CHAPTER X

THE PSYCHOSES WITH OTHER SOMATIC DISEASES

Mental disturbances of various types associated with somatic conditions and not sufficiently characteristic or circumscribed in their symptomatology to constitute definite and separate psychoses have long been recognized. That delirium is a complicating factor in certain acute febrile diseases has been known for centuries. Aristotle called attention to the occurrence of hallucinations and illusions during the course of fevers. Hippocrates referred frequently, not only to excitements, but to delirium and phrenitis. The word "delirus" appears in several places in the works of Horace and many of the early authors apparently used this term as synonymous with both mania and melancholia. That was probably true of Sennert. Flemming in 1844 mentioned fever delirium, hallucinatory and delusional clouded states and an encephalitic form in addition to the various alcoholic types. Sydenham referred to the mental symptoms associated with malaria and Bright in his original "Reports" described other delirious conditions at some length. Sir Thomas Watson showed that the brain was uninvolved at autopsy in the acute rheumatic affections with apparent cerebral complications. Mental symptoms have, of course, been associated for hundreds of years with meningitic processes. Diabetic coma was also recognized long since. Griesinger is said by some to have been the first to call attention to the psychoses caused by the acute infections. Post febrile mental disturbances were, however, referred to by Sydenham, Baillarger, Westphal, Greenfield, Gubler and many others. Delasiauve very elaborately described the psychoses associated with typhoid fever in 1849. The mental disorders accompanying gout were discussed at considerable length by Sydenham and were referred to as early as 1699 by Philander Misaurus.

According to Bucknill and Tuke[261], Misaurus made the following very interesting suggestions in an article entitled "The Honour of the Gout": "It would be worth inquiry, whether the gout is not as effectual against madness; and we may reasonably believe that it is so, if upon examination, it should be found that there are no gouty people in Bedlam; and then for the recovery of these poor creatures to their wits again, it will not need much consideration, whether they ought not to be excused the hard blows which their barbarous keepers deal them, and the Therapeutic method of Purging, Bleeding, Cupping, Fluxing, Vomiting, Clystering, Juleps, Apozemes, Powders, Confections, Epithemes, Cataplasms, with which the more barbarous Doctors torment them, and instead of their learned Torture, indulged for a time only, a little intemperance as to wine, or women, or so; or the scholar's delight of feeding worthily, and sleeping heartily, whereby they might get the Gout, and then their madness were cured." Clouston described a very definite form of phthisical insanity. Van der Kolk made the surprising statement that phthisis and mania often alternated in regular cycles. Nasse classified the mental conditions associated with fevers as either resulting directly from the febrile disturbance, constituting a prolongation of the delirium after the temperature subsided, or developing during convalescence.

The German psychiatrists during the first part of the nineteenth century were divided into two quite separate groups. One of these insisted that all mental diseases were purely psychic in origin, and the other, that they were in all instances directly attributable to somatic disease processes. The former school was ably represented by Heinroth and Ideler and the latter by Jacobi, Nasse and Friedreich. This led to a controversy which lasted for many years. Heinroth's views were illustrated by his statement[262] that "Insanity is the loss of moral liberty. It never depends upon a physical cause; it is not a disease of the body but of the mind—a sin.... The man who has during his whole life before his eyes and in his heart the image of God, has no reason to fear that he will ever lose his reason.... Man possesses a certain moral power which cannot be conquered by any physical power, and which only falls under the weight of his own faults.... From wrong doing springs all misfortune, including the disorders of the mind." His principal work was a "Lehrbuch der Seelenkunde," published in Leipsic in 1818. The teachings of the psychic school were summarized by von Feuchtersleben[263] as follows:—"The mind is the immediate seat of the disease, the bodily suffering is secondary. Mental disorders may be clearly traced to their origin, Sin, Error, Passion. Diseases of the brain, on the contrary, and of all the organs, occur, even in their greatest intensity, without mental disturbance, as also the latter without the former. The psychical mode of cure is that which is properly efficient; the somatic remedies in reality act psychically; for instance through pain, diversion of the thoughts, stupefaction, terror. Pathological anatomy has not discovered any decided relation between disorganization of the brain and mental disorders." In 1836 Friedreich[264]in opposing Heinroth's views outlined thirteen reasons for believing that all psychic disorders were somatic in origin:—"1. Because the mind cannot become diseased; 2. because the greater part of the causes producing those conditions is somatic; 3. because in all mental disorders there are somatic symptoms in addition; 4. because they are too permanent for pure conditions of the mind; 5. because they are subject to cosmical and telluric states; 6. because their crises always take place in a material way; 7. because they are not infrequently removed by strong material influences; 8. because the somatic mode of cure alone has a direct sanatory effect, the psychical at most an indirect effect on the body; 9. because the occurrence of psychical indisposition on one side only, must arise from the duality of the brain; 10. because the return of reason before death occurs in cases not only of psychical, but likewise of somatic diseases, and may be physically accounted for; 11. because mental disorders correspond with the temperaments; 12. because it may be proved that there are psychical conditions which depend on organic causes, and are therefore very analogous to psychical disorders; 13. because chronic delirium (mania) can be no other than febrile." Absurd as such discussions may seem at this time, they are no worse than the theological debates of that day. As a matter of fact, they were no more futile than the efforts still being made to classify the various psychoses on some one common ground, for any other than purely statistical purposes.

Kraepelin[265] divides the psychoses due to infection into febrile delirium, infection delirium, acute confusional states (amentia) and exhaustions. The result of the infectious process, as he says, may be merely to precipitate a manic-depressive psychosis, or an attack of dementia praecox, general paresis or delirium tremens. It may also be manifested in the form of a neuritis, myelitis, encephalitis, or a meningitis. Bonhöffer in 1910 described several forms of "symptomatic psychoses" due to infections and divided them into three main groups: deliria, confusions and mental enfeeblements. He also referred to epileptiform excitements, dream states, hallucinoses, manic types and amentias either hallucinatory, catatonic or incoherent in character.

Kraepelin speaks of several definite stages or forms of febrile delirium. In the mildest of these there is a feeling of discomfort with a sensation of fulness in the head and a marked sensitiveness to external impressions. In the second stage a suggestion of clouding becomes apparent and perception is distorted by hallucinations and illusions. There is an increased activity of the mental processes and consciousness soon assumes a dreamlike form. Hallucinations and illusions are mixed with realities. The restlessness increases and excitements or depressive moods may precede the appearance of the third stage. In this there is a more pronounced disturbance of consciousness with disorientation, confusion, flight of ideas, and variable emotional reactions, sometimes with actual manic manifestations. Evidences of stuporous tendencies may appear at times. In the fourth stage a state of weakness develops, with picking at the bed clothes, tremulous movements and a senseless muttering of words and syllables. This terminates in complete coma. In smallpox, scarlet fever, erysipelas, articular rheumatism and pneumonia there are often sudden confused excited states, while in typhoid fever stuporous delirium is the rule. Hendriks found the mental symptoms in typhoid greater during convalescence and not closely related to the febrile reaction. He describes a marked disturbance of attention with little involvement of apprehension or comprehension, but marked loss of mental capacity and sometimes a tendency to confabulation. Visual hallucinations and loss of sleep are common symptoms. Often there is restlessness, talkativeness, indifference, carelessness and disturbances of volition. In articular rheumatism and scarlet fever, according to Kraepelin, delirium sometimes develops with sudden rise of temperature. Restlessness, talking in the sleep, volubility or dulness precede an unusually violent delirium, sometimes terminating in stupor and death. The basis of these conditions in all cases is the toxic infection causing the fever, changes in metabolism, circulatory disturbances and an involvement of various organs, particularly the brain. A rapid and considerable rise of temperature usually causes delirium in typhoid, smallpox and erysipelas while it has no such effect usually in tuberculosis. This disturbance is a direct result of the influence of the toxins on the cortex. Alcoholism constitutes another well-known and common cause. In seventy per cent of the cases the duration was less than one week and the delirium disappeared with the fall in temperature. Some cases terminate in infection delirium or they may precipitate genuine attacks of manic-depressive insanity, dementia praecox or general paresis.

The so-called acute alteration of Nissl was a very common change found in the cortical cells at autopsy. This very generally involved the entire cortex. Kraepelin describes another characteristic alteration observed in cases of typhoid delirium. The Nissl bodies are clumped together in the periphery, and are deeply stained, the processes also being unusually dark. Some cells show a shrunken nucleus with swollen, lightly stained bodies. Around these neurones there are usually large accumulations of elongated glia cells.

In the infection delirium, so called, the mental disturbance develops in a case where there is no hyperpyrexia or where at least there is no relation between the psychosis and the temperature. A restless excitement ushers in the attack. Pressure in the head, mental dulness, depressed or sometimes cheerful moods, uneasiness, disturbed sleep and anxious dreams are common symptoms. Later a disturbance of consciousness appears and a special type known as "initial delirium" may develop. This is a common occurrence in typhoid fever.

Aschaffenburg described two forms of initial delirium. The first is a restless condition of clouding with hallucinations and delusions. The second form, which may develop from the first, shows active mental excitement. Mild in its onset, a confusional delirious state soon develops with flight of ideas, hallucinations, delusions, and marked anxiety. An initial delirium of this type often occurs in smallpox. This assumes a particularly severe form with a tendency to suicide and violence, strongly resembling epileptic dream states. Seizures and epileptiform convulsions may occur. The delirium usually develops from the third to the fifth day of the disease and mental enfeeblement sometimes follows. The attack usually lasts from several days to a week. It may continue as a fever delirium. About forty or fifty per cent die. Nissl in one case found a marked congestion of the vessels of the cortex, with an increase in the number of leucocytes, and a widespread destruction of the neurones. The cell bodies were swollen and the chromatin lumps destroyed. Karyokinetic changes were noted in the glia cells.

More or less similar delirious states occur in the course of intermittent malarial fevers. These usually take the form of a marked anxious excitement, often with stupor or a tendency to violence. The attacks begin suddenly, last only a few hours and end in sleep. Convulsions are frequently observed. These conditions occur in the quotidian or tertian types but rarely in the quartan. The delirium precedes a febrile disturbance or may take its place. It is apparently due to an accumulation of plasmodia in the cerebral vessels. In influenza, restlessness, confusion, anxious excitement or hallucinatory deliria may be associated with a low temperature. Polyneuritic manifestations have also been observed. The disturbance is undoubtedly caused by the influenza bacillus or the action of its toxins on the cortex. Abscesses are found in some instances. Deliria with phthisis are rare unless there is a tubercular meningitis. In the septic infections, conditions with marked clouding are often observed, and are to be attributed to embolism, metastases, etc. Muscular weakness, aphasia, perseveration and convulsions may be present in these cases. Infection delirium also occurs in chorea. This takes the form of a clouded dreamlike state with confusion of thought at times, hallucinations, delusions, and emotional excitement accompanied by characteristic choreiform movements. Apprehension, as a rule, is unimpaired, but attention is disturbed and the patients are forgetful and distractible. They do not have a clear grasp on their surroundings. Occasional hallucinations appear. The mood is anxious, excited, fearful or irritable, sometimes with outbursts of anger or threats of suicide. The choreiform attacks are aggravated and speech is affected. The reflexes are decreased and muscular weakness develops. The pupils are dilated and sleep is interfered with to a marked degree. This excitement lasts for a short time only, but often recurs. In nine per cent of the cases (Kleist) death results from heart failure, septic infection or other intercurrent diseases. Wassermann and Westphal demonstrated streptococci in the brain in several cases of chorea. Others have reported staphylococci in the blood. Choreic delirium is usually associated with endocarditis or rheumatic infections, and occurs in the acute type but not in the Huntington variety of the disease.

Delirious excitements, according to Kraepelin, also occur in acute cerebrospinal inflammatory processes and may be due to furunculosis or caused by infections from the mouth or the intestinal _tract_. There is nothing particularly characteristic in such conditions aside from their severity. They have been collectively described under the designation of "acute delirium." Their differentiation depends entirely on the demonstration of the source of infection. The anatomical basis for these disturbances is always found in the cerebral cortex. The pia is infiltrated with lymphocytes and plasma cells and leucocytes are found in the perivascular spaces. There is also a proliferation of the glia. The "grave" alteration of Nissl is often demonstrable. After the infectious process passes its maximum intensity and the delirium disappears, "residual" delusions may remain with a clear sensorium. These may last for several days or even weeks. They frequently follow typhoid fever. Occasionally hallucinations of sight and hearing persist in the same way.

"Collapse delirium" was first described by Hermann Weber in 1866. It takes the form of a stuporous state with confusion of thought, dreamy hallucinations, flight of ideas, an unstable emotional condition and an active motor excitement. The onset is usually sudden, following a period of sleeplessness and restlessness. Disorientation occurs early and consciousness is markedly clouded. Phantastic hallucinations and illusions are frequent. Excitement and confusion are also prominent symptoms. Flight of ideas is common and the patient often sings or expresses himself exclusively in verse or rhymes. Senseless and rapidly changing delusions are noted. The mood is elated, erotic, anxious or irritable, with outbursts of anger. Motor excitement is conspicuous and there is no sleep. Usually food is refused and nutrition disturbed with a great reduction of bodily weight. This condition is of short duration, usually not more than a few days, often terminating in sleep in favorable cases. Only a confused recollection of events remains on recovery. Collapse delirium, according to Kraepelin, is purely an infectious process and often occurs in pneumonia, erysipelas and influenza, following the subsidence of the active symptoms of the disease. It occasionally complicates articular rheumatism and scarlet fever. The characteristic features in erysipelas are hallucinations and delusions of a delirious type, while clouded states, confusional excitements and flight of ideas are more common after pneumonia. The symptoms usually develop after the temperature falls and other evidences of weakness are present. Kraepelin, however, recognizes infection as the only cause at this time, although he previously described these as exhaustive conditions.

Acute confusional states or amentia were described by Meynert in 1881. These are characterized by a clouding of consciousness with multiform manifestations of excitement both sensory and motor. Amentia is one of the sequelae of infectious diseases. It takes the form of a subacute development of a dreamlike confusion with hallucinations, illusions and motor excitement lasting usually for several months. It is very closely related to collapse delirium and the hallucinatory insanity of Hoche, Fürstner and others. The early symptoms are sleeplessness and unrest. The patients become anxious, forgetful, develop a fear of death, and cannot control their thoughts, complaining of dulness and confusion of mind. A difficult comprehension of external impressions develops. They may be attentive and seriously troubled at not being able properly to grasp their surroundings. A decided uncertainty and restlessness results. Everything seems changed or false. There is at first a feeling of inadequacy and a profound disturbance of thought which develops into a well defined confusional condition. A dreamlike state follows, sometimes with a tendency to fabrications. Rhymes, phrases and words may be repeated frequently. There is a tendency towards distractibility and flight of ideas with vague thoughts of persecution. Hallucinations sometimes become apparent, and illusions appear. The mood is usually one of irritable anxiety, suspicion and mistrust, seldom with complete dulness. Occasional outbursts of anger take place. A restless behavior is noted as a rule. Sometimes suicidal tendencies occur and mild stuporous states follow.

In another group of cases depression is an especially prominent feature as occasionally happens after typhoid fever; or states of excitement may exist with a flight of ideas and delusions of grandeur. Before the febrile disturbance has disappeared signs of restlessness are noted. Orientation is soon lost, apprehension is disturbed, the patient becomes distractible and begins to show hallucinations. Ideas of grandeur develop and fabrications are conspicuous and extravagant. The mood is angry and irritable, sometimes cheerful or elated, but very changeable. Restlessness, volubility, flight of ideas, senseless rhyming, confused writing and tendencies to sing, etc., soon appear. The sleep is very much disturbed. Very little nourishment is taken or it is refused entirely. Bodily weight is greatly reduced. The reflexes are usually increased, the pulse slow and the temperature subnormal. The duration of the disease is usually not more than from two to six months. Amentia usually follows typhoid, articular rheumatism, smallpox and cholera, and occasionally occurs after pneumonia. Symptoms invariably develop after the fever has subsided. After typhoid the characteristic features are excitement with hallucinations, delusions and variable moods; after articular rheumatism, disturbance of apprehension, restlessness, depression or even stupor; and after phthisis, hallucinations with preservation of consciousness and slight confusion.

Light forms of the infectious exhaustions, according to Kraepelin, may appear after convalescence from the more severe illnesses. The patient does not make a good recovery, is exhausted, cannot think clearly, tires easily and is not able to read or write letters. Mental activity is weakened and the patient remains in bed, apathetic and indifferent. Consciousness, orientation and perception are undisturbed, although hallucinations may appear when the eyes are closed or noises in the ears may be noticed. The mood is gloomy, hopeless, and sometimes irritable, with sudden attacks of anxiety at night. The patient becomes suspicious and has fears of death or poisoning. Hypochondriacal feelings with self-accusation may develop. Food may be refused and suicidal attempts occur. Some cases are reserved and quiet, even stuporous, expressing only a few delusional ideas at times. Sleep and appetite are affected and weight lost as a consequence. These lighter forms usually follow influenza, articular rheumatism, whooping cough, tuberculosis or chorea. The duration is ordinarily brief—a few weeks or months, followed by recovery. In some instances the disease may progress to a complete enfeeblement of the mental processes.

The exhaustive conditions in a large group of more severe cases are ushered in by a delirium or confusional state with a depressed mood. There is first a slight anxiety. Self-accusation and persecutory ideas appear early. Hallucinations of hearing and vision develop. The patients soon become clouded, inattentive, show difficulty of thought and loss of memory, with mental dulness. All grasp upon their surroundings is lost, they fail to recognize members of the family, and answer questions unintelligently. They have no appreciation of their condition and no memory for events. The mood is indifferent, apathetic or whining. It may be irritable, quarrelsome or violent. Usually they lie in bed and are entirely apathetic. Sometimes they show automatic movements and have to be fed. The conversation is often incoherent and meaningless. They are inclined to be emotional. Sleep is usually interfered with and they are restless at night. The appetite is lost. Occasionally evidences of brain lesions appear with paralyses, speech disturbance or epileptiform seizures. The duration is usually a matter of a number of months. At autopsy grave cell alterations and glia reactions are common. Rod cells are also found. Endothelial proliferation is frequently observed in the vessel walls. Some cases terminate in a chronic condition which may improve somewhat in time. There may be a persistent emotional and mental enfeeblement with indifference, loss of memory, lack of judgment and impairment of will. These "acute dementias" represent the terminal stages of cortical infectious processes. They have been observed after typhoid, rheumatism, erysipelas, cholera, smallpox and malaria. Usually after tubercular peritonitis or articular rheumatism there is a simple mental enfeeblement, while erysipelas is usually accompanied by mild excitements and an elated mood. The typhoid cases usually showed irritability, with outbursts of anger and confusional states with hallucinations and delusions. They occasionally terminate in more chronic conditions with permanent deterioration.

After typhoid, influenza and septic infections, Korsakow's "cerebropathica psychica toxaemica" sometimes occurs. This is the polyneuritic psychosis similar to that caused by alcohol. There is, however, a delirium or stupor at the same time.

The post-rheumatic psychoses have been studied exhaustively by Knauer.[266] Stuporous attacks were found in ninety-three per cent of his cases, following acute infections. He describes four groups showing psychotic manifestations:—

1. Anxious delirious excitements followed by stupor. 2. Excitements alternating with stupor. 3. Stuporous depression throughout. 4. Amentia-like excitements throughout.

The essential feature of Knauer's study was an analysis of post-rheumatic stupors. He describes these as clouded or dream states "not different from physiological sleep and the ordinary artificial narcoses." In them he sees a disturbance of apprehension, an interference with intellectual processes, a retention defect, and a loss of the power of attention. Catalepsy was found to be present in the majority of his cases. The loss of affect was described as being more complete than in manic-depressive psychoses. He speaks of the mood as sad, depressed, anxious, but above all, changeable.

Generally speaking this group of psychoses due to somatic disease is one which requires further study. We have comparatively little statistical information on the subject as yet. The differentiation of these conditions as outlined in the Association's statistical manual is as follows:—

"Under this heading are brought together those mental disorders which appear to depend directly upon some physical disturbance or somatic disease not already provided for in the foregoing groups.

"In the types designated below under (a) to (e) inclusive, we have essentially deliria or states of confusion arising during the course of an infectious disease or in association with a condition of exhaustion or a toxaemia. The mental disturbance is apparently the result of interference with brain nutrition or the unfavorable action of certain deleterious substances, poisons or toxins, on the central nervous system. The clinical pictures met with are extremely varied. The delirium may be marked by severe motor excitement and incoherence of utterance, or by multiform hallucinations with deep confusion or a dazed, bewildered condition; epileptiform attacks, catatonic-like symptoms, stupor, etc., may occur. In classifying these psychoses a difficult problem arises in many cases if attempts are made to distinguish between infection and exhaustion as etiological factors. For statistical reports the following differentiations should be made:

"Under (a) 'Delirium with infectious diseases' place the _initial deliria_ which develop during the prodromal or incubation period or before the febrile stage as in some cases of typhoid, small-pox, malaria, etc.; the _febrile deliria_ which seem to bear a definite relation to the rise in temperature; the _post-febrile deliria_ of the period of defervescence including the so-called 'collapse delirium.'

"Under (b) 'Post-infectious psychoses' are to be grouped deliria, the mild forms of mental confusion, or the depressive, irritable, suspicious reactions which occur during the period of convalescence from infectious diseases. Physical asthenia and prostration are undoubtedly important factors in these conditions and differentiation from 'exhaustion deliria' must depend chiefly on the history and obvious close relationship to the preceding infectious disease. (Some cases which fail to recover show a peculiar mental enfeeblement.) In this group should be classed the 'cerebropathica psychica toxaemica' or the non-alcoholic polyneuritic psychoses following an infectious disease as typhoid, influenza, septicaemia, etc.

"Under (c) 'Exhaustion deliria' are to be classed psychoses in which physical exhaustion, not associated with or the result of an infectious disease, is the chief precipitating cause of the mental disorder, _e.g._, hemorrhage, severe physical over-exertion, deprivation of food, prolonged insomnia, debility from wasting disease, etc.

"Of the psychoses which occur with diseases of the ductless glands, the best known are the thyroigenous mental disorders. Disturbance of the pituitary or of the adrenal function is often associated with mental symptoms.

"According to the etiology and symptoms the following types should therefore be specified under 'Psychoses with Other Somatic Diseases':

"(a) Delirium with infectious disease (specify) "(b) Post-infectious psychosis (specify) "(c) Exhaustion delirium "(d) Delirium of unknown origin "(e) Cardio-renal disease "(f) Diseases of the ductless glands (specify) "(g) Other diseases or conditions (to be specified)."

A study of 480 cases of psychoses with other somatic diseases reported from the New York state hospitals during 1918 and 1919 shows the following types represented:—

_Number_ _Percentage_ Delirium with infectious diseases 68 14.16 Post-infectious psychoses 102 21.25 Exhaustion delirium 94 19.58 Delirium of unknown origin 36 7.50 Cardio-renal diseases 69 14.37 Diseases of the ductless glands 20 4.16 Other conditions 91 18.90

An analysis of 140 cases from the Massachusetts state hospitals in 1919 shows the following:—

_Number_ _Percentage_ Delirium with infectious diseases 48 34.28 Post-infectious psychoses 25 17.85 Exhaustion delirium 26 18.57 Delirium of unknown origin 6 4.28 Cardio-renal diseases 16 11.42 Diseases of the ductless glands 1 .71 Other conditions 18 12.85

Three hundred and sixteen cases from hospitals in nineteen other states were reported as follows:—

_Number_ _Percentage_ Delirium with infectious diseases 69 21.83 Post-infectious psychoses 30 9.49 Exhaustion delirium 75 23.73 Delirium of unknown origin 33 10.44 Cardio-renal diseases 45 14.24 Diseases of the ductless glands 15 4.74 Other conditions 49 15.50

We have, thus, a total of 936 cases distributed as follows:—Delirium with infectious diseases, 19.76 per cent; post-infectious psychoses, 16.77; exhaustion delirium, 20.83; delirium of unknown origin, 8.01; cardio-renal diseases, 13.88; diseases of the ductless glands, 3.84; and other conditions, 16.88 per cent. Four and one hundredth per cent of the first admissions in Massachusetts, 3.45 per cent of the New York admissions, and 2.07 per cent of admissions to twenty-one other institutions during the same period of time were cases of psychoses due to other somatic diseases. They constituted 2.81 per cent of 34,935 admissions to all of the institutions above noted.