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CHAPTER II

MAIN CLINICAL FORMS OF NEUROSES AND PSYCHOPATHIES

            A brief outline of the classification of nervous and mental diseases, made by me in my various works, is of importance to a clear understanding of the etiology and differential diagnosis of the neurotic affections under discussion.

            The different forms of nervous and mental diseases may be classified into organic and functional.

           By organic affections we mean to indicate all pathological modifications of the neuron and its processes taking place in the very structure, probably in the cytoreticulum, of the nerve cell. Under this category come such maladies as general paralysis, dementia praecox, and mental and nervous affections of an involutionary and degenerative nature. Such diseases are termed by me Organopathies or Necropathies.

            By functional affections we mean to indicate all neuron changes in which the neuron functions and their reactions to external and internal stimulations are involved in the pathological process without, however, affecting the anatomical structure of the nerve cell. The pathological changes are not permanent, recovery of normal function is possible.

            Functional nervous and mental diseases may in their turn be subdivided into Neuropathies and Psychopathies.

            Functional neuropathic diseases are disturbances of functioning activity of the neuron, due to defective metabolism in cellular nutrition, brought about by external, and especially by internal stimuli-secretions, hormones, and other agencies. The pathological process in functional nervous and mental diseases produces few, if any, anatomical, structural changes in the neuron. The pathology of functional neuropathic diseases (probably of the cytoplasm) is essentially chemico-physiological in character.

            Neuropathic diseases include maladies in which the neuron undergoes degenerative changes which at first may bring about an apparent increase, then an inhibition, and finally a complete suspension of neuron function, not terminating in the destruction of the neuron.

            This follows the general physiological law that all causes which tend to destroy the vital functions of cell activity begin at first to work as stimulants and afterwards become depressants, finally ending in the total destruction of the cell or of the neuron in the case of the nervous system. Thus in many cases small doses of opium or of morphine, chloral or other toxic and autotoxic products bring about an excitement. In such cases we should increase the dose or repeat it, if we wish to obtain depressant effects. In ether and chloroform anesthesia before the deep state of anesthesia sets in there is a stage of excitement. This law holds true in the case of the process of degeneration of the nervous system in the various forms of nervous and mental diseases as in the process of the downward course of cellular disintegration.

            In neuropathic disturbances neuron restitution is possible. Neuropathic affections are produced by poisons, organic or inorganic, by autotoxic products, by hyposecretion or hypersecretion, or total absence of glandular secretion or hormones in the economy of the organism. Here belong all the temporary, or recurrent maniacal, melancholic, and delusional states, puerperal mania, epileptic insanity, the mental aberrations of adolescent and climacteric periods, periodic insanity, alternating insanities, and in general all the mental affections at present known under the description of manic-depressive insanity.

            Where the disease depends not so much on the neuron itself, but on the interrelation of neurons in a complex system, on association of systems of neurons, the condition is psychopathic in nature. In psychopathic troubles the neuron itself may remain unaffected, may be perfectly normal and healthy. The disorder is due to associations with systems of neurons which are usually not called into action by the function of that particular neuron or neuron system.

            Briefly stated:

            Organopathies or Necropathies include a group of psychophysiological symptoms accompanied by structural, necrotic changes of the neuron, terminating in the ultimate death of the neuron systems involved in the pathological process.

            Neuropathies include a group of psychophysiological manifestations due to pathological functional neuron modifications, capable of restitution through a more perfect, more normal metabolism.

            Psychopathies are pathological phenomena of psycho-physiological dissociation and disaggregation of neuron systems and the resultant disturbances of aggregate functions, the neuron itself, remaining undamaged and untouched.

            The Psychopathies may be classified into: Somatopsychoses or Somopsychoses and Psychoneuroses.

            This classification may be represented by the following diagram (Fig. 1):

            The psychopathies may present chiefly somatic symptoms, such as paralysis, contractures, convulsions, or anesthesia, hypoesthesia, hyperaesthesia of the various organs, glands, and tissues. Such mental diseases may be termed somatic psychoses, somatopsychoses. The somatic psychoses or neuroses would comprise the various manifestations of what is at present described as hysteria and neurasthenia as well as the milder forms of hypochondriasis. In all such diseases the psychical symptoms form the prominent elements of the mental malady. The patient remains unaware of the underlying mental grounds. So much is this the case that the patient is offended, if his trouble is regarded as purely mental in character. The mental side of the diseases is then said to be submerged subconsciously.

            In the psychoneuroses or neuropsychoses the physical symptoms are, on the contrary, few or none at all, while the predominating symptoms are entirely of a mental character. The patient ignores his physical condition, even if any exists, and his whole mind is occupied with mental troubles. Such conditions are to be found in all obsessions, fixed ideas, imperative impulses, and other allied morbid mental states. Thus one patient is in agony over the unrighteousness of his conduct, another is obsessed by a terror of some mysterious agency, or by religious and moral scruples.

            The two clinical forms of psychopathies are in strong contrast. In the somatic psychopathies or somatopsychoses, the patient brings before the physician physical symptoms—stomach derangements, intestinal pains, contractures of limbs, menstrual disturbances, affections of the sexual organs and their functions, paresis, paralysis, anesthesia, headaches, and similar bodily troubles. It is for the physician to discover the underlying mental states. In the mental forms, the psychoneuroses, the patient omits reference to his physical condition. He usually states that he has always been physically well, and some patients assert that they are sure that they will always be physically well, that the whole trouble is purely mental. “I have no physical trouble,” he tells the physician, “all my troubles are mental. If you could cure me of my mental suffering, I should be perfectly happy.”

            The psychosomatic patient lays stress on his physical symptoms and is offended when they are declared to be mental; the psychoneurotic, on the contrary, insists on his mental symptoms, and becomes impatient when the physician pays attention to physical symptoms or to bodily functions. The psychosomatic patient believes he is afflicted with some awful, incurable, physical malady, such as cardiac trouble, tuberculosis, or some other fatal bodily, disease. The psychoneurotic, on the contrary, ignores all physical troubles, but he thinks he is on the verge of insanity. The psychosomatic seeks to be assured that he is not an incurable invalid. The psychoneurotic wants to be certain that he is not crazy. The psychosomatic wishes to know whether or no he is really and truly free from some malignant disease, some horrible infection, or some fatal physical malady. The psychoneurotic is anxious to be convinced that he is not insane, and that he is not to end the rest of the days of his life in some retreat or asylum for the insane. The clinical difference between the somatopsychoses and neuropsychoses is a fundamental one, and is of the utmost consequence in prognosis and treatment.

            The somatopsychoses simulate physical and organic nervous troubles. Thus, many “hysterical” forms simulate tabes, or paralysis agitans, hemiplegia, paraplegia, or epilepsy, while many of the neurasthenic, hypochondriacal, and their allied states simulate tumor or cancer of the stomach, intestinal obstructions and glandular derangements; cardiac, laryngeal, pneumonic, hepatic, splanchnic, ovarian, tubal, uterine, renal, and hundreds of other bodily afflictions.

            The neuropsychoses or psychoneuroses simulate all forms of mental disease, beginning with melancholia and mania and ending with general paresis and dementia.

            Psychopathic affections can be differentiated from the various forms of insanity by the following important symptom: Readiness of the patient to get an insight into his trouble. The psychosomatic and the psychoneurotic are characterized by the fact that they are anxious to learn the nature and causation of their trouble. They are eager to learn the psychogenesis of their affection, and will do everything in their power to help the physician in his examination and study of their case. Even in the cases where the idea is fixed, the obsession intense, and the impulse uncontrollable, they are anxious to listen to views different from their own, and, in fact, are always on the lookout for some help to get rid of the insistent mental states.

            No matter how fixed the mental state may be, it will temporarily give way to suggestion and persuasion. No matter how deep and intense the emotional state of the psychoneurotic and psychosomatic, it can be distracted and dissipated by the personal touch of some firm and trusted friend, or by the influence of the confidential physician who has an insight into the nature of the malady. Neither the emotions nor the ideas are immovably fixed,—they are always ready to give way to other associations. Moreover, the psychoneurotic is always ready to receive such different associations and welcomes them with all his might and main. There is a great amount of optimism in the psychosomatic and psychoneurotic. This is clearly revealed in the various religious and mental cults which often delight the heart of the psychopathic patient. There is a large amount of cheerful hope in the very make-up of functional psychosis.

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