CHAPTER XIII

MOTOR, VISCERAL, AND CIRCULATORY DISTURBANCES

        IN this form of psychomotor disturbances a longer time is required to execute voluntary movements. This is shown by the fact that the reaction time is greater for the affected than the unaffected extremity, the difference may amount to one-fifth of a second. In the simple reaction time of the affected extremity it may rise to two seconds and sometimes, though rarely, to twenty seconds. Usually the affected extremity is hypoaesthetic or anaesthetic and the reaction time is more or less in proportion to the anaesthesia, or to the depth of the process of disaggregation. When voluntary movements are executed, they are carried out hesitatingly. This may be characterized as a kind of psychopathic ataxia.

        The kinaesthetic memory of processes is present, while the kinaesthetic sensations are lost; that is, the central process of kinaesthesia is preserved, while the peripheral is lost. Hence we often find the following phenomenon, the patient with his eyes closed is told to raise his hand, he tries to do so. If now the hand is seized and held down, the patient still exerting force and endeavoring to raise it, finally believes that the hand is fully raised.

        The voluntary movements become simplified or rather weakened in their range. Only simple movements can be executed, while the more complex are affected, the latter are carried out with effort, in a slow, uncertain way; simultaneous movements interfere with each other. If, for example, the patient is asked to close his hand, and at the same time to perform another movement, such for instance as raising the eyebrows, the one movement stops the other, they cannot be performed simultaneously.

        The voluntary movements become weakened in intensity. The movements and muscular power are less than one would expect from the general health and appearance of the patient. This condition is sometimes characterized as amyosthenia. Thus, for instance, it is sometimes surprising to find in one or both of the upper extremities affected, that the dynamometric force is unduly diminished. In some cases it may fall to nine or even five units. In such cases the muscular weakness is both for active and passive movement; the patient is deficient not only in pressing or squeezing or in the performance of similar acts, but he likewise lacks the power of active resistance.

        Amyosthenia, is as a rule, greater when the attention of the patient is diverted. Sometimes when the patient is asked to press the dynamometer with eyes closed, he does not press at all; it may register zero. The pressure increases when the patient is directed to concentrate his power of attention and will upon the effort. During all this time while the patient is unable to press upon the dynamometer, he may still in some other habitual exertions show great muscular power. We may call this form Systematized amyosthehia. The general law of amyosthenia is that the disturbance proceeds from the complex to the simple and from the less useful to the more useful, and the more habitual functions, from the functions more associated with traumatic disturbances to functions with fewer traumatic associations.

        The weakening of voluntary movements in psychopathies is especially pronounced in rapid repetition of the same movements, so that sometimes the patient may after a few endeavors be quite incapable of performing the movement. Tested, however, by other psychopathic methods, it is found that although the patient cannot perform these movements, he is still able to carry them out in a subconscious state.

        Psychopathic motor disturbances, like sensory troubles, are essentially morbid modifications of the subconscious.

        The general symptoms of psycho-motor disturbances in psychopathic diseases have been formulated as follows:

        (I) The patient's movements on the anaesthetic side are largely guided by the sense of sight. If the patient does not see the anaesthetic member, the movement is performed subconsciously.

        (II) In some cases when movements are apparently impossible without the sense of sight, if the eyes are closed in the middle of the movement, the process of movement may be continued.

    (III) In some cases, when without the knowledge of the patient, the anaesthetic member is raised, it becomes cataleptic.

        (IV) Movements can be induced in the patient without the help of sight, if the movements are brought about subconsciously.

        Among other phenomena observed in psychopathic motor disturbances are synkinesia, allokinesia, and heterokinesia.

        Synkinesia is the performance of associated movements. If the patient's limb is anaesthetic in the left upper extremity, for instance, he is able to raise either the right or left hand with his eyes open, and the right hand even with closed eyes. If, however, he is asked to raise the left hand alone, the eyes being closed, he raises both hands. When the patient is told to execute certain movements with the left anaesthetic hand, he makes synchronic, symmetrical movements with the right hand. The patient is able to move his right hand alone, but cannot move the left alone, without synchronous symmetrical movement of the right hand.

        The phenomena of allokinesia are parallel to those of allochiria. In allokinesia the patient is unable to localize well his peripheral kinaesthetic sensations. If for instance, the patient is asked to raise the right hand, he raises the left instead and is not aware of the difference. In this way the patient's anaesthesia or any form of motor disturbance may be transferred from one side to the other. The phenomenon of transfer is often due to this form of experiment.

        The phenomenon of heterokinesia is rare. It consists in the performance of opposite movements. When the patient, for instance, is told to close his hand, he opens it, or when he wants to bend the arm, he straightens it.

        Psychopathic tremor is usually hemiplegic or monoplegic that is, the tremor may occur on one side of the body, or it may be confined to one limb. The tremor, as in that of epilepsy, is usually present in the intervals between paroxysmal states. If, for example, the tremor is in the upper limb, and the patient is asked to extend the limb and keep it in a certain position a tremor of rather slight range, of about eight or ten oscillations per second is observed.

        There are two types of psychopathic tremor. The one form is present during repose and is only slightly affected by voluntary movement, while the other form may not be present during repose, but is greatly increased by voluntary movement. The tremor of the first type resembles that of exophthalmic goitre, while the second form is more like that of disseminated sclerosis. Emotional excitement increases both forms. The nature of psychopathic tremor like that of other psychopathic conditions, is some subconscious state. The duration of the tremors varies from a period of a few weeks to that of months or years.

        The tremor ceases during a psychopathic crisis, or so called "hysterical attack," but becomes exaggerated shortly after, and may also become marked when pressure is exerted over the so called hysterogenetic zones. The tremor may occur in many parts of the body, head, neck or extremities, and is increased by fixation of attention.

        Local and general clonic spasms of small range may occur. The movements in such spasms may assume a form which may be termed psychopathic chorea. Sometimes the movements are sudden and shock-like in character, suggesting electrical chorea. This form is easily acquired by imitation, and in the middle ages has at times become epidemic.

        Rhythmical movements of more extensive range may occur; this condition may be termed psychopathic rhythmical chorea, or psychopathic chorea major. The movements are of wide range, deliberate, and complex. They are of regular sequence and consist of more or less alternate contractions of the muscles, especially the flexors and extensors of the trunk and extremities. The movements are oscillatory, of regular rhythm and may last for weeks or months; they invariably cease during sleep.

        Different parts of the body may be involved; the tongue, the eyes or the jaw-muscles may be affected. The rhythmical movement may extend to various members, sometimes involving the whole trunk. The tremor may be of such a character as to suggest a neuropathic condition. The movements are sometimes arrested by a strong emotion or by an anaesthetic, such as ether, or by a hypnotic, such as morphine. The temporary arrest is succeeded by psychopathic paralysis or contracture.

        The convulsive attacks of psychopathic origin may be divided into minor and major seizures.

        The minor psychopathic convulsive attacks usually follow some deep emotional disturbance. During the attack the patient may make wild and purposeless gestures, or aimless movements, utter incoherent cries, go into uncontrollable fits of laughter or weeping, sometimes of an alternating character. The onset of the attack is usually preceded by a premonition consisting of spasmodic movements of the muscles of the throat, giving rise to a sensation of constriction or to a feeling as though a foreign body were in the throat. This phenomena is known as globus hystericus, so named because it was believed that the cause lay in the ascent of the uterus into the pharynx. Some muscular rigidity may be present. Rigidity or contraction of certain muscles may be premonitory of the attack.

        The movements in these convulsive attacks, unlike those of epilepsy, appear to be not altogether without purpose. The patient may make an effort to seize a person or object, or to kick at something or destroy it. Efforts to restrain the patient forcibly meet with opposition and increase the violence of the attack. Frequently a characteristic tremor or quiver of the eyelids is observed when the patient closes the eyes. Pulse and respiration usually remain unaffected, although the breathing may become shallow. After a time, varying from a few minutes to several hours, the patient becomes calm, passive, and then depressed.

        Major motor attacks, sometimes characterized by the inappropriate term of hystero-epilepsy, consist of convulsive seizures of a violent and extensive nature of definite types and stages. Attacks passing through definite stages are of rare occurrence, and when present are found in cases that show during the interparoxysmal period, some form of disaggregation, such as anaesthesia, aboulia or some motor disturbance.

        The major motor attacks are hypnoidic in character being reproductions of conditions that have induced the psychopathic state. The major attacks have prodromal symptoms, which appear several days before the paroxysm. These may consist of anaesthesia, aboulia, aphasia, general nervousness, etc.

        During the paroxysm, the sensibility of the patient is changed. There may be hyperaesthesia, or anaesthesia, clavus, epigastric pains or uneasiness, etc. This prodromal stage suggests the aura of epilepsy, but is altogether different in its nature. In epilepsy, the symptoms are due to neuropathic derangements, the neuron itself being affected, while in the psychopathic attacks the symptoms are due to dissociation of neuron-systems. Epileptic states are due to organic or neuropathic disturbances, while psychopathies are subconscious affections.

        The prodromal period is followed by the epileptoid stage, which may come on either suddenly or gradually. The face becomes pallid, the expression vacant, the eyes staring and the patient falls to the ground. The fall is not so violent and precipitate as it is in epilepsy, the patient rarely sustaining injury. The reason of this is that consciousness is really not lost. The subconscious self remains active and controls the movements and acts of the patient. In the beginning or during the epileptoid stage a sound is emitted, or word, or phrase is pronounced. At the height of this stage the muscles become rigid and finally the entire body is affected by tonic muscular contraction.

        This condition may be succeeded by relaxation of the muscles. The patient is motionless and only a perceptible movement of the eyelids is evident. In some cases the relaxation does not occur. The next stage in the epileptoid condition may be followed by clonism, or the rare phenomenon of opisthotonos may be encountered,—the body is arched and rests upon the back of the head and foot-soles, the abdominal muscles become exceedingly rigid. Soon opisthotonos gives place to bounding movements of great violence.

        The patient then passes through various emotions characteristic of the subconscious state. Various attitudes and expressions are assumed corresponding to the prevailing emotion. The patient talks incoherently. The movements are generally of such nature as to form more or less coordinated systems, they are usually of a struggling, defending nature.

        The eyelids, are usually closed, the conjurictival re-flex is diminished and general bodily sensibility is decreased. A pin stuck far into the flesh does not give rise to any manifestations or reactions of pain. A spasmodic laryngeal convulsion may be present giving rise to dyspnoea. The patient may be unable to swallow for hours or even days. There may be severe gastric disturbance, pain and vomiting. Anorexia may be so persistent, owing to fear of vomiting, that patients may absolutely refuse food for some time. The attacks may occur at long intervals and sometimes in such a rapid succession as to give rise to a psychopathic status epilepticus.

        The various stages of the major attacks should be regarded as the emergence of a hypnoidic state, as the growth and development of an abortive subconscious personality. A hypnoidic state consists of emotional disturbances with a change of sensibility accompanied by motor disturbances. The emotion forming the nucleus of the hypnoidic state is generally the manifestation of some event that had occurred in the patient’s life, but which afterward subsided within the subconscious, in a form more or less disaggregated from the patient's upper consciousness, and now recurring at each favorable opportunity. The hypnoidic state is the hallucination of an actual past event.

        The reason why the attacks recur, is that the emotional state with its train of psychomotor manifestations, is easily brought to the surface by the influence of certain stimuli, events and circumstances recalling the original trauma with all its consequences.

        These stimuli, acting on the patient, may modify his general sensibility. This modification of sensibility when associated with the hypnoidic state brings about a recurrence of that very state. If the patient is disposed to this hypnoidic state, that is, if there is a tendency to the arousal of those subconscious mental systems, the least stimulus that suggests any of the component associations that go to form the total complex system will bring about that particular synthesis of systems of sensibility that go with that particular hypnoidic state.

        The general law of psychology and especially of psychopathology is that a sensory state has motor and glandular accompaniments or reactions. As Pavlow and his pupils have shown, modifications of sensory impressions are associated with glandular secretions. The same holds true of ideas, every idea has relations to motor reactions and glandular changes. A change therefore of sensibility with its accompanying changes in ideas and images will bring about a motor disturbance. This motor disturbance is of a nature characteristic of that hypnoidic state with which that particular modified sensibility is associated.

        If two states have been associated, the presence of the one will recall the other. Thus epileptoid states arise with their sensori-motor disturbances and glandular changes. Sensori-motor, visceral, and glandular disturbances give rise in their turn to a change in the emotions, because different emotions are made up of various peripheral and organic sensations, coming from different parts of the body. A change, therefore, in sensori-motor activity gives rise to a profound modification of emotional life. It is clear that a profound disturbance of sensori-motor, ideo-motor life and glandular activities must be followed by emotions with their concomitant motor expressions.

        The emotions develop a fully systematized hypnoidic state, recalling and reviving in a perceptual form all the circumstances that occurred at that time; the patient, being in a delusional state having hallucinations and illusions, considers himself in quite another environment. Thus in the psychopathic convulsive attacks the hypnoidic state is apparently passing in an inverse form through the various stages of its original occurrence. In reality all the manifestations and symptoms are guided and controlled by the awakening of the submerged, subconscious, emotional, hypnoidic state.

        Contracture is common in the psychopathies, but it is less frequent than anaesthesia. Contracture may be caused by various stimuli, such as a blow, electric current, massage, etc., and often follows a convulsive seizure, or an intense overwhelming emotion. As a rule, contracture occurs suddenly, and when of gradual onset follows amyosthenia, paralysis, or convulsive attacks. The contracture may affect a bundle of muscle giving rise to a kind of tumor or it may affect a number of muscles. As a rule the voluntary muscles are affected, but the involuntary muscles, such as those of the bowels may be involved.

        Psychopathic motor disturbances may be of the monoplegic, the paraplegic, the hemiplegic, the crossed, the general, the periarticular, or the irregular type. In contracture of the upper extremity the fingers are strongly closed upon the palm, the wrist and forearm flexed in the position of pronation or supination. When the lower limb is affected, the thigh and leg are strongly extended and the foot is in the equinovarus position. The thigh is in a position of adduction, the entire limb is held in strong muscle contraction. Occasionally flexion instead of extension occurs. In the hemiplegic form the arm is usually flexed and the leg extended.

        The left side is often more involved than the right. Both extremities may be involved or the contracture may pass from one to the other. In the paraplegic type both legs are extended and adducted. All for extremities may be involved. In the so-called periarticular variety, in which the muscles about the joint are involved the several forms of talipes are simulated. Contractures of the muscles of the face may also occur.

        Generally the contracture is uniform while it continues, but sometimes it varies at irregular periods. It is as a rule greater when an attempt is made to overcome it, and the increase of resistance of the muscle in proportion to the effort made to overcome it is of great value in the determination of the psychopathic nature of the contracture. The contracture, unless of a mild degree, may persist during sleep, but disappears in hypnosis and deep anaesthesia, induced by such drugs as alcohol, chloroform, and ether. In rare cases of very long standing structural changes may occur.

        So-called hysterical trismus is due to contracture of the muscles of mastication. In this condition the jaws resist all efforts to operate the mouth. When the trismus follows a motor paroxysm is generally persists until another paroxysm occurs. Contractures in the jaw depressors leading to opening of the mouth are very rare. Contraction of the abdominal muscles and intestines may give rise to the so-called phantom tumor. Pressure may sometimes change the form of the tumor.

        Psychopathic paralysis consists of a loss of control in certain muscles, and is a frequent symptom in psychopathic diseases. The paralysis may vary in intensity, and is usually of very rapid or sudden onset.

        The most familiar form of paralysis is the hemiplegic type and usually follows a paroxysm. When only one limb is affected, all of its muscles are involved, and the member is simply dragged along and not swung in a semi-circle as is the case in familiar forms of hemiplegia of organic nature. The loss of power is not complete. Certain forms of psychopathic ataxia are also observed. Resistance to passive motion is regularly sustained, but varies from time to time or moment to moment. An effort by the patient to set in motion a certain group of muscles, such as the flexors of the foot, may throw into activity the opposite group, the extensors, thus bringing about the inhibition of the intended movements. A tremor is often present in the partially paralyzed muscles. There may be slight atrophy present due to disuse.

        The electrical reactions remain normal. Pain in the spine is not uncommon, and may intensify the paralysis. Complete loss of power is rare, the patient is able to move the limb slowly, but falls to the ground, when attempting to stand. The myotactic irritability is of ten increased. A pseudo or spurious foot clonus, however, is sometimes elicited due to a subconscious contraction in the calf muscles. The contractures in psychopathic states are often persistent remnants of hypnoidic states, after the states themselves have subsided into the subconscious regions.

        The origin of psychopathic contractures, as indeed of all motor disturbances, may be well demonstrated by experiments which may be made in hypnosis. If, for instance, during the hypnotic state the patient is directed to do something, to take an imaginary bird, for example, and keep it tightly in the hand, the subject upon coming out of the hypnotic state, will keep the hand closed and will be unable to open it, though he does not know why it remains in that position. Such states are termed by me “hypnonergic.”

        These contractures, like all other allied conditions in psychopathic states, are of the same nature as those induced during hypnosis and persisting in the post-hypnotic state. In the psychopathic disturbances the hypnonergic states are more persistent, although they may pass away again as easily and suddenly as in those of hypnosis They are due to present and past mental and emotional disturbances.

        Astasia-abasia is a form of psychopathic incoordination observed most frequently in children, the principal psychomotor manifestation being the inability to maintain the upright attitude. Tremors and movements of a choreic nature are sometimes present. In reclining postures the legs have normal power, but on attempting to stand or walk the patient falls or moves in a most awkward manner. There are no objective signs to indicate organic change in the motor apparatus. The onset is sudden and is generally due to subconscious emotions, to dissociated mental states. Other psychopathic symptoms may be present. The psychomotor manifestations of astasia-abasia are as sudden in their disappearance as in their onset.

        Psychopathic mutism, or aphonia is often of sudden onset and usually disappears suddenly. The difference between psychopathic aponia and psychopathic mutism is that while in the former the patient can still speak in a whisper, in the latter he cannot speak at all.

        Sometimes in mutism words and phrases can still be produced, and are usually those that were uttered during the accident or fright that caused the functional disturbance. Such phrases are hypnoid in character. In sleep the subject of psychopathic mutism shows the ability to talk during dreams.     Such dreams are really hypnoidic states.

        Psychopathic aphonia may have its origin in the local affection of the larynx, but in some instances it appears spontaneously, specially after an intense emotion with subconscious mental dissociation. The laryngoscope may show paralysis of the adductor muscles of the vocal cords. The voice may often be brought out during coughing, and is then found to be possessed of its usual character. Frequently the patient, though not able to speak aloud, is still able to use his voice in singing. In rare cases of psychopathic aphonia the tongue may also be affected in the paralysis.

        Stammering is often present in psychopathic persons. It is very much like the aphonia in character and is often the result of intense dissociative emotional states, occuring mostly in children. In cases of aphonia under my care the patients talked in dreams or in the deep conditions of induced subconscious states.

        The phenomena of stammering may be explained best by a brief reference to the factors operating in the production of speech.

        In the production of speech we have two sets of mechanisms: the laryngeal and the oral; the former produces the vocal elements of speech and the latter, the oral, modifies the sounds of the larynx as to tone or timbre and helps in the production of new sounds.

        In stammering the common defect is due to delayed activity of the laryngeal mechanism; occasionally the oral mechanism may be at fault. When the patient tries to speak he throws the increased force into the lips. The centre of the oral mechanism thus becomes surcharged with energy and spasmodic movements even of great extent may occur. The nerve-centres of the speech-mechanism become so surcharged with energy that its liberation may give rise to irritation of other centres and extensive movements in various parts of the body may result.

        Stammerers find it especially difficult to pronounce the first syllables of words. No matter how difficult it may be for the patient to speak he can always sing with ease, because the vocal elements which form a part of speech and by which song is produced are formed in the larynx, and the laryngeal mechanism in itself is not effected, but only its cooperation, or association-activity with the oral is interfered with. Stammerers in ordinary conversations may be excellent preachers, and in rapid conversation or speech, experience but little difficulty.

        Partial catalepsy is a psychopathic motor disturbance in which the extremities of the patient tend to maintain any position impressed upon them, and is due to a local disaggregation of the systems of neurons innervating the particular limb. The pathology of this state may be well represented as follows. Let C represent the muscles of the limb, B the motor centre which innervates them, A the centre for the kinaesthetic sensation of the limb, D and E the fibres going from the centre to the limb and from the limb to the centre. Assume now that the centres A and B are dissociated from the other brain centres, thus forming a closed system. Any impulse brought to the centre B, will provoke a discharge, which propagated through D will excite movement in C. The contraction of C gives rise to a discharge which is propagated through the sensory nerve to the kinaesthetic centre, A, awakening a kinaesthetic sensation. The energy from A is then propagated to B and there is once more a discharge of energy in B which again gives rise to a contraction of C. This goes on until the centres are exhausted, the limb being maintained in the same position. This form of catalepsy is known as a recurrent state or as circular reaction.

        Partial catalepsy usually occurs in limbs which are anaesthetic. A very slight stimulus may change the position of the limb leaving it in the same state of rigidity and catalepsy. The cataleptic condition is characterized by its persistency and duration, the affected limb retaining for a long time positions impossible in the normal state. So rigid and steadfast is the cataleptic limb that tracings taken of it on a smoked drum show a straight line, while the normal member held in the same position shows a quite irregular tracing, due to tremor. The rigid limb can often maintain its position for a half an hour, and the interest lies in the fact that no fatigue is felt by the patient, although sometimes he may complain of severe pain in the limb.

        During the cataleptic state the patient does not know the position of the limb, and may have an erroneous impression as to its position when his attention is distracted. If the patient is asked to change the attitude of the limb, he is unable to do it, not knowing its position.

        In the cataleptic state the phenomena of rapport may be present. If the arm, for instance, is placed in a certain position, that position can be changed only by the experimenter who induced it, and by no one else. If a definite movement is imparted to the cataleptic limb, the member will continue to move with regular rhythm, the patient being unconscious of the movements. If however, the patient's attention is drawn to the movements, they cease at once, to be resumed when the attention is withdrawn. If the arm is placed in a cataleptic state, adaptation to certain objects placed in the hand, occurs. For instance, if a pencil is put in the hand, the fingers grasp it, and sometimes begin to write.

        Catalepsy is said to be general, when it involves the whole body. General catalepsy is common in the third stage, that of emotional attitudes, of the major attacks of the psychopathic paroxysm. At the beginning of the attack there may be some rigidity and then a condition of wax-like flexibility (cerea flexibilitas) follows. Such a condition occurs also in insanities as in katatonia. General catalepsy may also be produced in hypnosis. It occurs also in melancholia, and is some-times present in epileptics.

        In complete catalepsy the entire body becomes more or less rigid, the limbs remaining in the position they have originally assumed. At first the muscular rigidity is considerable and an attempt at passive movement is resisted. Soon however, the limbs become flexible and remain in any position in which they are placed. The rigidity finally yields when the energy from the innervating centers becomes exhausted. The state of sensibility varies. In deep cataleptic states sensibility to touch, pain, and electricity is lost. The reflexes including the conjunctival are lost. In rare cases the reflexes and the general sensibility remain unaffected. Cataleptic attacks are sometimes preceded by hiccough, headache, and dizziness.

        It is not uncommon to find a periodicity in the recurrence of the cataleptic attacks. This periodicity, however, is readily understood, since the cataleptic state is hypnoidic in character. Catalepsy is a hypnoidic state.

        The physiological tendency of systems of cells in their functional activity is to form habits in which the energy discharges or runs down in some regular clock-like form. The hypnoidic state in catalepsy may be called up by stimuli which may happen to come at regular or irregular intervals. More often, of course, they will come at irregular intervals, and the hypnoidic cataleptic state will then occur irregularly. Some stimuli, however, may happen to come a few times at regular intervals, the disaggregated systems thus form a habit to appear at regular intervals; hence the periodicity of the attacks.

        Lethargy is a psychopathic disturbance in which the patient is in a sleep-like state, with slowness of muscular movement, due to exhaustion of neuron energy. The patient is aroused with difficulty. Etiologically hereditary or neurotic predispositions play important roles. Excessive mental work, exhausting fevers, such as typhoid, etc., influenza and trauma, especially when associated with strong emotion are among the proximate causes. Intense emotions alone in those predisposed may be an exciting cause.

        Lethargy is generally sudden in its onset, the state lasting from a few days to several weeks. During the attack the limbs are limp and the face is pallid. The closed eyelids cannot be opened, the subject apparently resisting the attempt. The eyeballs are turned upward; the pupils remain normal in size and in their reaction. There is occasionally a change in reflex activity, the nasal and conjunctival reflexes sometimes being absent. The upper consciousness is in abeyance and the special senses may be unusually keen, although motor manifestations are inhibited, owing to a disaggregation within the psychomotor areas.

        The pulse, as in sleeping states generally, is often small and the respiration may become shallow and scarcely perceptible. The temperature is normal. The urine may be retained or may be passed involuntarily. The vital functions may be so depressed that the patient may be seemingly dead: This state is sometimes characterized as morbus hypnoticus. If the trance-state is long in duration, the patient may awaken partially and partake of nourishment. The end of the state is often indicated by sighing or deep breathing.

        Vaso-motor changes, such as extravasations, may occur. The deep lethargic state sometimes closely simulates real death, the fundus of the eyeball, however, is normal, the muscles react to electricity, and there are no signs of degeneration.

            The lethargic state, like the cataleptic, is doubtless of a hypnoidic nature, subconscious activity being occasionally made manifest by movements and exclamations. In some cases it is possible to come into direct communication with the disaggregate subconscious, and to induce illusions, hallucinations, various movements and reactions and adaptations to the illusory and hallucinatory environment.

        In visceral disturbances of psychopathic character, gastric paraesthesia is common, giving rise to sensation of fullness or distention, sinking, emptiness, etc. So called nervous dyspepsia with its attendant feeling of distress may be present. There may be spasmodic contracture of the oesophageal or pharyngeal muscles produced by taking food in solid form. The spasm may last for a short period, or may persist for months. When there is vomiting, it may or may not be accompanied by nausea; the vomiting sometimes seems to be provoked by food, irritating the gastric mucous membrane. There may be slight haematemesis, the blood being of a bright color.

        Psychopathic anorexia or anorexia nervosa is not uncommon. The patient in this condition has a disgust for food and rejects it. A perverted taste for odd or indigestible material is occasionally present. The patient's nutrition may suffer severely, and he may lose greatly in weight.

        `Intestinal derangements are not unusual, nervous diarrhoea or obstinate constipation is sometimes observed. Accumulation of gas in the bowels giving rise to borborygmus is common, often causing cardiac palpitation and respiratory difficulty. The heart-beat is rapid and weak; there is paleness, general muscular weakness and dizziness which may end in syncope. Polyuria, either permanent or temporary, is not uncommon, the patient sometimes passing a large quantity of pale urine; haematuria is rare. Ischuria occasionally occurs. Perspiration may be profuse. There may also be severe vomiting.

        In psychopathic states patients, especially women, often locate the trouble in some part of the genital apparatus. This gave rise to identification of psychopathies in general with those associated with uterine disturbances, under the name of hysteria, or sometimes hystero-neurosis, which really bear no relation to sexual organs in general and to the uterus in particular.

        The sexual organs, like any other organs, may give rise reflexly to psychopathic disturbances, but psychopathic states, can be as little identified with sexual troubles as with gastric disturbances. Women are prone to refer their ills to sexual derangements, because by education, training, and persistent suggestion the sexual functions are given undue prominence in the patient's mind. Frequently, especially in former years, all sorts of operations, hysterectomy, ovariotomy, etc., have been resorted to for the alleviation of psychopathic affections.

        The recent psychoanalytic theories of hysteria and hystero-neurosis, implying the relation of psychopathic states to sexual life are scientifically fallacious and practically extremely harmful to the patient and pernicious to the community. A good deal of the sexual matter claimed to be revealed by psychoanalysis is due to suggestions given by the patient's surroundings and education, and then specially enforced by the physician’s psychoanalytic, preconceived prejudices.

        Among the psychopathic visceral disturbances involving the mechanism of respiration we find psychopathic asthma. There may be cough and profuse expectoration, occasionally followed by convulsive or spasmodic attack of dyspnoea. There is often a reflex so called “nervous cough,” of psychopathic nature. It is of a hard, dry, paroxysmal character; it may occur many times during the day, and be of short or of long duration. The cough ceases during the night when the patient sleeps. Psychopathic coughs are sometimes produced in imitation of the cry of an animal, such as the barking of a dog or mewing of a cat. These peculiar noises sometimes occur in epidemic form. Hiccoughs, yawning, sobbing, etc., may occur in paroxysms.

        Irregularities in cardiac rhythm are common and these are provoked by the least emotional excitement. Tachycardia is frequent. The attacks may be of several hours' duration. Angina pectoris of psychopathic origin is sometimes observed. Bradycardia is rare.

        Vasomotor changes are found in some cases. Sudden flushing or pallor of the face, or of the upper part of the body accompanied by heat and cold sensations are observed. At times constriction of the blood vessels may cause local cyanosis.

        Various skin eruptions are occasionally observed in psychopathic cases. These have been regarded and described as hysterical or psychopathic. They are, however, neuropathic in their nature, though they may be often associated with psychopathic states.

        We cannot impress too much on the physician’s mind that all psychopathic disturbances, whether sensory, motor, visceral, and glandular, are essentially morbid affections of the patient's subconscious life.

        One important law holds true of all psychopathic maladies and that is all conscious losses are subconscious gains. Whatever function is lost to the upper consciousness is present to the subconscious. This can be tested by the various methods for reaching the subconscious.

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