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Popular Science Monthly/Volume 85/December 1914/Common Factors in Mental Health and Illness

< Popular Science Monthly‎ | Volume 85‎ | December 1914

COMMON FACTORS IN MENTAL HEALTH AND ILLNESS
By Dr. F. LYMAN WELLS

MCLEAN HOSPITAL

Denn sie hatte,—wie die meisten Menschen,—nur die Wahl zwischen Tobsucht und Ergebenheit.—Simplicissimus, 18, 661.

I AM asked to deal in these remarks with variations in different human traits which are produced by pathological conditions. For example, although in health John's eyesight is sometimes better or worse than at others, yet John's eyesight is so consistently better than James's that we speak of John as having better eyesight than James. But John's eyesight might become much worse as the result of a central lesion, and, if it remained fairly stationary at its new level, John would have much worse eyesight than James as the result of the pathological condition, and a new individual difference would be produced. The psychoses of which we shall speak, however, do not act in altogether this way. The differences associated with them are not sufficiently stable at any one level to make it just to say, e. g., that a general paralytic has on the average one half the memory capacity of the normal. We can therefore speak of the kind, direction and limits of such changes, but not of their amount as representative of any clinical group.

It is one of the gentle ironies of scientific history that the concept of individual differences should have originated with one of its least significant functions. One must needs be the assistant of a pre-Galtonian astronomer to suffer for his simple reaction time. This fact, together with the necessary technical complications, has not encouraged the accumulation of pathological data on the "personal equation." The most important determinations are those of Diefendorf and Dodge, on the reaction time of the eye-movements. They found lengthened time in all the psychoses tested, slightest in the manic-depressive excitements and in dementia præcox, most marked, as would be expected, in manic-depressive depression. The angular velocity of eye-movements was found by these authors to be somewhat more rapid than normal in dementia præcox, general paralysis, and slightly also in manic-depressive excitement, while the slowest movements were seen in the depressions and in epilepsy. The generally quick movements of manic cases and the slowness of depressed ones are a clinical commonplace.

The rapidity with which some small movements can be repeated has a special neurological meaning, and many observations have been made with the psychoses. The rate is probably a little faster than the normal in manic cases, but if anything more fatigable. It is much slower in the depressed phase of the psychosis, and increases somewhat as it is kept up, and the retardation is partially overcome by the continued work. E. K. Strong has recently followed this and other functions through different clinical stages of the disorder. Nothing particular has appeared in the other psychoses, save that in terminal cases of dementia præcox a disorganization of control is sometimes seen, similar to what appears, and would be expected, in coarse nervous lesions. W. G. Smith found a rate averaging a little above the normal in epileptic cases, owing to a notable persistence of speed.

The most psychologically interesting observation of choice reactions is that of Franz, in which the psychomotor retardation produces a longer simple than choice reaction time, owing, apparently, to a greater overcoming of retardation in the more complex process. A similar finding is reported by Marie and Vaschide.

The tremors of the "steadiness test" play no part in mental pathology outside of the coarse nervous lesions. Defectiveness in the speech movements, where it is a real defect and not a mannerism, is usually also produced in this way. For the same considerations as apply with the eye-movements, accurate registration should enhance their diagnostic significance. Something of the sort has already been reported by Scripture in reference to epilepsy.

A number of fairly definite motor phenomena of the psychoses ought to be mentioned, though they have not been brought under experimental control. Eetention of the limbs in positions where placed is most common in dementia præcox states, but is also seen in extremely retarded cases of the manic-depressive type, where it has been psychologically interpreted as an extreme ideomotor perseveration. Closely allied to this is the type of motor disorder in dementia præcox known as "waxy," or flexibilitas cerea, in which the limbs are movable from one position to another like those of a wax figure. On the other hand, the resistiveness may be of the spring type, the member strongly resisting displacement, and at once returning to its original position. Extreme motor stupor combined with mental alertness is also met with in this psychosis; while the stereotypy and mannerisms of normal life are often tremendously exaggerated in it.

There is a good deal of ground for suspicion that these phenomena are far from motor in the sense that they originate at the same levels with tremors or reflexes. Thus in some cases the resistance to pressure is begun in anticipation of the pressure, and, if, for example, a finger nearly but not quite touching the forehead be slowly drawn away, the patient, resisting the suggested pressure, may bend forward until equilibrium is lost. There is more likely an ideational element in such phenomena, and like their counterparts that we shall see among the higher mental processes, they are obscurely purposeful. So also are the impulsive acts of dementia præcox as compared with those of general paralysis.

The psychology of feeling is one in which the standpoint of individual differences has played very little part. The field is both tempting and difficult, and there has been the least progress in proportion to the experimental work done in mood and emotional reaction. Common observation shows that there are true individual differences, and for the adaptation to life, these differences are of paramount significance.

In many of the psychoses, the mood and emotional reactions are markedly and fundamentally altered. Heightened emotional sensitiveness, or lability of mood, is especially characteristic of exophthalmic goiter or Graves' disease. The source of intoxication here being internal secretion, it is a noteworthy illustration of the interdependence between mental activity and various extraneural processes. Functional atrophy of the thyroid gland is accompanied by a converse picture showing dulness and stupor, and with generally opposite symptoms, both physical and mental, to Graves' disease.

Still other psychoses are characterized by feelings of exaggerated well-being. The manic excitement shows a typically active exhilaration, often with no apparent diminution of intellect, manifesting itself as we should expect to see it manifested in an exaggeratedly happy normal person, with dancing, singing, jibing, half-jocular overestimations of one's powers and the like. Another phase of the manic-depressive psychosis shows a sort of mute transport, or silent ecstasy, in which it is very difficult to get at the mental content at all; it is termed the manic stupor. The most genuinely beatific state of mind that is maintained in terrestrial relations is probably seen in general paralysis; a state of easy-going, beaming euphoria, which the patient himself has no words to describe, but which finds some expression in grandiose but feeble delusions, scarcely if at all reacted to, as that he possesses countless millions, is king of the world, the super-god. It is interesting to note that this unitary disease process is associated with a great variety of mental pictures, sometimes with melancholic symptoms instead of the euphoria.

Simple, persistent depression of spirits is not a normal mental reaction to any external cause, but it is a most common reaction of the psychoses, where it is classified with the depressed phase of the manic-depressive group. This is the correlate of the manic condition above mentioned, sometimes alternating with it; though alone, it represents much the more benign process of the two. As in exhilaration, a number of delusions may arise secondarily to the emotional condition, which here favors depressive or persecutory interpretations of the events about one. These ideas are generally superficial and changeable; there is quite another origin for more fixed and elaborated delusions, as we shall see.

As in normal life we notice that some people are quiet when they are depressed, and others agitated, so here we have very agitated as well as retarded or even stuporous melancholias; the latter especially in younger people. All forms tend towards suicide, and as the condition is not necessarily accompanied by any of the features popularly associated with mental derangement, it happens that many, perhaps the great majority of suicides are allowed to occur in this way.

The underlying mood regularly influences the emotional reaction to the environment. So while we contemplate with gladness the signs of returning spring, the melancholia is more depressed by them. It is also a law of normal emotion that a mental process with strong emotional reaction tends to endow with similar emotional value any mental process with which it stands in close association. Thus if we witness a very harrowing accident on a certain street, it is not pleasant for us to pass down that street next time—we may even pass down another street, though it is no safer to do so—and what is most important, the unpleasantness of passing down this street can exist whether the memory of the accident comes into consciousness or not. Such transfers of emotional reaction are worse than useless in life, and the personality much subject to them soon ceases to be "normal." In psychopathology it has long been observed that incoordinate emotional reaction—the "intrapsychic ataxia" of Stransky—particularly characterizes the mental pictures of certain neuroses and of dementia præcox. The psychogenic origin of these "ataxias" in normal life is clear enough, and in these disorders it can be traced sufficiently well to make it improbable that any new process is involved. The connection is often bizarre, especially in dementia præcox.

Although it is far from the most difficult of psychopathological questions, but little knowledge exists on the subject of the speed of the higher mental processes beyond that afforded by clinical observation. Many of its basic problems are scarcely touched. Thus we do not know whether mental time in manic excitement is quicker than normal, and if it is, at what level of the nervous system the difference lies. The elementary process of addition has been found to be somewhat more rapid, at least at first, in manic than in normal individuals, but how far this is gained at a sacrifice of accuracy, or whether staying power would be as good as normal, does not appear. There is no question however, of a specific slowing in the case of the corresponding depressed phase of the psychosis. We have spoken of it before at the motor level, and it can pervade the entire mental system. Clinically it is here known as "thinking difficulty," and is shown by general delay or loss in responses that require mental effort. It may simulate a memory defect. The normal range of about 2:1 in such processes is thus indefinitely extended.

In other mental diseases these questions scarcely apply. Thus we do not speak of a characteristic psychomotor retardation or acceleration in general paralysis, arteriosclerosis, or dementia præcox. Only in the case of immediate drug intoxication has a stimulating effect been attributed to such poisons as alcohol, morphine and cocaine. Experimentally, the effect of alcohol seems to be to remove inhibitions, so that there is greater freedom of motor response. Many premature and false reactions occur. Morphine and cocaine are too dangerous for experiment, though both may be taken with the idea of temporarily stimulating the mental powers. The former does appear to bring about a certain facilitation of the thought processes, its effects being in some ways opposite to those of alcohol.

The range of normal variation is so great that few abnormalities in the association experiment can be attributed to pathological conditions except with knowledge of the subject's normal reaction. The rather stable character of the association type through normal life makes its fluctuations through the psychoses of considerable significance; but the individual differences there are of very doubtful interpretation. It is scarcely evident that there are features of themselves characteristic for different psychoses except in dementia præcox, where irrelevancies, neologisms and stereotypies are frequent in the presence of good appreciation of the experiment. "Narrowing of mental horizon," according to Kent and Rosanoff, is prominent in grave neural disorders such as epilepsy or general paralysis. Nothing approaching specific alterations has been observed in other psychoses. It is certain that normal performance is not incompatible with severe manic-depressive states; and the marked tendency to unusual associations—the prime feature of the psychoses in general—occurs also in personalities that are distinctly better than the normal average.

There is no clinical entity among the psychoses in which memory is improved, though the hysterical hyperamnesias furnish particular instances of it, as the corresponding amnesias do of memory gaps. Memory defect is a special characteristic of mental disease accompanying the coarser brain lesions, as general paralysis, arteriosclerosis, or senile dementia. It is most prominent in the last named, and also more especially associated with recent experiences. The loss in general paralysis is rather generalized over the entire memory field, and in arteriosclerosis it tends to be "patchy," so to speak, losing and retaining here and there, though not with systematic amnesia in the hysterical sense. The most prodigious memory defects are seen in a psychosis of usually alcoholic origin, the Korsakoff syndrome, where, in spite of good understanding, all impressions are immediately lost; indefinite practise does not suffice to learn what a normal person gets with one or two repetitions. Memory seems essentially unaffected in dementia præcox and in the manic-depressive psychoses, though it may be masked by confusion, apathy or stupor. These factors are mainly responsible for the poorer performance in memory tests that most other pathological cases show.

Various attempts have been made to experiment with the suggestibility of mental life, as by measuring the extent to which judgments could be influenced by suggestion. Scott's ingenious experiments showed that this could be different in different functions, so that we might not speak of general suggestibility any more than we should speak of general sensory acuity. But as an acute sense of sight would be much more important for our behavior than an acute sense of smell, a relatively great importance doubtless attaches to suggestibility in the higher levels of conduct, though the level of human activity where suggestibility really counts be not represented in experiments on the simpler sensory and motor processes. In a sense, the distractible manic case might be called over-suggestible because he catches up the examiner's interjected phrases and weaves them into his talk, or is easily diverted from one thing to another. But it is in the hysterical and in some dementia præcox mechanisms that suggestibility is increased to the point of giving real control over conduct. The Lata of the East Indies, and the Jumpers of the lumber camps are the most conspicuous examples of the former. Here we see an automatic, positive response to the idea suggested. In dementia præcox this occurs, but is not so very common. The striking feature of heightened suggestibility in dementia præcox is that it is negative to the suggestion. Not only may the individual be "blocked," as we say, making no response whatever, but so far as possible the opposite response may be made. It represents the extreme of the "contrariness" that is met with in normal life. It even may become possible to direct the individual's actions through asking the opposite of what one wishes; but the negativism is strictly to the idea conveyed. These cases know what they are about, and when it is clear that the thing wished is the opposite of the thing suggested, it is no longer obtained in this way. Bleuler has given a unified formulation of how this symptom is related to the underlying psychosis to which latter I shall subsequently allude.

Individual differences occur in a number of mental processes more involved than the above, which are but slightly subject to experiment. There is no reason to suppose any specific alteration of sense imagery as a result of mental disease. But those hyperfunctionings of it that we call hallucinations are quite different in various mental disorders. There is a delirious type of hallucination produced by poisons, like alcohol, morphine and cocaine, generally visual, and not especially systematized. It has rather the appearance of a selective action of the drug upon particular nervous elements. The hallucinations of delirium tremens are typical of this. Epilepsy is said to favor hallucinations of blood, fire, and catastrophe; cocaine, images of a microscopic character. Detailed analyses are apt to be unsatisfactory, owing to the unclear condition of the patient; when the alcoholic reads from or describes in detail the picture on a blank page, he confabulates rather than hallucinates. A number of curious clinical observations, such as illusory completion of lost fields in hemianopsia, doubled hallucinations to prisms or pressure, made greater or smaller by opera-glasses, hallucinations in one eye or ear only, need be no more than mentioned.

Hallucinations are reported in all the major psychoses, but for the understanding of the clinical picture, they, and the delusional ideas which supplement them, play the most important role in those types of mental disorder which have been termed biogenetic; that is, where the personality as such fails to meet the normal mental demands of the environment, and reacts to it along certain fairly definite pathological lines. These types of reaction may be for us summed up in the manic-depressive and dementia præcox groups. A most significant development in the conception of these conditions is that their basic hallucinations and the delusions, whether or not involved with them, are the expressions, not of the selective action of some fortuitous intoxication, but of instinct trends, detached from, or not controlled by, the main personality, and lived out through fantasy. Both Tuttle from the pathological and Cattell from the normal side have indicated how ideas can develop into hallucinations through abnormal reaction to them. These hallucinations and delusions are thus absolutely continuous with normal imagery and imagination, and the minor satisfactions which these latter supply to the normal individual are here magnified to take the place of reality, in response to coercive instincts and desires for whose adjustment reality must be escaped. Are some patients beset by unrecognized erotic longings? The voices horrify them with accusations of immorality. Is there some obscure maladaptation in the patient's marriage? The response may be a tragic imagination of the partner's death. The husband who visits his wife is then not her husband, but an impostor. Or there may be a fancied alteration of personality, as when under similar circumstances a young man calls himself at different times "Harry Thaw," "Clarence Richeson," the "king of the fairies."

Following Cattell's formulation of those higher mental qualities not directly measurable, we should say that defects, particularly of judgment, lead to the most serious consequences in general paralysis, arteriosclerosis, and sometimes in manic excitement. Refinement deteriorates especially in dementia præcox and in general paralysis, being, however, curiously preserved in cerebral syphilis; also comparatively well in the depressions. The preservation of clearness as opposed to clouding of consciousness is especially noteworthy in dementia præcox, confusion is most prominent in infective, exhaustive and toxic conditions. Many cases of dementia præcox have all the originality of Alice's White Knight; and the catatonic with his floor-polisher surpasses in perseverance. The most striking abnomalies with Aussage experiments would probably be met in the Korsakoff psychosis.

It is obvious that, in any social sense, leadership and independent efficiency are practically wiped out in the mental diseases we have discussed. The fact that as a group they must be removed from society sufficiently attests this, though in many cases a diminished capacity for work under direction is preserved. But to this rule there are important exceptions, which fall into three classes. In spite of real suffering from neurosis or psychosis, special aptitudes enable some persons to maintain themselves independently, and even to perform valuable service in a highly organized society. Most neurologists number such individuals among their patients. In a second group of cases there is a clearer connection between the greater efficiency and the immediate symptoms of the psychosis. There are two types of these. Mild cases of manic excitement derive therefrom an energy which, if only the judgment be enough preserved, enables them to do tremendous amounts of work, bear troubles, and carry off situations that would be impossible to them in their normal states. I have often quoted a case of alternating excitements and depressions who used his excitements to earn enough money to tide over his depressions in private hospitals. This hypomanic state may be constitutional, giving energy and capacity far surpassing that of normal men, but complicated with pathological features. The personality of Alexander the Great, with its stupendous accomplishment, its egotism and its excesses, is a distinct historical example. The other of these types of effectiveness results through paranoic rather than manic traits. Paranoia carries with it a faith, singleness of purpose, persistence and self-confidence greatly in advance of normal personality, but these regularly attach to ideas whose working out throws that individual permanently out of adjustment with the social order. But if the ideas are such as to arouse social response, great leaders are produced. In the religious sphere it is evident that strong personalities may found systems of belief which, not to mention the occasional amassing of worldly goods, attract many followers, and are genuine moral forces, with no other support than their autistic convictions and indomitable zeal. The inspiring power of such characters in secular history is fitly represented by Joan of Arc.

Lastly, we may take up the question of the general cohesion in the different elements of the personality. As one may gather from the late Professor Pierce's thoughtful contribution to the Garman Commemorative Volume, the extreme cases of splitting that attract so much forensic attention under the names of double or alternating personality, are psychologically continuous with divisions of personality that are quite usual and normal. We sometimes think of systematic amnesia as the criterion of a real alternation of personality. The lives of many normal persons, however, are so ordered that they at various times make a total change of environment to another to which they are equally accustomed, but with practically no associative links between them. In such cases the abandoned mode of life may be lost sight of with truly hysterical completeness, and its most common passages require distinct effort for recall. The differences between these normal alternations of personality and those of hysteria are simply that the latter are more independent of environmental change, less subject to voluntary control, and in that the associations from the other personality or association system are more difficult of recall, they are more complete alternations. The pathological condition simply brings about the fuller working out of a tendency that in some degree is common to all of us, though never quantitatively measured.

The same is true of those splittings of personality where we do not have two or more associative systems alternating, but running side by side, and contending for expression in action; as in some reported hysterical automatisms, where the patient is said to write answers to one set of questions, and answer another by mouth. It has been remarked that all of us are a little hysterical, and it is again true that all of us are a little schizophrenic. Every one carries about with him numerous systems of likes and dislikes, attractions and counter-attractions, impulses and counter-impulses. Some of these favor the social adaptations of the personality, and others are in truly Mephistophelian opposition to it. The discipline of the former and the control of the latter are the balance of the personality. The lack of these qualities, with the conspicuous preservation of other mental functions, gives us some of the most striking features of dementia præcox. Here we observe that certain egocentric, sometimes formulated as autoerotic, tendencies, that all persons have in some degree, acquired a markedly independent organization, and crush the objective, social instincts of normal personality; covering it with hallucinatory insult, picturing to the mind's eye offensive scenes, preventing the personality from doing as it would, forcing it to think and do things which are hateful. The acutest mental suffering that occurs seems to ensue when the main personality attempts the unequal contest against them; sentiment can paint a lurid picture of its tortures in the death-grip of the destroying "complex." But as a rule these trends gain the mastery without the struggle; and we see simply the general failure of reaction to external things that gives us the apparent apathy of these cases.

It is quite probable, too, that there is a mere disintegration of the personality without its destruction by an organized trend; such a one is certainly impossible to demonstrate in many cases.

Here, too, it is easier to observe than to measure, and there is no telling now if the degree of personal integration for very complicated reactions will ever be brought under experimental control; for the lower psychomotor levels of reaction, however, there is considerably better hope.

I will quote two instances of the way in which this disintegration of personality is spoken of by the cases themselves. It is not often clearly expressed, dementia præcox cases being commonly inaccessible. First in the case of a young woman of twenty-five, with nothing very definite appearing in the previous history. At various times in the psychosis she makes such utterances as these:

My mind seems to be in layers like strata in geology. . . . Something seems to push my mind into channels I don't want it to be in. . . . I don't know why I think of these things. I seem to be bound to find out a lot of things I am not interested in, as if some one was teasing me. It makes me feel frightened, as if I was changing to something else. It is like the difference between a good and a bad person. All at once I seem to wish somebody would die. I don't mean it, of course, but I can't keep it down. . . . If I could gather up a good will it would be all right. Instead these vague ideas seem to be wandering all around as if you were going through a sort of labyrinth. . . . I can't say anything I want to. It is like going through a river where there are a lot of weeds and they get in your way and you can't get through. . . . I seem to be imagining a lot of things. I can 't get my mind together. . . . I seem all of a sudden to sink right down into deep thoughts as though I were covered up in a snow-bank. Whether it is a loss of the train of thought or of the spirit I don't know—it seemed as if my mind had been crushed back and I had lost control. . . . I try to use my mind but there is no thought there; it is empty. Somebody takes my mind away every two seconds. . . . If they want something to experiment on let them take a rabbit. I want my intellect.

And a young man of about thirty, of shut-in personality, and of somewhat coarser mental fiber than the previous case, expresses himself in this way, with more delusional coloring, the disconnected fragments of his own personality being rationalized as "spirits."

My life is apparently in the hands of others the way I am now situated. . . . It seems as though the air about me were made thicker; it is condensed about me so that it gives the spirits some support, foundation, to act and carry on. . . . It is a peculiar trick for strangers to use other strangers in that light. . . . I feel as if I was supporting this column of spirit realm, as you might say, and I was wondering whether if hundreds of other spirits came into it if I could stand the tension. . . . The more persons that enter, the greater the tension, and in the last analysis I don't like any such existence. I am a human being the same as any one else, and I want my freedom and independence. . . . The spirits show themselves through voices, forms and various practises; they are very clever about some of their practises and cover them up. Any spirit that enters this realm can gauge the clearness and distinctness of the form—they can make themselves plain or just give you a faint idea of what they are doing, but you or any one else can imagine that they would be practises of sexual intercourse; of the spirits having intercourse with each other. It seems to me right now that this room is all filled with miles and miles of them all doing anything they can think of. . . . Now I am sort of carrying the load, as you might say, and any one who uses this (spirit) realm ought to be fair enough to keep out of my sight; I don't want to see all this business. Another thing, these people are total strangers to me, and if this business is going to keep me from engaging in remunerative employment there is going to be some remuneration, because I'm not running a free lunch counter!

We have reviewed the major exaggerations and distortions of personal traits which characterize the psychoses—individual differences due to pathological conditions. But there has been mentioned a group of disorders, the biogenetic, that arise upon constitutional incapacity for mental adaptation to life, and in this aspect do the psychoses represent pathological conditions due to individual differences. Here we see individuals, who, though in early years presenting no such abnormalities as would bring them into the group of feeble-minded, and adapting themselves at least passably well to the situations of childhood, yet, when they meet situations of a certain character in later life, are not able to cope with them as normal individuals, but are precipitated into psychosis.

The fact that these situations are common ones in every-day experience has been held to refute the supposition that they could be the precipitating factor in psychosis. Thus, if a girl, such as I have in mind, develops a brief, dementia-præcox-like episode on the death of an old lover, this would not be an occasion for the psychosis, because thousands of people live through the situation with no abnormal reaction. But this fairly obvious reasoning that the shock could not occasion the psychosis has to yield before the very obvious fact that it does. The truth is rather that in these individuals certain particular shocks would tend to be followed by psychotic reactions, and this girl developed her psychosis because, as further observation indicated, the death of that old lover meant to her something very different from what the corresponding event means to the average person.

Just what mental events will in any given individual be of the character to precipitate a psychosis is a psychogenetic matter, and varies as people's life-histories do. But that they have the property of precipitating one at all, and what kind of psychosis they will precipitate, depends on individual differences of constitution.

The most definite conception has been reached in regard to those mental constitutions on which dementia præcox reactions develop. It has been found by Adolf Meyer, August Hoch, and others who have repeated their observations, that individuals who develop these psychoses tend to be distinguished by a combination of traits which they sum up as the shut-in personality. In the time at my disposal the conception can not be fully discussed. The characteristic picture, however, is one of repression, seclusiveness, secretiveness, failure of normal "participation in cares, pleasures and pursuits" of others, self-centered stubbornness as contrasted with aggressive persistence, special oddities of conduct, the so-called "in-growing conscience," strong religious or mystical trends, with relative emphasis of passive virtues. A concrete example is described in the following words:

As a child he was precocious but in school had to study hard. He lacked confidence, was pessimistic, brooding and egotistical in disposition. He preferred reading to athletic sports, and gave religious scruples as a reason for not attending the theater. He did not use alcohol, tobacco, tea or coffee, and it was also noted that he did not care to associate with the opposite sex. At the age of 17 he began work as a clerk and was steady, honest and exact. ...

The manic-depressive group shows a larger number of cases where abnormal traits are not seen before the psychosis, and the shut-in traits are nearly absent. But as an elementary point here it is brought out in some recent figures of Hoch's that persons who develop manic-depressive psychoses have also shown special tendency to exaggerated emotional reactions in their normal lives. These may be of either a euphoric or a depressive nature; when they are euphoric the individuals are more likely to have manic attacks, when they are depressive to have depressive attacks; and the melancholic personalities, manic ones. The apparent influence of the personality on the form of the attack diminishes to zero as the difference between the cheerfulness and depression of spirits in health becomes less marked.

In dementia præcox the psychotic mode of adjustment is regularly adhered to; in other words, the psychosis is not recoverable. The manic-depressive states, whose picture is as a whole much less detached from reality, represent rather a temporary mode of adjustment; that is, the psychosis is recoverable. The manic-depressive psychosis makes for any port in a storm; dementia præcox scuttles the ship.

Both conditions, however, with paranoia, and in a more circumscribed way the neuroses, show definite and systematic effort of adaptation to the patient's life-circumstances. The final understanding of these cases is given in the questions, "Why did you have to have this thing?" what made this adjustment a necessary one for the patient? and what needs must now be met in a more normal way, what particular danger points must be guarded, what false views of life corrected?

It is now apparent, I hope, that the mental criterion of psychosis is essentially one of mental maladjustment to the surroundings, and often it is the only criterion, mental or physical. The individual differences that distinguish psychotic and normal personalities are not so much differences in motor power, sensory acuity, affectivity or intellect, but depend on the way in which this complex enables the individual to make appropriate reactions to his environment. An individual becomes psychotic when he fails to behave with a certain more or less arbitrary degree of appropriateness. Where the mental malfunctioning follows a sufficiently definite line, we may formulate a definite psychotic entity, as the manic-depressive or the hysterical states. The experimental side of the dynamic psychopathology is therefore distinct from the academic psychology in that it is essentially grounded in the measurement of the reaction's adequacy or fitness. It involves a fundamental recasting of psychological methods, more along the lines of comparative psychology, whose details have only begun to be worked out.

These things shall enable us to observe certain mechanisms of adaptation, from which we must learn about the individual's fundamental adaptability. There are very few adaptations which every individual must make, but life places very many persons in situations which they can not meet. Some can not meet them within themselves; they react with the "flight into the psychosis." Some can not meet them as members of society; they react along criminal lines. Others can do neither, and they have led us into the absurdness of a dividing line of responsibility for action where not the shadow of a line exists. We have seen how continuous all normal human traits are with the pathological. The value of all attempts at controlling the actions of men, as with automobiles or waterfalls, depends upon taking account of the mechanical principles upon which they act. A chief legislator of my native state lately remarked, "Men do not make laws, they discover them." The problems of the jurist, even more than those of the psychiatrist, are failures of mental adaptation; and as we discover its laws we shall discover the best laws to regulate human conduct for both the happiness of the individual and the order of society.