Gentlemen!

By confused mania [W] we wish to identify a clinical picture that is manifest as an exaggeration, imposed at a peak of mania, and presenting as its external signs a motor impulse and conspicuous loquacity with confused content; but, in addition, as soon as we analyze its individual symptoms, it can certainly present with entirely different components. Crucial to our approach is therefore the practical and clinical perspective, that this is an acute psychosis, which can begin and end as mania, but in intervals between peaks of illness, which may predominate overwhelmingly, it often loses some typical features of mania and, in their place, acquires all manner of strange admixtures. In this complex clinical picture, the chief signs derived from mania, are flight of ideas, loquacity, and motor impulse. The foreign elements that are added range between two extremes, sometimes in pure form, usually in combination, are either psychosensory or psychomotor disorders of identification, dominated by symptoms of irritation. If confused mania is to be regarded as an independent illness, as is often in fact justified, when the initial or end stages of pure mania are only very short in duration, it could be called agitated confusion [W], and its subdivisions could be differentiated as confusion with sensory or motor agitation. In the first case agitation is based on an essentially reactive motor and speech impulse, that is, on those that can be traced back to sensory states of irritation; in the second case it takes on the guise of a hyperkinetic motility psychosis. In the vast majority of cases these two contrasting sets of phenomena occur in combination. The rarer exceptions are mainly purely sensory cases; existence of purely hyperkinetic ones must remain questionable.

The preceding brief empirical principles may indicate to you the range within which we can manoeuvre. Such defining of boundaries is essential, because frequently you will find ‘confusion’ [Ed] described under the headings of ‘primary confusion’ [Ed] or ‘dissociative confusion’ [Ed] (according to Ziehen) [1], as an actual illness. Usually all that is thus designated is the respective state of a patient, in whom we always still have the task of determining the individual elements that lead to the state of confusion. In so doing we will at least have to raise the claim that confusion, as a symptom of stimulation—that is, one connected to flight of ideas and loquacity—is separated in principal from the corresponding state of deficit—that is simple incoherence by sejunction (dissociation). Only the first case would call for special consideration, in the task before us.

You may thus conclude that, despite this difficulty, I am motivated purely by empirical considerations, because generally, with a consensus all too rare in our discipline, the internal connection between mania and confusion, and the frequent transition of one into the other, has been accepted and is taught. I refer only to Meynert, who earlier (that is before the appearance of his clinical lectures) had even gone so far as to see every acute psychosis that we would call mania arising from a state of confusion, by way of weakened associations, leading to the clinical picture of Amentia, which he himself analyzed so masterfully; while later he designated under mania cases of illness that differ not significantly from our ‘pure mania’ [Ed]. What Meynert has expressed on this occasion about flight of ideas and associative weaknesses belongs among the most extreme views written by this thinker on psychological questions. Without being able to follow him completely, I would still try to shell out the kernel of this and make it useful for our purpose. My comments about the flight of ideas in mania summarized above—all too briefly—will thereby be complete. I disregard the fact that the basis will be vasomotor flux, or functional hyperaemia, a consequence of nutritive attraction as Meynert expresses it, an action produced by association fibres, corresponding to the ‘closed thought pathway’ between an idea being registered—Meynert’s ‘attack idea’ [W]—and the idea of its ‘objective’ [Ed]. For our purpose, we may disregard vasomotor influences and be satisfied that, also according to Meynert, the closed train of thought is a functional acquisition pointing towards a most minute localization in definite anatomical elements. We rely upon the fact of pathways well-worn by use, which consequently have become more ready to respond and more excitable, in comparison to the others. Overvaluation of certain ideas—accepted by us—and the ‘closed train of thought’ [Ed], also have a definite internal connection, according to Meynert’s formulation [2]. The majority of associations, are located within ordered thought processes characterized by Meynert as ‘large, widely branched, long, profoundly and strongly coordinated’, [W] and find their counterpart in simply coordinated ‘narrow, brief, unbranched, weakly and shallowly ordered, aimless’ [W] associations. ‘The association intensity corresponds to the molecular tissue attraction as a source of strength. The mass of arching fibres, within which two sources of force, that of the idea of an “objective” and that of the initial idea, tend towards each other, as it were, in the act of thinking, always attaining vital force for elevation above the threshold of consciousness from two ideally centralized cortical areas; but the secondary association arises from only one of these areas: either that of the “objective” [Ed] or that of the initial idea, according to whether for example the rhyme fits its word picture. Functional attraction is the weaker here, and is inhibited by the stronger.’ What is here called ‘tissue attraction’ [Ed], we again designate as increased excitability. If we disregard such functional differences of excitability in the functions of the organ of association, the primordial condition of the childlike brain—Meynert’s ‘genetic confusion’ [W]), in which any given association is possible—reappears to some extent, and may be retained for a while, because anatomically preformed combinations exist between any two given cortical areas. Different gradations of ‘flight of ideas’ [Ed] can then increase to the highest grade, which, for us, represents disjointedness or incoherence, when, after uniform and general increase of excitability, individual differences between various association pathways are largely obliterated. It is such confusion, arising from an exaggeration of mania that we have in mind when we recognize the clinical picture of confused mania. A decisive criterion for this is the state of irritation evidently present, seen as loquacity and motor impulse, and—in the absence of any actual deficit—in the breakdown of associations. Therefore it remains possible for patients to fixate their attention momentarily, when they are given external stimulation, and likewise by their being given increased motor force; and they may even occasionally be amenable to more complex trains of thought. In other words, previously acquired contents of consciousness remain essentially untouched.

We must thereby return to the difference between activity and content of consciousness. Yet every ordering in contents of consciousness consists of gradations of excitability acquired by practice, in which total dissolution would have to occur of the contents of consciousness into their simplest elements, that is, into fragments. The immediate consequence of this must be total disorientation in all three domains of consciousness, which should appear in the same way in the contents of the loquacity, as it does in the way a patient’s motor impulse becomes manifest. However, in confused mania we require that the levelling of ideas does not go beyond the autopsychic domain: No actual symptoms of deficit should appear with regard to the external world and to corporeality; yet even in the autopsychic domain we will no longer include in confused mania those states of the so-called confusion in which real deficits in contents of consciousness are demonstrable as reactions, such as when time is no longer correctly perceived, or when a person fails to be able to make a tally of different coins, even when given sufficient attention. These must be classed amongst the more severe clinical pictures.

In a word, we must try to confine the clinical picture of confused mania to those cases which do not actually show a close connection in their course with mania, but also, according to the degree of confusion, which appear just as a further increase of intrapsychic hyperfunction; that is, the incoherence, to whatever degree it reaches, remains largely a formal disturbance, without resulting in more severe deficit states for contents of consciousness. Evidence that such deficits do not exist can be gained from the fact that it is sometimes possible to elicit reactive statements from patients, showing their retaining the possibility of ordered trains of thought, albeit only exceptionally, and with special efforts to sustain attention (by the influence of the process which Meynert calls ‘partial wakefulness’ [Ed]). No firmer view can therefore be gained from the fact of incoherence in the flight of ideas, seen in the spontaneous loquacity of these patients; yet the patients’ reactive statements can then themselves be judged correctly only when the fact of their constant diversion by internal irritation is taken into account.

If we recapitulate our views about the flight of ideas as expressing intrapsychic hyperfunction, we can differentiate three grades: The first and the second, the ordered and the disordered flight of ideas, are both peculiar to mania and determined more fully by accompanying abnormal euphoria. Moreover, the contained, closed train of thought—the ordered [Ed] flight of ideas—has the characteristic that it is organized essentially by its content, whereas the disordered flight is determined more by similarity of word sound, rhyme, assonances, sequences, etc. In the incoherent form—or flight of ideas of the third grade—which characterizes confused mania, word similarity and sequences likewise play a large part, but this can also extend to every comprehensible connection of the sequence of words brought up during loquacity, or only fragments of words, which are lost to us. An example of disordered flight of ideas is taken from a later demonstration [3] of one of our cases of mania, Miss P. To my question: ‘Was your admission necessary?[ she replied literally: ‘Was it necessary Professor? Am I the girl from Wahrendorf? Were you then in the village or in the city? Are you educated, reared, trained in the village? Or are you a relic piece, or what are you really, or which piece will you have? A rib, liver, a pair of feet or a couple of pickled ham hocks, brawn, ah, brawn perhaps? A bit of jelly perhaps?’ In this example the jump to the relic piece is confined to incoherence, while we are well able to follow the mechanism of the combination of ideas.