuals' intellectual niveau became greatly lowered and all the faculties and functions depending on it were correspondingly affected. The inhibiting power was reduced to a minimum, and for this reason the defectives who possessed an emotivity with exaltation exhibited unusual impulsiveness, extreme anger, violence and conspicuous brutality; while those who possessed an emotivity with depression exhibited extreme timidity. Those who prior to the psychoses showed various perversions, now exhibited a deeper development of the latter.
Conclusions.—The present study reveals the fact that the intellectual and emotional peculiarities and abnormalities of defective individuals become more conspicuous when additional psychotic disturbances are superimposed. Each individual characteristic in the various faculties, which being combined constitute the mental personality, becomes mobile and is given a greater oppor
tunity for displaying its influence upon the defective's attitude, behavior and general mode of acting and feeling. To the observer is given an opportunity to measure and estimate the degree and intensity of deficiency in the various characteristic features of the defective individual, because of its modifying effect on the habitual manifestations of a psychosis. The impress that mental deficiency leaves on psychoses, viz., depressive, maniacal, paranoid, delirious and confusional, is that they are modified in their typical manifestations because of the fundamental defect in the formation and association of ideas. On the other hand, the psychoses have reciprocally their modifying effect upon the basal mental deficiency; they produce such a profound disturbance in the latter that the recovery from the superadded incidental psychoses is always followed by a deeper diminution of mental power in the original mental status. The reason of it probably lies in the fact that the psychoses disappear invariably more slowly than in non-defective individuals. For the same reason probably it is more difficult to obtain favorable results from therapeutic efforts. The prognosis is therefore more serious in psychoses of defectives than of non-defectives. When the psychoses disappear instead of recovery we witness a greater reduction in the intellectual horizon than before the psychoses had developed.