Gentlemen!

In the 43-year-old patient, Mrs H. [1], who I present to you today, you will notice, from her posture and facial expression, the deeply depressed mood. When she notices me speaking of her bad mood, she bursts into tears. When I ask the reason, she replies that she feels unhappy.

‘Why unhappy?’

‘You cannot do anything more; you are physically tired and always prefer just to sleep.’

‘What about thinking?’

Thinking strains her.

How about memory?

This too has become worse. To test her memory retention, she is given the unfamiliar word ‘Antananarivo’ [Ed] to remember. It turns out that comprehension of a foreign word is more difficult for her and slower than normal, whilst her answers are otherwise prompt. What job did she do? She helped with housework in her parents’ inn; something that was hitherto not difficult for her. Once she became ill, she could do this no longer, could not settle down to anything. Even getting up in the morning was an effort for her. Everything that she had to do seemed terribly difficult; and she was terrified of the coming days. Thoughts of the future frightened her, and brought her to thoughts of suicide.

By what method?

She wanted to go into the nearby pond, but was thwarted, because she was not allowed to be left alone.

Was she afraid of anything else?

No, just the thought of the future.

Where was anxiety located?

In her breast and head.

Returning to the question of which word she had been given to remember, it turns out that she had forgotten it after a few minutes, and knows only that it began with ‘A’ [Ed]. However, she recognized it again amongst a number of words spoken to her. Does she have any other reason to take her own life, such as a physical ailment?

No, she was in good standing with her loved ones, but everything was indifferent to her, even as far as her parents and siblings. Whether her siblings came to visit her in the clinic or not, even were war to be declared, or the Kaiser should die, this would not affect her. She could feel neither joy nor grief; her heart was turned to stone. In fact she was constantly confined to bed, taking no part in the events around her; takes no notice of visits by her relatives; and never expresses any wishes. This even includes care of her body, satisfaction of her needs, making beds, and the like. She shows no initiative at all for chores undertaken at certain times by all patients on the ward, and generally does not speak about herself except when asked—yet this, as has been noted, is always prompt, provided the question makes no hard demands. When asked whether she thinks of anything at all, she replies that she goes over and over an agonizing thought, namely that, after the death of her husband (a year before), she has felt so alone and abandoned.

She is fully orientated as to her situation, feels sick, and has total confidence in what the doctors have arranged; and she came to the clinic voluntarily, to protect herself from suicide. Her spirits are brightened by encouragement, but she can never overcome her doubts of ever being healthy again. She is physically healthy and reasonably well fed. However, her appetite is very poor; she eats enough only at the behest of others. Despite her need for sleep, it occurs only with the aid of sleeping pills. Fifteen years ago she suffered an attack of melancholia, from which she recovered. For many years she was then one of the best female warders at hospital X. She was married for 6 years and, since the death of her husband, just a year ago, she has several times suffered bouts of an illness similar to that she presents with today; their duration is usually about 4 weeks, with intervals of similar length in between. She describes healthy times as feeling totally comfortable, sleeping well, eating well, and enjoying hard work. The abnormal state always comes on fairly quickly, within 1 or 2 days, its arrival being preceded by cessation of her usual copious armpit perspiration. Such dryness in her armpits remains throughout the period of illness. Perimetric examination produced results of great interest for the concept of this illness state. This revealed concentric narrowing of the visual fields in both eyes, which, in the horizontal meridian, went laterally up to 50°, and medially up to 40°, and, in fatigue tests could be increased by a further 8–10°. (The visual field examination in the healthy state shows itself normal.)

Presentation of our second patient, the 24-year-old shop assistant Bertha Pr. [2], as expected, takes the form of a dialogue.

The patient enters the auditorium convulsed with laughter, and greets those present in a loud, somewhat imperious voice (imitating a lieutenant).

‘Good morning, gentlemen, good morning Storch, good morning Liepmann, how’s the little woman doing? Ah, good morning Professor, I am very pleased to see you. How are you? Better every day? Right? I’m always a bit funny, but that doesn’t hurt, right? Why shouldn’t I be funny?’

Me: ‘Now, just quieten down a bit; and sit down; I want to say something to the gentlemen and then you can talk again.’

The patient sits down quite unabashed, legs outstretched, supporting her face in her hands, turned towards the audience.

‘Of course, I will be very quiet. Only you will speak. I won’t say a word. Ah, what is that?’ (upon seeing the water pipe with a basin). ‘You have a nice closet,’ goes closer, ‘Ah, a basin, a fine basin, and soap, and such a clean towel.’

‘I think you want to be quiet?’

‘Yes, I am too, but ugh, this is dirty’ (runs her finger over the basin, shakes it in disgust and then sticks her finger in her mouth).

‘Now, just sit down again. Are you Bertha Przytek?’

‘Yes, but we have known each other for such a long time, Professor. Oh, what a fine frock coat you have; you are a very handsome man, Professor.’ Grabbing me by the hand and posing herself with me after the style of song-and-dance people, in a pas de deux [W], she sings as off-key as possible in a loud, harsh voice:

Then in another corresponding theatrical position:

Nodding familiarly to everyone, she departs, laughing loudly, as she came. ‘Adieu, Liepmann, remember me to the little woman. Adieu, gentlemen.’

Gentlemen! The main point in presenting these two patients is their entirely opposite mental state, and their equally contrasting conduct. I shall soon point out that I consider them to be relatively pure examples of those alterations derived from our scheme which I have designated as ‘intrapsychic loss of function’ [Ed] (or ‘hypofunction’) [Ed], and ‘intrapsychic hyperfunction’ [Ed], that is, expressing abnormally reduced and, by contrast, abnormally increased activity of intrapsychic pathways. However, our experience so far is that disturbances of conscious activity, derived from our scheme sAZm, always lead to changes in content of consciousness, mainly in one of the three areas of consciousness we have differentiated; and this is also confirmed here. We will find that autopsychic orientation is disturbed in both cases, and accordingly intrapsychic loss of function is shifted towards belittlement, and in hyperfunction towards grandiosity. Functions of consciousness also include that act, which constitutes self-awareness of the mental condition, which, momentarily, we are in. This fact led Griesinger [3] to speak of a ‘psychic tonus’ [W], and to clarify the abnormally exalted mood from a release of—and the depressed mood from an inhibition of—movements occurring in the ‘psychic reflex arc’ [W]. However, changed mental states, as the fundamental deviation of intrapsychic function, are, to an equal extent, essential qualities of personality or individuality. Therefore it is hardly surprising that an active consciousness notices such changes in personality and reacts to it. This results in an autopsychic disturbance of identification in the sense of my introductory comments in Lecture 28 (p. 185). In transferring such a disorder of identification, assumed to occur in psychosensory areas, to consciousness of personality, it should be seen as a ‘paraesthesia’ [Ed], according to our schema. Since we learn from experience that there are numerous relatively pure cases in which the totality of symptoms are to be derived from hypothetical states, such as we assume, for intrapsychic loss of function and hyperfunction, we therefore have a way to define two sharply differentiated forms of autopsychosis, which we can call ‘melancholia’ [Ed] and ‘mania’ [Ed].

We cannot avoid here some brief detail about what we understand by will [W] from our standpoint. For anyone to ‘will’ [Ed] a certain action presumes making a decision, unquestionably an action of pure thought (even if not totally pure: the reduction in memory retentiveness and the concentric narrowing of the visual field are admixtures, which are not present in the majority of cases and possibly belong to a particular, very rare, recurrent form.). In content, this implies that two or more, possibilities have been weighed against each other. It is only natural that in normal situations, one [W] possibility easily wins a victory, having gained its advantage through habit and usage. Making a decision is then a normal process, through evaluation of ideas and trains of thought. Let us take a simple example. I wake up in the morning and have to get up and dress, which requires a decision. The two possibilities are to get up and to stay in bed; nothing is more natural than to get up promptly if one has done this all one’s life. But then—getting up may depend on other factors. For instance the time: a glance at the clock makes you decide to stay in bed; or, I have spent a restless night, or believe I have a fever and feel sick, and so decide to stay in bed. Clearly the decision is only correct and rational when a large number of cooperating ideas have their normal value; and it becomes abnormal when the value of these ideas changes as a result of a mental illness. Thus a hypochondriacal patient does not get up, perhaps because of the abnormal physical sensations arising from the mental illness make him feel physically ill and too weak to rise.

If, as in this example, only two possibilities are to be weighed up, either to do or not do something, it would be thought that only the first case concludes an action, and that therefore the conditions for its [Ed] occurrence are always harder than for the second case. That would in itself probably be correct, as we shall see soon. However, for this partially ‘prepared’ [Ed] state of consciousness in an awake person, the ‘value’ [Ed] a certain idea has attained by usage, training and habit becomes decisive; and in comparison to this, it is fairly irrelevant whether ‘to do’ [Ed] or ‘not to do’ [Ed], forms the essence of the idea. If we assume that, over a long period, ideas have come to possess a certain ‘value’ [Ed], which is then lost or greatly reduced, a more severe dementia occurs, for example in a paralytic patient. Then this habitual relation will be validated; and for the simplest of all reasons, he decides to stay in bed. However, under certain circumstances, inaction [Ed], the refraining from action, requires a greater effort of will. Think, for example, of a conscientious mother, accustomed to getting up at a certain time to care for her child: In the case of severe physical illness, she will need all her self-control to obey the physician, and refrain from her accustomed activity.