REVIEW OF INFECTIVE-EXHAUSTIVE PSYCHOSES WITH SPECIAL REFERENCE TO SUBDIVISION AND PROGNOSIS.*

BY SAMUEL W. HAMILTON, M. D.,1

Second Assistant Physician, Utica State Hospital, Utica, N. Y. In the New York State Hospital classification as projected by Dr. Adolf Meyer one of the divisions is called the infective-exhaustive group. It includes "autotoxic or infective or exhaustive psychoses not included in the group with a nervous disease or nervous complex or tangible brain disease; subdivided into (a) thyrogenous disorders, (b) uremic, eclamptic and demonstrated gastro-intestinal disorders, (c) febrile and postfebrile deliria, (d) exhaustive deliria and kindred psychoses." An allied group includes "those to all intents and purposes the same, but in which we cannot demonstrate such an etiology." Such cases have been in the past grouped in various ways by different writers. Let us review a few.

Ziehen describes acute hallucinatory paranoia which arises from exhaustion, intoxication, infection, trauma, hysteria and epilepsy, polyneuritis, puberty, climacteric, senility or the puerperium. Its diagnosis depends on proof of primary hallucinations which prevail throughout. Out of these develop delusions. Affect and association are only secondarily disturbed. With its varieties and subdivisions this would seem to include so many cases as to be of little help to us in any direction. For example there is the greatest possible range of prognosis. Moreover we find in cases. otherwise similar that hallucinations were not prominent, and the existence of these can be determined only on recovery.

Krafft-Ebing object that this is not a paranoia and does not pass into a paranoia. He calls it primary hallucinatory insanity.

* Read _at_the_sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

'To Dr. Wm. Mabon, superintendent and medical director of Manhattan State Hospital, I am indebted for permission to use the hospital records; and to Dr. George H. Kirby, director of clinical psychiatry, for the impetus to this study and very many suggestions as to the form and content of this paper.

It is to be diagnosed from mania and melancholia because the be havior is purely reactive. Constant symptoms are poor sleep, nervous excitement and confusion of ideas.

Ziehen presents a large group of conditions of clouded consciousness. These are alike in that the beginning and ending are very abrupt, course very short, amnesia follows; hallucinations and delusions may be absent, but the orientation and connection of ideas are disturbed. The principal causes are sleep, epilepsy, hyseria, alcohol and other toxic drugs, congestion or spasm of the arteries, migraine, neuralgia, strong affect, trauma. We need not discuss these varieties, which indeed from their symptomatology could hardly be differentiated. Accompanying or symptomatic deliria are distinguished from the preceding groups in that the course is closely related to the infection.

Wernicke describes in his own peculiar terminology confused mania or agitated confusion. There are psychomotor or psychosensory disorders and dominant symptoms of irritation. An asthenic confusion also with allopsychic disorientation is met after other exhaustive psychoses.

Kraepelin attempts to distinguish infection from exhaustion psychoses. The first include fever delirium, infection delirium (such as arises during the incubation period of some severe infection) and post-infection mental debility apprearing in convalescence on the ground of a fever or infection delirium. Exhaustion psychoses are collapse delirium at the crisis of some fever, acute confusion or amentia, and chronic acquired nervous exhaustion, which differs from other nervous exhaustions merely in that its starting point is some severe illness or strain. Thus his divisions are determined partly by the stage of the illness at which the disturbance develops, partly by the form of the psychosis.

Observe Kraepelin's types briefly with reference to experience at Manhattan State Hospital. Few fever deliria reach us, for it is the policy of Bellevue Hospital, whence most of our patients come, to transfer as few fever cases as possible. Infectious deliria, since they usually precede the outbreak of some severe illness, are sifted out by the general hospitals of New York City. Collapse delirium occurs in a state of such weakness that transfer to a state hospital would be unlikely. Chronic acquired nervous exhaustion is not certainly the result of that alone which appears as

the upsetting factor, and is generally not grouped by us with the infective-exhaustive cases. The bulk of those left are post-infection mental debilities or similar states apparently based on poor health and in a few cases on prolonged worry. Amentia is the only remaining type, and I do not find it frequent.

Kraepelin divides these debilities into four degrees: The first shows mental and emotional weakness; he is dull, tired, unable to ecollect his thoughts, may see vivid pictures when his eyes are closed. There are premonitions of death, suspicions leading to violence, attempts at suicide. The second stage shows prominent hallucinations, fantastic delusions, anxious excitement, profound obscuration, disconnected talk. There are dead people behind the bed, walls and furniture move, devil or Virgin appears, he does not know whether he is in heaven or hell, is given horsemeat, and so on. Recovery is slow with decreased efficiency and weak memory. The third subdivision passes rapidly into stupor, and patient later continues stupid or tearful with deficient memory and judgment. In the fourth degree occurs vivid delirious excitement with marked flight, delusions of grandeur, loss of orientation, great distractibility, voices, angels at the ceiling and such like. Misidentifications are frequent. Particularly with the third group (he says) the patient may remain mentally and emotionally incapable, apathetic, undecided, but apart from these defects he assumes a favorable outcome by assuming that any other is due to a different process. "In a few cases . . . develop . . . . mental diseases which might also occur under other conditions— manic-depressive insanity, dementia præcox, general paralysis. In these cases the fever is not the cause but the occasion."

I wish to review with you a number of cases (22) observed at Manhattan State Hospital to see if they throw any light on the composition and outcome of the infective-exhaustive group. It must be admitted that patients with adequate etiology, symptoms apparently sufficient for classing with this group, notwithstanding show deterioration indistinguishable from dementia præcox, and a few such cases are considered in this list. Cases ending in death are with one exception excluded, since they do not illuminate the issues. We will divide them so far as possible into Kraepelin's degrees of severity.

A comparatively mild case was K. L. During typhoid fever

she jumped out of bed, demanded a priest, said she was going to die. She would not eat for a time, complained that her arms were heavy, misidentified, replied only when urged, thought people were calling her. She grasped mental tests slowly and avoided mental effort, refusing to count change with the words “It puzzles me." It was four months before her normal state returned fully though she left the hospital earlier. F. P. during puerperal fever became "delirious," then depressed, and had to be tube-fed. She lost track of time and movement from one hospital to another, saw faces and pictures on the wall, heard voices at night. With us she was afraid the patients would hurt her, thought one was mocking her by belching, said the medicine tasted like paint, heard voices of enemies. Soon she cleared up but had little idea of time duration during the hazy period. J. G. after uterine hemorrhage thought someone wanted to kill her, that they tried to get into her room at night. She talked freely but incoherently, was worried and restless, complained that the food was not what she wanted, that she was lonesome. Recovery in nine months. Another typhoid case with different outcome was P. M. During conva lescence he became moody and once was excited, throwing his chair about. On going home from the general hospital where he had been sick he sang, shouted and thought he was driving. Gradually he reached a state where he complained of books being put in his head, that his thoughts were read, that machines were used on him. He thought Central Islip was Blackwell's Island. He is discontented, idle, surly, irritable. These four cases would fall in Kraepelin's first division.

The second degree with prominent hallucinations, fantastic delusions, etc., were more numerous. C. T., after a period of poor health, grew confused and could hardly find her way around the streets of a city she had formerly known well and was now visiting. She grew uneasy and agitated, smelled peculiar odors and saw "such horrible people" staring. She misidentified strangers as members of her family, thought the blowing off of a gas retort was a deadly explosion and shouted for the police between mouthfuls of her supper. Her husband's voice came from outside the building. Later she tried determinedly to kill herself. Gradually she became clear. A. F., in the eighth month of lactation, while in poor general health, developed peculiar bodily sensations which

she thought due to poison. Then she talked of Black Hand persecution, heard Italians at the foot of the stairs and negroes on the roof. Once she did not recognize her husband, saying, “This is the man that killed my baby." Symbols of the Black Hand appeared everywhere; she was annoyed by hallucinations of sight and hearing. A newspaper portrait she thought hers and two physicians her brothers. She ran about the place half clad, thought it was the House of the Good Shepherd. For a time she was cheerful, flippant, sometimes resistive. Then she recovered. A. S.'s trouble started during the fever of gastro-enteritis. In a general hospital she misinterpreted all sorts of sounds and tried to choke the physician who, by giving her mercury, had caused all her troubles. Her mood, arising out of grandiose delusions, was cheerful; nevertheless she was suspicious. She never gained complete insight, but has done well outside the hospital a long time. H. H. was worried over sexual irregularities and working un› necessarily hard during the weeks following labor. She saw ghosts, cats and dogs. Misidentifications, perplexity, her husband's voice from the floor, disorientation are noted. Improvement came slowly and judgment lagged behind other faculties. B. P. suffered general ill health and was grieved by the death of her children. During another pregnancy she heard fire engines, people talking outside and shots fired by people who were coming to kill her husband. Her speech became incoherent, but she was evidently intensely worried. She refused food, got extremely suspicious and apprehensive. Remarks by other patients she thought were aimed at her; people said she had coons for brothers. Gradually she gained strength and courage. L. N., during convalescence from erysipelas, thought people would kill her and believed herself poisoned. Orientation was hazy and she was suspicious and fearful. At time of discharge she would not yet speak unreservedly of her experiences but did mention seeing and hearing things. F. K. had poor health and nephritis. She complained that she was not given food, predicted that the doctor's medicine would kill her, told in what clothes she was to be laid out. Violence, an attempt at suicide and incoherent speech followed. Her most prominent hallucinations were tactile. She thought the place a telegraph office and could tell only the month when a calendar was before her. Other patients she thought men and all talked