Gentlemen!

Before we approach clinical examination of mental patients, we shall try to get an overview of the tasks we face. Taken altogether, we call the subject of our study ‘mental disturbance’ [Ed]—a term quite familiar to lay people, and well suited to include all mental conditions deviating from the norm. Among such conditions it is useful first to select the simplest ones for study, i.e. those that we might hope to understand with no prior specialist knowledge, but just on the basis of general notions, such as were discussed in earlier lectures. The simplest are those with persisting alterations in the content of consciousness after recovery from mental illness. These in turn are divided into two major groups depending on whether they are qualitative—falsifications of consciousness, or quantitative—deficit states of consciousness. We encounter far more complex symptoms in ‘real’ [Ed] mental illnesses; the more so, the more acute and stormy their course. The contrast is between stable conditions and diseases actually in the process of developing; and to understand the former intrinsically presents fewer difficulties. This is just the same distinction as discussed earlier between the content of consciousness and conscious activity: Dealing with alterations to the content of consciousness in the course of normal or near-normal conscious activity is a simpler task. On the other hand, when actual mental illnesses unfold, we are spectators of conscious activity whose actual course is abnormal. Conscious activity shifts as a function of time, and its output is the specific content of consciousness; thus we can define acute mental illnesses as the process of altering the content of consciousness, which we see taking place in a defined time period. Such changes are often linked with Affects and changing moods, just as they are under conditions of healthy mental life. Acute mental illnesses are therefore almost universally accompanied by vivid Affects, and we note that these complicate understanding and treatment of acute mental illnesses. The shorter the duration of the acute mental illness, the more stormy the accompanying Affects tend to be; and in the event of the outcome not being an actual return to health, the greater are the resulting alterations in content of consciousness, be they qualitative or quantitative.

We thus have to assume that equivalent normal mental activity can take place within consciousness, despite the richness of content being of infinite variety. You can hardly doubt this, since, as mentioned earlier (see p. 22), amongst people who function with only a small number of concepts can be found individuals whose intelligence matches that of people with extensive learning.

Gentlemen! Our immediate task might therefore be to get to know cases of mental disturbance which, after recovering from actual illness, carry its residue in the form of altered or defective content of consciousness. Activity of consciousness has returned to normal, and the strong Affects, which accompanied the emerging changes in content, have disappeared. Patients therefore do not lack Affects, and their Affects are not generally abnormal. Thus, the latter, even when related to altered content of consciousness, are not specific signs of illness, and can be understood using the same criteria as for healthy people. We come across quite similar behaviour in many patients with very chronic mental illnesses. These reveal a very slow and gradually-occurring change in the content of consciousness, a process also occurring when the organ of consciousness is healthy, but which here is due to internal morbid changes in the organ. In fact, content of consciousness of mentally healthy individuals undergoes steady increase right into old age. This applies particularly to consciousness of personal identity, since such awareness assimilates the entirety of individual experience. If the same is accomplished by similarly slow disease processes, we observe a very gradual change of personality, without this requiring the normal changes to have occurred in external conditions. Extreme Affects, from which the healthy are not spared either, are here not in themselves abnormal, but are often built upon an abnormal shift in personality. If we seek an analogy with brain disorders, the gradual change in the content of consciousness may be likened to the gradual accumulation of focal symptoms in the case of a slowly growing tumour substituting for (and not just displacing) brain tissue. As in such cases, symptoms of mental illness in extremely chronic cases thenceforth also bear the hallmark of an incurable disease. In our case, this is due to complete amalgamation with the healthy content of consciousness, and in the tumour due to purely local effects of destruction. It is almost superfluous to point out that, in exactly the same way, content-related alterations after recovery from acute stages of mental illness—with exceptions yet to be mentioned—represent incurable conditions. Thus our clinical material will consist primarily of incurable, so-called old cases [W], and also of some patients with ongoing conditions who, in outward appearance and in expressions of their conscious activity, are very similar to cases that recover. Most long-term inmates of large mental institutions are such patients, usually without differentiating the two categories based on their very different modes of origin. If we eliminate conditions of deficit from this material, we can summarize the still very large number of remaining cases under the heading ‘paranoid states’ [W] because they share the common feature—an aberrant alteration of content of consciousness, in other words, a falsification of consciousness. The content of the falsified consciousness may be either residual, if it is retained after recovery from a mental illness, or may be an expression of a chronic, progressively developing mental illness.

The full range of ‘residual falsifications of consciousness’ [W] will, of course, be relevant for further classification. We have already seen that we can speak of three different aspects of consciousness—personhood, the external environment, and the physicality of a person’s own body; for a brief description of symptoms related to each of these areas, I propose the names: autopsychic, allopsychic, and somatopsychic. ‘Residual autopsychic falsification of consciousness’ [W] includes, for example, the many cases who are discharged from institutions, following recovery from mental illness, as only ‘improved’ [Ed], yet unable to be classed as ‘recovered’ [Ed], because they have not achieved full insight into their mental illness (see p. 39). Misconceptions, mostly false judgments made by these individuals, usually relate to the manner of their treatment and the necessity for their staying in the institution, to which they owe their relative recovery; and since they are reinforced in their opinion by similar false judgments about other patients during their stay in the institution, and believe that they have witnesses amongst the latter, it is understandable that they complain about, and discredit, the institutions more or less vigorously and constantly, according to their individual temperaments. I remind you of the high school teacher with a doctorate, discharged only as ‘improved’ [Ed], who subsequently resumed his teaching activities, and the wine merchant treated here years ago who even now conducts a flourishing business: They have both gone to highest authorities with their complaints over injustices suffered at the hands of the clinic. A portion of these attacks, which in recent years have also been expressed in the press against our treatment of lunatics, can be traced back to such sources.