Gentlemen!

Before we make acquaintance with new patients, we should dwell for a moment on patients we have already seen, while they are still fresh in our minds. Firstly, let us face the question of nomenclature. According to current labels, all those patients would be examples of ‘chronic insanity’ [Ed] or ‘paranoia’ [Ed]. However, if we wanted to comprehend [W] it in this way—that paranoia was a well-characterized clinical form of illness—then the floodgates of greatest confusion of concepts would be opened, for the cases show very great differences from one another. We can avoid this misunderstanding if we talk of paranoid states [W], which include all those chronic mental disorders where we encounter falsification of content of consciousness, while conscious activity remains well preserved. In so doing, we believe that we cater for the view, often expressed by earlier authors, that we should include under paranoia an overriding disturbance of intellectual activity. Under this very broad definition, we might accept that, amongst cases I have shown, there are conspicuous differences not only in terms of presenting findings but also of their histories and origins. The diversity of presenting medical conditions could easily be characterized in greater detail if we were to use the terms autopsychosis, allopsychosis, somatopsychosis, and their various combinations. For any material falsification of consciousness covering all three areas of consciousness, the term would then be ‘total psychosis’ [Ed]; but when it was just a portion of this totality which had been attacked, the name in question would be some appropriate combination of these terms. According to this classification, the first patient presented, the gardener Rother, would be classed as an example of a total chronic psychosis; Frau Reisewitz, a chronic auto-allopsychotic; the patient Tscheike, a chronic auto-somatopsychotic; the Biega case, a pure somatopsychotic; Frau Schmidt, a combined chronic allo-somatopsychotic; and Frau Reising, a chronic allopsychotic. By addition of ‘residual’ [W] you could emphasize the importance of that group of patients in whom the disease process had apparently run its course, with the patients returning to health, without their having gained any insight into their illness.

The necessity of the latter distinction can, however, lead us to introduce other, somewhat simplified terms into the field. It might, perhaps, be advisable to reserve the term ‘chronic mental disorder’ [Ed] just for residual cases, and apply the term ‘psychosis’ [Ed], with appropriate combination of words, only to those cases of mental disturbance actively in progress. If we were to prefer this nomenclature, then all cases which, relatively speaking, have recovered (but without insight into their illness), and the two patients Rother and Tscheike, would be included in the area of chronic residual mental disorder. All cases I presented—and others mentioned in passing—belong in the area of actual chronic psychoses. All psychotics who do not progress to full recovery but reach a standstill fall in the group of chronic mental disorder, under this classification.

However, if we dig deeper, we come to understand an indisputable connection between the two. Allow me to suggest what is for me the critical aspect, even if I cannot now treat it with the breadth it deserves from a theoretical point of view:

The content of our consciousness was presented to you in introductory lectures as something acquired, indeed acquired through functioning of the organ of consciousness itself. Each new acquisition corresponded to a specific pattern of associative elements functioning in concert. We came to recognize that the strength of these functional links varied, depending on how often they were used. However, since this strength was intrinsic to the most complex, highest level of associative links, we were led to conclude, quite generally, that there existed a balanced and regular organization in the flow of mental activity in any normally developed person. So, let us assume that in the reverberations of the same combination of associative elements, the same mental processes always take place. We would then not be too bold were we to conclude that, in this sense, the set of ‘specific energies’ [Ed] of sensory elements may be transferred to the entire organ of association. The way in which such associative links are triggered into action is thus somewhat irrelevant: Under some circumstances it can be an aberrant internal stimulus which starts off various psychic processes, depending on its localization. For purposes of this analysis, all changes in content of consciousness can then be likened to focal symptoms, and will behave just as do more familiar focal symptoms of brain diseases; but these naturally will have different clinical ‘weighting’ [Ed] depending on whether they correspond with the stimulus state or the paralysis state.

Let us take examples from neurology: A major cerebral haemorrhage of the well-known marginal artery of the lentiform nucleus or an embolism of the f. S. artery generates during the period of acute illness not only hemiplegia, but also a series of severe accompanying symptoms, to be seen as secondary effects of local brain injury. Residual hemiplegia remains as a permanent outcome, while side effects of the focal damage disappear. However, exactly the same finding of hemiplegia may come about when a slowly-growing tumour or chronic brain-softening causes tissue destruction only very locally; at first (usually) there is a slowly developing monoplegia affecting for example the leg; then a brachial monoplegia may arise, then one involving the facio-lingual area, so that, finally, hemiplegia emerges. Corresponding with such slow progression, there may be total absence of severe general symptoms. However, the site of brain destruction is the same in both cases, so it is fair to compare a residual focus with a chronically developing one. In exactly the same way we can fairly equate residual alteration in content—as a localized process—with changes in content when psychoses progress slowly.