PART I

Psychiatry is the stepchild of medicine. All the other branches of medicine have one great advantage over it--the scientific methods can be applied; there are things to be seen, and felt, physical and chemical methods of investigation to be followed: the microscope shows the dreaded bacillus, the surgeon's knife halts at no difficulty and gives us glimpses of most inaccessible organs of vital importance. Psychiatry, which engages in the exploration of the mind, stands ever at the door seeking in vain to weigh and measure as in the other departments of science. We have long known that we have to do with a definite organ, the brain; but only beyond the brain, beyond the morphological basis do we reach what is important for us--the mind; as indefinable as it ever was, still eluding any explanation, no matter how ingenious. Former ages, endowing the mind with substance, and personifying every incomprehensible occurrence in nature, regarded mental disorder as the work of evil spirits; the patient was looked upon as one possessed, and the methods of treatment were such as fitted this conception. This mediæval conception occasionally gains credence and expression even to-day. A classical example is the driving out of the devil which the elder Pastor Blumhardt carried out successfully in the famous case of Gottlieb in Deltus.[196] To the honour of the Middle Ages let it also be said that there are to be found early evidences of a sound rationalism. In the sixteenth century at the Julius Hospital in Würzburg mental patients were already treated side by side with others physically ill, and the treatment seems to have been really humane. With the opening of the modern era, and with the dawn of the first scientific ideas, the original barbaric personification of the unknown Great Power gradually disappeared. A change arose in the conception of mental disease in favour of a more philosophic moral attitude. The old view that every misfortune was the revenge of the offended gods returned new-clothed to fit the times. Just as physical diseases can, in many cases, be regarded as self-inflicted on account of negligence, mental diseases were likewise considered to be due to some moral injury, or sin. Behind this conception the angry godhead also stood. Such views played a great _rôle_, right up to the beginning of last century, especially in Germany. In France, however, about the same time a new idea was appearing, destined to sway psychiatry for a hundred years. Pinel, whose statue fittingly stands at the gateway of the Salpetrière in Paris, took away the chains from the insane and thus freed them from the symbol of the criminal. In a very real way he formulated for the world the humane and scientific conception of modern times. A little later Esquirol and Bayle discovered that certain forms of insanity ended in death, after a relatively short time, and that certain constant changes in the brain could be demonstrated _post mortem_. Esquirol had described as an entity general paralysis of the insane, or as it was popularly called "softening of the brain," a disease which is always bound up with chronic inflammatory degeneration of the cerebral matter. Thus was laid the foundation of the dogma which you will find repeated in every text-book of psychiatry, viz. "diseases of the mind are diseases of the brain." Confirmation of this conception was added about the same time by Gall's discoveries which traced partial or complete loss of the power of speech--a psychical capacity--to a lesion in the region of the left lower frontal convolution. Somewhat later this view proved to be of general applicability. Innumerable cases of extreme idiocy or other intense mental disorders were found to be caused by tumours of the brain. Towards the end of the nineteenth century Wernicke (recently deceased) localised the speech centre in the left temporal lobe. This epoch-making discovery raised hopes to the highest pitch. It was expected that at no distant day every characteristic and every psychical activity would be assigned a place in the cortical grey matter. Gradually, increased attempts were made to trace the primary mental changes in the psychoses back to certain parallel changes in the brain. Meynert, the famous Viennese psychiatrist, described a formal scheme in which the alteration in blood-supply in certain regions was to play the chief part in the origin of the psychoses. Wernicke made a similar but far more ingenious attempt at a morphological explanation of psychical disorders. The visible result of this tendency is seen in the fact that even the smallest and least renowned asylum has, to-day, its anatomical laboratory where cerebral sections are cut, stained, and microscoped. Our numerous psychiatric journals are full of morphological contributions, investigations into the structure and distribution of cells in the cortex, and other varying source of disorders in the different mental diseases.

Psychiatry has come into fame as gross materialism. And quite rightly, for it is on the road--or rather reached it long ago--to put the organ, the instrument, above function. Function has become the dependent accessory of its organs, the mind the dependent accessory of the brain. In modern mental therapy the mind has been the loser, whilst great progress has been made in cerebral anatomy; of the mind we know less than nothing. Current psychiatry behaves like a man who thinks he can unriddle the meaning and importance of a building by a mineralogical investigation of its stones. Let us attempt to realise in which mental diseases obvious changes in the brain are found, and what is their proportion.

In the last four years we have received 1325 patients at Burgholzi;[197] 331 a year. Of these 9 per cent. suffered from congenital psychic anomalies. By this is understood a certain inborn defect of the psyche. Of these 9 per cent., about a quarter were imbeciles. Here we meet certain changes in the brain such as microcephalus, hydrocephalus, malformations or absence of portions of the brain. The remaining three-quarters of these congenital defects present no typical changes in the brain.

Three per cent. of our patients suffer from epileptic mental troubles. In the course of epilepsy there arises gradually a typical degeneration of the brain. The degeneration is, however, only discoverable in severe cases and when the disease has existed for some time. If the attacks have only existed for a relatively short time, not more than a few years, the brain as a rule shows nothing. Seventeen per cent. of our patients suffer from progressive paralysis and senile dementia. Both diseases present characteristic changes in the brain. In paralysis there is most extensive shrinkage of the brain, so that the cortex is often reduced by one half. The frontal portions of the brain more especially, may be reduced to a third of the normal weight. There is a similar destruction of substance in senile decay.

Fourteen per cent. of the patients annually received are cases of poisoning, at least 13 per cent. of these being due to alcohol. As a rule in slight cases nothing is to be found in the brain; in only a relatively few severe cases is there shrinkage of the cortex, generally of slight degree. The number of these severe cases amounts to less than 1 per cent. of the yearly cases of alcoholism.

Six per cent. of the patients suffer from so-called maniacal depressive insanity which includes the maniacs and the melancholics. The essence of this disease is readily intelligible to the public. Melancholia is a condition of abnormal sadness without disorder of intelligence or memory. Mania is the opposite, the rule being an abnormally excited state with great restlessness; likewise without deep disturbance of intelligence and memory. In this disease there are no demonstrable morphological changes in the brain.

Forty-five per cent. of the patients suffer from the real and common mental disease called dementia præcox. The name is a very unhappy one, for the dementia is not always precocious, nor in all cases is there dementia. Unfortunately the disease is too often incurable; even in the best cases, in those that recover, where the outside public would not observe any abnormality, there is always present some defect in the emotional life. The picture presented by the disease is extraordinarily diverse; generally there is some disorder of feeling, frequently delusions and hallucinations. As a rule there is nothing to be found in the brain. Even in cases of a most severe type, lasting for years, an intact brain is not infrequently found _post mortem_. In a few cases only certain slight changes are present which, however, cannot as yet be reduced to any law.

To sum up: in round figures a quarter of our insane patients show more or less clearly extensive changes and destruction of the brain, while three-fourths have a brain which seems to be generally unimpaired or at most exhibit such changes as give no explanation of the psychological disturbance.

These figures offer the best possible proof that the purely morphological view-point of modern psychiatry leads only very indirectly, if at all, to the understanding of the mental disorder, which is our aim. We must take into account the fact that those mental diseases which show the most marked disturbances of the brain end in death; for this reason the chronic inmates of the asylum form its real population, consisting of some 70 to 80 per cent. of cases of dementia præcox, that is, of patients in whom anatomical changes are practically non-existent. The psychiatry of the future must come to grips with the core of the thing; the path is thus made clear--_it can only be by way of psychology_. Hence in our Zürich clinic we have entirely discarded the anatomical view and turned to the psychological investigation of insanity. As most of our patients suffer from dementia præcox we were naturally concerned with this as our chief problem.

* * * * *

The older asylum physicians paid great attention to the psychological precursors of mental disorder, just as the public still does, following a true instinct. We accepted this hint and carefully investigated the previous psychological history wherever possible. Our trouble was richly rewarded, for we often found, to our surprise, that the disease broke out at a moment of some great emotion which, in its turn, had arisen in a so-called normal way. We found, moreover, that in the mental disease which ensued a number of symptoms occurred which it was quite labour in vain to study from the morphological standpoint. These same symptoms, however, were comprehensible when considered from the standpoint of the individual's previous history. Freud's fundamental investigations into the psychology of hysteria and dreams afforded us the greatest stimulus and help in our work.

A few instances of the latest method in psychiatry will make the subject clearer than mere dry theory. In order to bring home to you the difference in our conception I will first describe the medical history in the older fashion, and subsequently give the solution characteristic of the new departure.

The case to be considered is that of a cook aged 32; she had no hereditary taint, was always industrious and conscientious, and had never been noticeable for eccentric behaviour or the like. Quite recently she became acquainted with a young man whom she wished to marry. From that time on she began to show certain peculiarities. She often spoke of his not liking her much, was frequently out of sorts, ill-tempered, and sat alone brooding; once she ornamented her Sunday hat very strikingly with red and green feathers, another day she bought a pair of pince-nez in order to wear them when she went out walking with her fiancé. One day the sudden idea that her teeth were rather ugly would not let her rest, and she resolved to get a plate, although there was no absolute need. She had all her teeth out under an anæsthetic. The night after the operation she suddenly had a severe anxiety-attack. She cried and moaned that she was damned for ever, for she had committed a great sin; she should not have allowed her teeth to be extracted. People must pray for her, that God might pardon her sin. In vain her friends attempted to talk her out of her fears, to assure her that the extraction of teeth was really no sin; it availed nothing. At day-break she became somewhat quieter; she worked throughout the day. On following nights the attacks were repeated. When consulted by the patient I found her quiet, but she wore a rather vacant expression. I talked to her about the operation, and she assured me it was not so dreadful to have teeth extracted, but still it was a great sin, from which position, despite every persuasion, she could not be moved. She continually repeated in plaintive, pathetic tones, "I should not have allowed my teeth to be extracted; oh yes, that was a great sin which God will never forgive me." She gave the impression of real insanity. A few days later her condition grew worse, and she had to be brought into the asylum. The anxiety-attack had extended and was persistent, and the mental disorder lasted for months.

The history shows a series of entirely unrelated symptoms. Why all the queer story of the hat and pince-nez? Why those anxiety-attacks? Why this delusion that the extraction of her teeth was an unpardonable sin? Nothing here is clear. The morphologically-minded psychiatrist would say: This is just a typical case of dementia præcox; it is the essence of insanity, of madness, to talk of nothing but mysteries; the standpoint of the diseased mind towards the world is displaced, is "mad." What is no sin for the normal, the patient finds a sin. It is a bizarre delusion characteristic of dementia præcox. The extravagant lamentation about this supposed sin is what is known as "inadequate"[198] emotional emphasis. The queer ornamentation of the hat, the pince-nez, are bizarre notions such as are very common in these patients. Somewhere in the brain certain cells have fallen into disorder, and manufacture illogical, senseless ideas of one kind and another which are quite without psychological meaning. The patient is obviously a hereditary degenerate with a weak brain, having a kink which is the origin of the disorder. For some reason or other the disease has suddenly broken out. It could just as easily have broken out at any other time. Perhaps we should have had to capitulate to these arguments had real psychological analysis not come to our aid. In filling up the certificate required for her removal to the asylum, it transpired that many years ago she had had an affair which terminated; her lover left her with an illegitimate child. Nobody had been told of this. When she was again in love a dilemma arose, and she asked herself, What will this new lover say about it? At first she postponed the marriage, becoming more and more worried, and then the eccentricities began. To understand these we must immerse ourselves in the psychology of a naïve soul. If we have to disclose some painful secret to a beloved person we try first to strengthen his love in order to obtain beforehand a guarantee of his forgiveness. We do it by flattery or by caresses, or we try to impress the value of our own personality in order to raise it in the eyes of the other. Our patient decked herself out with beautiful feathers, which to her simple taste seemed precious. The wearing of "pince-nez" increases the respect of children even of a mature age. And who does not know people who will have their teeth extracted, out of pure vanity, in order that they may wear a plate to improve their appearance?

After such an operation most people have a slight, nervous reaction, and then everything becomes more difficult to bear. This was, as a matter of fact, just the moment when the catastrophe did occur, in her terror lest her fiancé should break with her when he heard of her previous life. That was the first anxiety-attack. Just as the patient had not acknowledged her secret in all these years, so she now sought to guard it, and shifted the fear in her guilty conscience on to the extraction of the teeth; she thus followed a method well known to us, for when we dare not acknowledge some great sin we deplore some small sin with the greater emphasis.

The problem seemed insoluble to the weak and sensitive mind of the patient, hence the affect became insurmountably great; this is the mental desire as presented from the psychological side. The series of apparently meaningless events, the so-called madness, have now a meaning; a significance appertains to the delusions, making the patient more human to us. Here is a person like ourselves, beset by universal human problems, no longer merely a cerebral machine thrown out of gear. Hitherto we thought that the insane patient revealed nothing to us by symptoms, save the senseless products of his disordered cerebral cells, but that was academic wisdom reeking of the study. When we penetrate into the human secrets of our patients, we recognise mental disease to be an unusual reaction to emotional problems which are in no wise foreign to ourselves, and the delusion discloses the psychological system upon which it is based.

The light which shines forth from this conception seems to us so enormously powerful because it forces us into the innermost depths of that tremendous disorder which is most common in our asylums, and hitherto least understood; by reason of the craziness of the symptoms it is the type that strikes the public as madness _in excelsis_.

The case which I have just sketched is a simple one. It is transparent. My second example is somewhat more complicated. It is the case of a man between 30 and 40 years of age; he is a foreign archæologist of great learning and most unusual intelligence. He was a precocious boy of quite excellent character, great sensitiveness and rare gifts. Physically he was small, always weakly, and a stammerer. He grew up and was educated abroad, and afterwards studied for several terms at B----. So far there had been no disorder of any kind. On the completion of his university career he became zealously absorbed in his archæological work, which gradually engulfed him to such an extent that he was dead to the world and all its pleasures. He worked incessantly, and buried himself entirely in his books. He became quite unsociable; before, awkward and shy in society, he now fled from it altogether, and saw no one beyond a few friends. He thus led the life of a hermit devoted entirely to science. A few years later, on a holiday tour, he revisited B----, where he remained a few days. He walked a great deal in the environs of the town. His few acquaintances now found him somewhat strange, taciturn, and nervous. After a somewhat protracted walk he seemed tired, and said that he did not feel very well. He then remarked he must get himself hypnotised, he felt his nerves unsteady. On top of this he was attacked by physical illness, viz. inflammation of the lungs. Very soon a peculiar state of excitement supervened which led to suicidal ideas. He was brought to the asylum, where for weeks he remained in an extremely excited state. He was completely deranged, and did not know where he was; he spoke in broken sentences which no one could understand. He was often so excited and aggressive that it took several attendants to hold him. He gradually became quieter, and one day came to himself, as if waking out of a long, confused dream. He soon completely regained his health, and was discharged as cured. He returned to his home and again immersed himself in books. In the following years he published several remarkable works, but, as before, his life was that of a hermit living entirely in his books and dead to the world. He then gradually acquired the name of a dried-up misanthrope, lost to all meaning of the beauty of life. A few years after his first illness a brief holiday brought him again to B----. As before he took his solitary walks in the environs. One day he was suddenly overcome by a faint feeling, and lay down in the street. He was carried into a neighbouring house where he immediately became extremely excited. He began to perform gymnastics, jumped over the rails of the bed, turned somersaults in the room, began to declaim in a loud, voice, sang his own improvisations, etc. He was again brought to the asylum. The excitement continued. He extolled his wonderful muscles, his beautiful figure, his enormous strength. He believed that he had discovered a natural law by which a wonderful voice could be developed. He regarded himself as a great singer, and a marvellous reciter, and at the same time he was a great inspired poet and composer to whom verse and melody came spontaneously.

All this was in pitiable and very remarkable contrast to reality. He is a small weakly man of unimposing build, with poorly developed muscles betraying at the first glance the atrophying effect of his studious life. He is unmusical, his voice is weak and he sings out of tune; he is a bad speaker, because of his stutter. For weeks he occupied himself in the asylum with peculiar jumping, and contortions of the body which he called gymnastics, he sang and declaimed. Then he became more quiet and dreamy, often stared thoughtfully in front of him for a long time, now and then sang a love song which, despite its want of musical expression, betrayed a pretty feeling for love's aspirations. This also was in complete contrast with the dryness and isolation of his normal life. He gradually became accessible for lengthy conversations.

We will break off the history of the disease here, and sum up what is furnished so far by observation of the patient.

In the first illness the delirium broke out unexpectedly, and was followed by a mental disorder with confused ideas and violence which lasted for several weeks. Complete recovery appeared to have taken place. Six years later there was a sudden outbreak of mania, grandiose delusions, bizarre actions, followed by a twilight-stage gradually leading to recovery. Here we again see a typical case of dementia præcox, of the katatonic variety, especially characterised by peculiar movements and actions. In psychiatry the views obtaining at present would regard this as localised cellular disease of some part of the cortex, exhibiting confusional states, delusions of grandeur, peculiar contortions of the muscles, or twilight-states, which taken all together have as little psychological meaning as the bizarre shapes of a drop of lead thrown into water.

This is not my view. It was certainly no accidental freak of the brain-cells that created the dramatic contrasts shown in the second illness. We can see that these contrasts, the so-called grandiose delusions, were very subtly determined by the deficiencies in the patient's personality. Without doubt, any one of us would naturally regard these deficiencies seriously in ourselves. Who would not have the desire to find compensation for the aridness of his profession and of his life in the joys of poetry and music and to restore to his body the natural power and beauty stolen from it by the study's atmosphere? Do we not recall with envy the energy of a Demosthenes who, despite his stammering, became a great orator? If our patient thus fulfilled the obvious gaps in his physical and mental life by delusional wishes, the supposition is warranted that the whispered love-song which he sang from time to time filled up a painful blank in his being, which became more painful the more it was concealed. The explanation is not far to seek. It is simply the old story, born anew in every human soul, in a guise befitting the destined creature's highest sensibilities.

When our patient was a student he learnt to know and love a girl-student. Together they made many excursions in the environs of the town, but his exceeding timidity and bashfulness (the lot of the stammerer) never permitted him an opportunity of getting out the appropriate words. Moreover, he was poor and had nothing to offer her but hopes. The time came for the termination of his studies; she went away, and he also, and they never saw one another again. And not long afterwards he heard she had married some one else. Then he relinquished his hopes, but he did not know that Eros never emancipates his slaves.

He buried himself in abstract learning, not to forget, but to work for her in his thoughts. He wanted to keep the love in his heart quite secret, and never to betray that secret. He would dedicate his works to her without her ever knowing it. The compromise succeeded, but not for long. Once he travelled through the town where he heard she lived--it seems to have been an accident that he travelled through that town. He did not leave the train, which only made a short halt there. From the window he saw standing in the distance a young woman with a little child, and thought it was she. Impossible to say whether it was really so or not. He does not think he felt any peculiar feeling at that moment; anyway he gave himself no trouble to ascertain whether it was she, which makes the presumption strong that it was not really she. The unconscious wanted to be left in peace with its illusion. Shortly afterwards he again came to B----, the place of old memories. Then he felt something strange stir in his soul, an uneasy feeling, akin to Nietzsche's--

"Not for long shalt thou thirst, O burning heart! There is promise in the air, Winds come to me from unknown mouths-- The healing coolness comes."

Civilised man no longer believes in demons, he calls in the doctor. Our patient wanted to be hypnotised. Then madness overcame him. What was going on in him?

He answered this question in broken sentences, with long pauses, in that twilight-stage that heralds convalescence. I give as faithfully as may be his own words. When he fell ill he suddenly lost the well-regulated world and found himself in the chaos of an overmastering dream, a sea of blood and fire; the world was out of joint; everywhere conflagration, volcanic outbreaks, earthquakes, mountains fell in, followed by enormous battles where the peoples fell upon one another; he became involved more and more in the battle of nature, he was right in the midst of those fighting, wrestling, defending himself, enduring unutterable misery and pain; gradually he was exalted and strengthened by a strange calming feeling that some one was watching his struggles, that his loved one saw all from afar. That was the time when he showed real violence to the attendants. He felt his strength increasing and saw himself at the head of great armies which he would lead to victory. Then more great battles and at length victory. He would try to get his loved one as prize of victory. As he drew near her the illness ceased, and he awoke from a long dream.

His daily life again began to follow the regular routine. He shut himself up in his work and forgot the abyss within himself. A few years later he is again at B---- Demon or Destiny? Again he followed the old trail and again was overborne by old memories. But this time he was not immersed in the depths of confusion. He remained orientated and _en rapport_ with his surroundings. The struggle was considerably milder, but he did gymnastics, practised the arts, and made good his deficiencies; then followed the dreamy stage with the love-songs, corresponding to the period of victory in the first psychosis. In this state, according to his own words, he had a dreamlike feeling as if he stood upon the borders of two worlds and knew not whether truth stood on the right or on the left. He told me, "It is said she is married, but I believe she is not, but is still waiting for me; I feel that it must be so. It is ever to me as if she were not married, and as if success were yet attainable."

Our patient here portrayed but a pale copy of the scene in the first attack of psychosis, when he, the victor, stood before his mistress. In the course of a few weeks after this conversation the scientific interests of the patient again began to predominate. He spoke with obvious unwillingness about his intimate life, he repressed it more and more, and finally turned away from it as if it did not belong to himself. Thus gradually the gate of the under-world became closed. There remained nothing but a certain tense expression, and a look which, though fixed on the outer world, was turned inwards at the same time; and this alone hinted at the silent activity of the unconscious, preparing new solutions for his insoluble problem. This is the so-called cure in dementia præcox.

Hitherto we psychiatrists used not to be able to suppress a laugh when we read an artist's attempts to portray a psychosis. These attempts have been generally regarded as quite useless, for the writer introduces into his conception of the psychosis psychological relationships quite foreign to the clinical picture of the disease. But the artist has not simply proceeded to copy a case out of a psychiatric text-book; he knows as a rule better than the psychiatrist.

The case which I have sketched is not unique, it is typical of a whole class for which the artist Spitteler has created a model of universal validity; the model is _Imago_. I may take for granted that you know his book of that name. The psychological gulf, however, between the creation of the artist and the insane person is great. The world of the artist is one of solved problems; the world of reality, that of unsolved problems. The mental patient is a faithful image of this reality. His solutions are unsatisfying illusions, his cure a temporary giving up of the problem, which yet goes on working in the depths of the unconscious, and at the appointed time again rises to the surface and creates new illusions with new scenery; part of the history of mankind is here seen abridged.

Psychological analysis is far from being able to explain in complete and illuminating fashion all cases of the disease with which we are here concerned. On the contrary, the majority remain obscure and difficult to understand, and chiefly because only a certain proportion of patients recover. Our last patient is noteworthy because his return to a normal state afforded us a survey of the period of his illness. Unfortunately the advantage of this standpoint is not always possible to us, for a great number of persons never find their way back from their dreams. They are lost in the maze of a magic garden where the same old story is repeated again and again in a timeless present. For patients the hands of the clock of the world remain stationary; there is no time, no further development. It makes no difference to them whether they dream for two days or thirty years. I had a patient in my ward who was five years without uttering a word, in bed, and entirely buried in himself. For years I visited him twice daily, and as I reached his bedside I could see at once that there was no change. One day I was just about to leave the room when a voice I did not recognise called out--"Who are you? What do you want here?" I saw with astonishment that it was the dumb patient who had suddenly regained his voice, and obviously his senses also. I told him I was his doctor, whereupon he asked angrily, why was he kept a prisoner here, and why did no one ever speak to him? He said this in an injured voice just like a normal person whom one had neglected for a couple of days. I informed him that he had been in bed quite speechless for five years and had responded to nothing, whereat he looked at me fixedly and without understanding. Naturally I tried to discover what had gone on in him during these five years, but could learn nothing. Another patient with a similar symptom, when asked why he had remained silent for years, maintained, "Because I wanted to spare the German language."[199] These examples show that it is often impossible to lift the veil of the secret, for the patients themselves have neither interest nor pleasure in explaining their strange experiences, in which as a rule they realise nothing peculiar.

Occasionally the symptoms themselves are a sign-post to the understanding of the psychology of the disease.

We had a patient who was for thirty-five years an inmate at Burghölzli. For decades she lay in bed, she never spoke or reacted to anything, her head was always bowed, her back bent and the knees somewhat drawn up. She was always making peculiar rubbing movements with her hands, so as to give rise during the course of years to thick horny patches on her hands. She kept the thumb and index finger of her right hand together as in the movement of sewing. When she died I tried to discover what she had been formerly. Nobody in the asylum recalled ever having seen her out of bed. Only our chief attendant had a memory of having seen her sitting in the same attitude as that she afterwards took up in bed, at which time she was making rapid movements of extension of the arm across the right knee; it was said of her that she was sewing shoes, later that she was polishing shoes. As time went on the movements became more limited till finally there remained but a slight rubbing movement, and only the finger and thumb retained the sewing position. In vain I consulted our old attendant, she knew nothing about the patient's previous history. When the seventy-year-old brother came to the funeral I asked him what had been the cause of his sister's illness; he told me that she had had a love-affair, but for various reasons it had come to nothing. The girl had taken this so to heart that she became low-spirited. In answer to a query about her lover it was found that he was a _shoemaker_.

Unless you see here some strange play of accident, you must agree that the patient had kept the memory-picture of her lover unaltered in her heart for thirty-five years.

One might easily think that these patients who give an impression of imbecility are only burnt-out ruins of humanity. But such is probably not the case. One can often prove directly that such patients register everything going on around them even with a certain curiosity, and have an excellent memory for it all. This is the reason why many patients become for a time pretty sensible again, and develop mental powers which one believed they had long since lost. Such intervals occur occasionally during serious physical disease, or just before death. We had a patient with whom it was impossible to carry on a sane conversation; he only produced a mad medley of delusions and words. He once fell seriously ill physically, and I expected it would be very difficult to treat him. Not at all. He was quite changed, he became friendly and amiable, and carried out all his doctor's orders patiently and gratefully. His eyes lost their evil darting looks, and shone quietly and understandingly. One morning I came to his room with the usual greeting: "Good morning. How are you getting on?" The patient answered me in the well-known way: "There again comes one of the dog and monkey troupe wanting to play the Saviour." Then I knew his physical trouble was over. From that moment the whole of his reason was as if "blown away" again.

From these observations we see that reason still survives, but is pushed away into some corner by the complete preoccupation of the mind with diseased thoughts.

Why is the mind compelled to exhaust itself in the elaboration of diseased nonsense? On this difficult question our new insight throws considerable light. To-day we can say that the pathological images dominate the interests of the patient so completely, because they are simply derivatives of the most important questions that used to occupy the person when normal--what in insanity is now an incomprehensible maze of symptoms used to be fields of vital interest to the former personality.

I will cite as an example a patient who was twenty years in the asylum. She was always a puzzle to the physicians, for the absurdity of her delusions exceeded anything that the boldest imagination could create.

She was a dressmaker by trade, born in 1845, of very poor family. Her sister early went wrong and was finally lost in the swamp of prostitution. The patient herself led an industrious, respectable, reserved life. She fell ill in 1886 in her 39th year--at the threshold of the age when so many a dream is brought to naught. Her illness consisted in delusions and hallucinations which increased rapidly, and soon became so absurd that no one could understand her wishes and complaints. In 1887 she came to the asylum. In 1888 her statements, so far as the delusions were concerned, were not intelligible. She maintained such monstrous things as that: "At night her spinal marrow had been torn out; pains in the back had been caused by substances that went through the walls and were covered with magnetism." "The monopoly fixed the sorrows which are not in the body and do not fly about in the air." "Excursions are made by breathing in chemistry, and by suffocation regions are destroyed."

In 1892 the patient styled herself the "Bank Note Monopoly, Queen of the Orphans, Proprietress of the Burghölzli Asylum;" she said: "Naples and I must provide the world with macaroni" (Nudel).

In 1896 she became "Germania and Helvetia from exclusively pure butter"; she also said, "I am Noah's Ark, the boat of salvation and respect."

Since then the disease has greatly increased; her last creation is the delusion that she is the "lily red sea monster and the blue one."

These instances will show you how far the incomprehensibility of such pathological formations go. Our patient was for years the classic example of meaningless delusional ideas in dementia præcox; and many hundreds of medical students have received from the demonstration of this case a permanent impression of the sinister power of insanity. But even this case has not withstood the newer technique of psychoanalysis. What the patient says is not at all meaningless; it is full of significance, so that he who has the key can understand without overmuch difficulty.

Time does not allow me to describe the technique by means of which I succeeded in lifting the veil of her secret. I must content myself by giving a few examples to make the strange changes of thought and of speech in this patient clear to you.

She said of herself that _she was Socrates_. The analysis of this delusion presented the following ideas: Socrates was the wisest man, the man of greatest learning; he was infamously accused, and had to die in prison at the hands of strange men. She was the best dressmaker, but "never unnecessarily cut a thread, and never allowed a piece of material to lie about on the floor." She worked ceaselessly, and now she has been falsely accused, wicked men have shut her up, and she will have to die in the asylum.

Therefore she is Socrates; this is, as you see, simple metaphor, based upon obvious analogy. Take another example: "_I am the finest professor and the finest artist in the world._"

The analysis furnishes the remarks that she is the best dressmaker and chooses the most beautiful models which show up well and waste little material; she puts on the trimming only where it can be seen. She is a professor, and an artist in her work. She makes the best clothes and calls them absurdly "The Schnecke Museum-clothes." Her customers are only such persons as frequent the Schnecke House and the Museum (the Schnecke House is the aristocratic club. It is near the Museum and the Library, another rendezvous of the aristocratic set of Zürich), for she is the best dressmaker and makes only Schnecke Museum[200] clothing.

The patient also _calls herself Mary Stuart_. Analysis showed the same analogy as with Socrates: innocent suffering and death of a heroine.

"_I am the Lorelei._" Analysis: This is an old and well-known song: "I know not what it means," etc. Whenever she wants to speak about her affairs people do not understand her, and say they don't know what it means; hence she is the Lorelei.

"_I am Switzerland._" Analysis: Switzerland is free, no one can rob Switzerland of her freedom. The patient does not belong to the asylum, she would be free like Switzerland, hence she is Switzerland.

"_I am a crane._" Analysis: In the "Cranes of Ibykus" it is said: "Whosoever is free of sin and fault shall preserve the pure soul of a child." She has been brought innocent to the asylum and has never committed a crime--hence she is a crane.

"_I am Schiller's Bell._" Analysis: Schiller's Bell is the greatest work of the great master. She is the best and most industrious dressmaker, and has achieved the highest rung in the art of dressmaking--hence she is Schiller's Bell.

"_I am Hufeland._" Analysis: Hufeland was the best doctor. She suffers intolerably in the asylum and is moreover treated by the worst doctors. She is, however, so prominent a personality that she had a claim to the best doctors, that is to a doctor like Hufeland--hence she is Hufeland.

The patient used the expression "I am" in a very arbitrary way. Sometimes it meant "it belongs to me" or "it is proper for me"; sometimes it means "I should have." This is seen from the following analysis:

"_I am the master-key._" Analysis: The master-key is the key that opens all the doors of the asylum. Properly, according to all rights, the patient should long since have obtained this key for she has been for many years "the proprietress of the Burghölzli Asylum." She expresses this reflection very much simplified in the sentence, "I am the master-key."

The chief content of her delusions is concentrated in the following words:--

"_I am the monopoly._" Analysis: The patient means the banknote monopoly, which has belonged to her for some time. She believes that she possesses the monopoly of the entire bank notes of the world, thus creating enormous riches for herself, in compensation for the poverty and lowliness of her lot. Her parents died early; hence she is the Queen of the Orphans. Her parents lived and died in great poverty. Her blessings are extended to them also, the dreamlike delusions of the patient benefit them in many ways. She says textually: "My parents are clothed by me, my sorely-tried mother, full of sorrow--I sat with her at table--covered in white with superfluity."

This is another of these malleable hallucinations which the patient had daily. It is one of those scenes of wish-fulfilment, with poverty on one side and riches on the other, recalling Hauptmann's Hannele; more especially that scene where Gottwald says: "She was clothed in rags--now she is bedeckt in silken robes; and she ran about barefoot--now she has shoes of glass to her feet. Soon she will live in a golden castle and eat each day of baked meats. Here has she lived on cold potatoes...."

The wish-fulfilments of our patient go even further. Switzerland has to furnish her with an income of 150,000 francs. The Director of the Burghölzli owes her 80,000 francs damages for wrongful incarceration. She is the proprietress of a distant island with silver mines, the "mightiest silver island in the world." Therefore she is also the greatest orator, possesses the most wonderful eloquence, for, as she says, "Speech is _silver_, silence gold." To her all the beautiful landed estates belong--all the rich quarters, towns and lands, she is the proprietress of a world, even a "threefold proprietress of the world." Whilst poor Hannele was only elevated to the side of the Heavenly Bridegroom, our patient has the "Key of Heaven," she is not only the honoured earthly queens Mary Stuart and Queen Louise of Prussia, but she is also the Queen of Heaven, the Mother of God as well as the Godhead. Even in this earthly world where she was but a poor, ill-regarded homely dressmaker she attained fulfilments of her human wishes, for she had taken three husbands from the best families in the town and her fourth was the Emperor Francis. From these marriages there were two phantom children--a little boy and a little girl. Just as she clothed, fed and feasted her parents, so she provided for the future of her children. To her son she bequeathed the great bazaar of Zürich, therefore her son is a "Zur," for the proprietor of a _Bazaar_ is a "Zur." The daughter resembles her mother; hence she becomes the proprietress of the asylum and takes her mother's place so that the mother is released from captivity. The daughter therefore receives the title of "Agency of Socrates," for she replaces Socrates in captivity.

These instances by no means exhaust the delusional fancies of the patient. But they will give you some idea, I hope, of the richness of her inner life although she was apparently so dull and apathetic, or, as was said _imbecile_, and sat for twenty years in her workroom, where she mechanically repaired her linen, occasionally uttering a complex of meaningless fragments which no one had hitherto been able to understand. Her odd lack of words can now be seen in another light; they are fragments of enigmatical inscriptions, of fairy-story phantasies, which have escaped from the hard world to found a world of their own. Here the tables are ever laden, and a thousand feasts are celebrated in golden palaces. The patient can only spare a few mysterious symbols for the gloomy dim shores of reality; they need not be understood, for our understanding has not been necessary for her for this long time.

Nor is this patient at all unique. She is one of a type. Similar phantasies are always found in patients of this kind, though not always in such profusion.

The parallels with Hauptmann's Hannele show that here likewise the artist has shown us the way with the free creation of his own phantasy. From this coincidence, which is not accidental, we may conclude that there is something common both to the artist and the insane and not to them alone. Every human being has also within himself that restless creative phantasy which is ever engaged in assuaging the harshness of reality. Whoever gives himself unsparingly and carefully to self-observation, will realise that there dwells within him something which would gladly hide and cover up all that is difficult and questionable in life, and thus procure an easy and free path. Insanity grants the upper hand to this something. When once it is uppermost, reality is more or less quickly driven out. It becomes a distant dream, and the dream which enchains the patient wholly or in part, and often for life, has now the attributes of reality. We normal persons, who have to do entirely with reality, see only the products of disordered fancy, but not the wealth of that side of the mind which is turned away from us. Unfortunately only too often no further knowledge reaches us of the things which are transpiring on that other side, because all the bridges are broken down which unite this side with that.

We do not know to-day whether these new views are of universal or only of limited validity; the more carefully and perseveringly we examine our patients, the more we shall meet cases, which, despite apparent total imbecility, will yet afford us at least some fragmentary insight into the obscurities of the psychical life. This life is far removed from that mental poverty which the prevailing theories were compelled to accept.

However far we are from being able to understand fully the concatenations of that obscure world, at least we may maintain, with complete assurance, that in dementia præcox there is no symptom which can be described as psychologically baseless and meaningless. The most absurd things are in reality symbols of ideas which are not only generally understandable, but also universally operative in the human heart. In insanity we do not discover anything new and unknown, but we look at the foundation of our own being, the source of those life-problems in which we are all engaged.