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SYMPTOMATOLOGY, PSYCHOGNOSIS, AND DIAGNOSIS OF PSYCHOPATHIC DISEASES
Boris Sidis, Ph.D., M.D.
Boston: R. Badger, 1914
THE aphasias are on the border of the domain of psychopathic states and a knowledge of them is instructive to the student of psychopathology. To comprehend the aphasias we must again make a brief review of the process of perception. In perceiving an object, in having impressions come from a particular object, these impressions give rise to sensations, and the sensations bring into operation subconscious processes, the results of associative, synthetic activity of other sense organs. These enter once more into association and give rise again to the synthesis of a percept.
In the formation of a percept subconscious associative groups and systems are awakened by the impression produced by the stimuli of the particular object. The impressions or their accompanying psychic elements, the sensations, form the cue and also the centre of the awakened, subconscious groups.
The sensations produced by the object form the living elements of the percept. To give an example: In seeing an orange, the orange impresses the eye, peripheral physiological processes are induced in the optic nerve; these processes go to the centre, the occipital lobes, where sensation of sight is awakened. At the same time, movements are induced in the eye. The eye explores, so to say, the outside of the orange; some sensations of form may be excited, the orange may appear somewhat round. These sensations form the cue to the percept.
Really what is directly experienced is only a group of sensations of light and form. But this does not yet constitute the percept of orange. As soon as such particular sensations of form and light are experienced the entire percept of orange emerges, that is, previously experienced states of consciousness emerge, become associated with the given sensation, and the percept orange arises. In other words, as soon as we see the orange and experience the particular sensations of its color and form, we see that it is an orange; that it is juicy, has a certain taste and weight, is globular in form, that if touched it will give a certain sensation of hardness or resistance, or when taken in the mouth it will give a certain taste sensation; all that is directly seen by the eye as soon as the peripheral stimulus is given by the external object, the orange.
We say we see the orange. The eye, however, cannot feel taste, cannot feel pressure, cannot feel coolness; what the eye can specifically see is only color and perhaps some form due to kinaesthetic sensations, arising from movements of the muscles of the eye ball. We are not conscious of all this mechanism. As soon as we get the visual sensation from the orange, at once all other states are brought into synthesis in consciousness.
To show that such is really the case, let us see what happens, if an artificial orange is substituted. We take it for the real orange, we try to smell it, we try to feet it, and then we find out that it is not the real object, and we then often say we are surprised to have been deceived.
The fact is in. seeing an object we never directly experience all the other sensations which arise from the particular object and which go to constitute the particular percept. In other words, in perception, far more is indirectly than directly experienced. The sensations directly experienced form the nucleus of the percept. In the particular example given, the orange as seen, the nucleus, is the sensations of light and form. The other elements come indirectly, they are reproductions of previously experienced subconscious processes.
What do we mean by subconscious processes previously experienced? How do they happen to come to us? The orange has been experienced many times, we have handled the orange, we have smelled it, pressed it, tasted it. The external object, the orange, acted on our tactual organs, giving rise to sensations of touch; it acted on our muscles and gave rise to kinaesthetic sensations; it acted on the olfactory organ, giving rise to sensations of smell; it acted on our gustatory organs and awakened sensations of taste. These sensations have been repeatedly associated in our lives; we cannot possibly eat the orange without handling, seeing, and tasting it. Now when mental or sensory states become associated, the excitement of one of them awakens all the others, and all the states emerge in the same synthesis as before, in the percept. That is why when we see an artificial orange or when we see another fruit which looks like an orange or would give rise to altogether different sets of sensations and other experiences than the orange, we still in seeing it, perceive the orange.
It is possible so to arrange light and shade as to give the eye sensations similar to the ones that come from the real object, the orange. The sensations being similar, the percept emerges to the surface and once more we see an orange. Every one is familiar with this effect in art, in pictures. In experiencing a certain sensation, we also have the immediate knowledge of the object that gives rise to the sensation, in other words, simultaneously with the sensation, many other experiences emerge which have been associated with this particular sensation and which correspond to the sensations that this particular object may excite, if it were applied to other sense-organs.
It is usually said that the other sensations are revived memory-images. Thus in hearing a ring and having immediately the presentation of a bell, we say that the bell has in the course of our life given rise to many different sensations, and that each sensation was preserved in memory, it has, so to say, left a memory image in the particular area that regulates this particular sense. The areas have become associated, on account of the associated stimuli of the particular object, the bell, and now when one sensation arises, such for instance, as the auditory sensation, the rest of the sensations are also revived in memory.
This account is not exactly true; we must remember that a revived sensation is a sensation itself, but the memory image is certainly not a sensation. In hearing a sound and thinking of a bell we do not actually have the sensation of seeing the bell, but we only represent to ourselves the bell. A memory image is not a revived sensation. Had the sensation of sight been actually revived we would have had a perceptual experience, perhaps a secondary sensation, but not a representation. Memory-images are not of the nature of revived sensations, they are peculiar ideational processes, different in nature from sensations. Physiological processes of representation differ fundamentally from sensory processes.
It is wrong to assert, as some are apt to do, that sensations leave a kind of after-sensation, a memory image, which can at any time be revived. The most we can say is, that the physiological process that goes on within the respective sensory centers gives rise to other physiological processes within some other neighboring centers, processes different in character, but analogous as to content. Thus, for instance, the vibration of the air acting on the drum of the ear induces a peripheral physiological process within the auditory nerve. This physiological process reaches the sensory area, a physiological process takes place then which gives rise to particular sound sensations. At the same time the sound is here directly presented in consciousness.
We may now close our ears, we no longer hear the sound. The sensation is no longer present in consciousness, but we can represent to ourselves the same sound; the sound is now represented in consciousness. The representation of the sound is not the same as the sensation of sound, nor is it another sensation of sound; in fact it is not a sensation at all; it is rather an idea or image that corresponds to that sensation.
We cannot say that the representation of the sound is the same as the sensation of sound but less in degree. For if that were so, we should experience not the same sensation as the original one, but rather a sound of less intensity, and hence really a different sound. In short, we must conclude that every presentation has its corresponding representation which is different in its psychic nature from the original sensation.
A representation or image therefore is not a revived sensation, it is a psychic process sui generis. What we can say is that every sensation gives rise to a psychic process which we call “a memory-image” or representation, and which has the same functional relation to sensation as the sensation to the external stimulus.
Every percept consists of a synthesis of a central presentation in one sensory area associated with sensory elements coming from other sensory areas. Thus let O be an object in the external world; let a, b, c, d, be the respective sensations which this object gives, if applied to different sense organs. Let a', b', c', d', be the respective reproduced sensory elements which may be termed secondary sensory elements of the sensations given to the object O, a' corresponding to a, b' to b, c' to c and d' to d. Now a, b, c, d, will become associated, in the course of the individual's life, with their respective secondary sensory elements and corresponding representations, so that when a occurs, the secondary sensory elements and corresponding representations of the others that were not directly excited in this particular experience also recur so that a brings up a' b' c' d'; b brings up a' b' c' d' and so on. The percept recurs each time as one of the constituent sensations is excited.
Physiologically regarded, a percept, therefore, consists of many processes taking place in various sensory and associative areas. On seeing an orange, there is a sensory process going on in the visual areas supposed to be in the occipital lobe, in the areas that subserve gustatory sensations supposed to be located in the lower part of the fourth temporal convolution, and those of touch and muscular sense in the post parietal precuneus and gyrus fornicatus convolutions, associated with these there may be also sensations of sound going in the auditory area, the first and second temporal convolutions. Along with the perception there are also present motor adjustments due to physiological processes in the motor areas grouped about the Rolandic fissure. Moreover, the percept is localized in space and time and is associated with respective representations, and with the consciousness of personality. We may, therefore, say that such a simple function as perception involves the activity of the whole cortex.
As soon as the object, orange, produces the impression and gives rise to a physiological process in the sensory area of the occipital lobes, all the other cortical areas associated with it, become sub-excited, systems of neurons in the different areas begin to function, and give rise to the psychic concomitant, the percept, orange. These different associated areas and the physiological processes of systems of neurons, corresponding to the representations, each one near its sensory area, form all kinds of combinations, adjusted to external objects, responsive to particular stimuli, and go to constitute what we term the associative areas. What happens if dissociation or a lesion occurs between the sensory area of the occipital lobe, thus cutting off the occipital area from the other centres? The patient experiences the particular sensation awakened in the occipital lobe. He will see the shades and colors of an object, for example, the orange, and if the muscular sensations of the eyes are still associated with the occipital lobe, the person may even see the form, and may even be able to represent to himself the particular sensations experienced, but no percept will come to consciousness, the sensation will have for him no meaning, that is, there are no associative, sensory and ideational interrelations with other cortical and subcortical systems with their consequent motor adjustments and glandular reactions. The patient suffers from what is termed visual apraxia.
The same may happen for example with gustatory sensations. You may ask a man to close his eyes and you place a bit of orange in his mouth; he may immediately recognize the taste as belonging to the particular fruit. Should there be, however, a lesion in the temporo-sphenoidal lobe, affecting the gustatory area, so as to separate it from the other areas of sensation, the patient will experience the sensation of taste, possibly, also that of pressure, if this area is not dissociated by the lesion; he will be able to represent the sensation afterward, i.e. he will have a memory of the sensation, but he will not know the character of the object, he will not know it is an orange, for instance. This may be called gustatory apraxia.
In hearing a bell, the image of the particular object rises to our consciousness with all its accompanying associated secondary sensory elements and corresponding representations. Should, however, a lesion occur in the third temporo-sphenoidal convolution, thus shutting off the auditory area from the rest of the areas, the other areas will not be stimulated, the secondary sensory elements and corresponding representations will be absent and the patient will not know the character of the object, the bell. As soon as the sound ceases the subject will be able to represent again to himself the sound, but he cannot form an idea as to the character of the original object, no image of bell arising in his consciousness. This may be characterized as auditory apraxia.
Systems of tactual presentations may similarly become disaggregated. External stimulations may give rise to sensory processes, but no representations are awakened; the memories relating to this particular class of sensations are gone, and no appreciation of tactual stimulations is aroused. The patient does not know of the stimulations, he is not directly conscious of them, since the stimuli fall below the threshold of representative consciousness, although they may be subconsciously present to simpler moments of lower types.
If the clustering memory representations of the other senses become disaggregated from the psychic elements of the tactual sense, then the functioning of those elements does not give rise to the associative activity of unlike representations entering into synthesis with tactual elements to form particular systems of moments. The patient on being stimulated through tactual sense realizes and knows the nature of the stimulus, he feels and knows the touch, the pain, the pressure, the prick, the burn, but no particular object or system of objects is called up in his mind.
In the individuals in which the visual sense is present and forms the focus of most of the lower presentation moments the sensory elements of the tactual sense rarely, if ever, become the integrating nuclei of moments-consciousness. Their combination with other unlike elements is rather of the nature of representative association, than that of integrating synthesis. If I happen to touch an object in the dark, the visual representation of the object, or rather the associated memories with visual representations as nuclei arise in my mind, the elements of the tactual sense are felt in a synthesis with the revived associates.
This, of course, varies with individuals of different types, such as the auditory, the motile, and others. In the motile type the tactual sensory elements are no doubt of far more integrating value than is that of the visual type. Still it remains true that in man the visual sense predominates and forms the nuclear elements of psychic synthesis. This is especially seen in perceptual activity where synthesis is at its height.
In the blind, tactual as well as kinaesthetic and auditory psychic elements are of importance in the life of the individual as they form the nuclei of moment-consciousness. A disaggregation of these nuclei gives rise to forms of amnesia of much interest. It goes without saying that a disaggregation of the tactual memories affects the blind far more profoundly than a similar disaggregation in normal individuals.
The patient may become quite helpless, especially is this the case, if the loss involves representations of tactual and pressure sensations, coming from the more deeply situated tissues, such as the muscles, joints, and tendons, thus also involving kinaesthetic representations. If the process of disaggregation affects the interrelation between the tactual, sensory presentations and representations, the result will be that the patient on touching one object, say a bell, or a liquid, as water, will be unable to know the object, but he will immediately know it when sensory stimulations will awaken presentations in other senses.
This will become still more evident in the educated blind. The blind who have learned to read by passing their fingers over raised symbols, have acquired a special system of representations corresponding in complexity to our visual system of representations in reading written and printed characters. Should this system become disaggregated, the patient loses his knowledge of reading with his hands, although he may be able to write, that is, to make the raised signs of objects, qualities, actions, and relations. This will correspond to alexia, only in this case it is not visual, but tactual alexia. The patient is able to write, but he cannot read his own writing.
If the auditory representations are disaggregated, the patient will not be able to understand spoken words, will be unable to write to dictation, but he will be able to speak spontaneously, write, and read, although he will be unable to understand his own reading. In this respect there is no difference in the psychomotor manifestations or symptoms from what is ordinarily observed in similar cases of otherwise normal individuals.
In the same way apraxias of other sensations may occur. There may be apraxia of two or more sensations. In fact any combination may occur. It is clear that in visual apraxia, for example, although the patient in looking, say at the orange, will be unable to tell the character of the object, he will, however, be enabled to tell its nature, if the object is acting upon some other sense organ, not dissociated from the system of sense areas. Thus he will be able by smell or taste or even by touch to know that it is an orange, although he will be unable to perceive it in visual terms. He will be much as the blind man who has never seen an orange, and hence has his representations in terms of other senses, yet appreciates the character and use of the orange.
The percept formed will lack the representation of the particular dissociated sense area. For instance in case of gustatory apraxia the patient in seeing the orange will have the representation of every sensation of the orange except as to its taste. Or in auditory apraxia the patient in seeing a bell will lack the representation of sound.
If now there is a lesion of such extent as to prevent the associative activity of all the special sense areas, we have a condition termed mental blindness or total apraxia. The patient will be unable to know the character of objects no matter which sense is impressed. The sensations are correctly perceived, and each may even be represented in consciousness, but their representative association in synthesis will be absent.
Man’s mental life, however, is not so simple as we have described it. Man is a social being. Living in a social environment he communicates his experiences to his fellow beings. This communication is expressed either by gesture, such for instance, as we find among deaf mutes and among different Indian tribes, or what is more common, by sound or by different combinations of sound. Sound being more variable than are gestures, it is better adapted to express the variety of experiences.
In the synthesis of the percept, therefore, there must be associated also sound representations and kinaesthetic memories of production of sounds. These sounds, their representations and the kinaesthetic memories of their productions, do not directly come from the object itself, they are symbolical, calling up the synthesis of the percept, or the percept calls up its particular symbol. To give an example: On seeing the orange not only all the constituent representations of the percept orange arise in consciousness, but also the sounds that constitute the symbol of the orange, or its name, likewise arise, and not only the name of the object, but also the kinaesthetic representations of the name.
On seeing the object the name occurs to us, and vice versa on hearing or pronouncing the name of the object its representation appears in consciousness; the percept itself, the characteristic of which is that in normal life it must have as a center a particular sensation awakened by peripheral stimuli only, is not present. The percept gives rise to representation of the word or name, and the hearing of the name or word gives rise to the representation of the percept.
In other words, on perceiving the object the name occurs to us, and vice versa on hearing or pronouncing the name the representation of the taste of the orange or of the sound of the bell calls up the rest of the associated representations of the object. The same is true in more complex mental life, the representation of a word will call out other associated representations, that is, the meaning of the word or the representation of the object of which that word is a symbol.
Should however the auditory area, or those systems of neurons the function of which are concomitant with the sensations and representations of words, become affected, be dissociated, the hearing of the word or of the name no longer calls up its associated representations of which it is a symbol. The patient hears a word, can represent the sounds to himself, can repeat it, if the motor area of speech is not dissociated, but he no longer knows the meaning of the words he hears. This condition is called sensory aphasia.
Should, however, the kinaesthetic sensations, or the motor area of speech alone be affected, hearing of the word will call out its associated representations of which it is a symbol, but not the kinaesthetic representations. The patient, on hearing the word, will know its meaning, but will be unable to pronounce it. This condition is termed motor aphasia.
In reviewing the disturbances of speech we have endeavored to simplify matters. The mental mechanism we are now examining is rather of a more complex nature. Not only has man in his social life, in his intercommunication with his fellow beings, developed sound symbols, expressed in speech, but in the course of social development there was also worked out a whole system of signs symbolizing the auditory symbols. The word is represented by a written sign. A child learns first to speak, to call different objects by their names which are symbols of objects, and afterwards, as he grows up, he learns to write, that is, to express these sound symbols by visual symbols.
The association of mental states, called up by an object, becomes still more complicated. In the first place a sensation produced by an object acting on the sense organs calls up conscious and subconscious representative states corresponding to this object and synthetized in the percept; then the representations of the name with the kinaesthetic representation of its production are awakened, and besides there may also be awakened visual representations of the sound representations and also kinaesthetic sensations by which these visual representations are manifested, that is, expressed in motor terms. In the second place, one may see these visual signs of auditory symbols, and all the complexities of representations, corresponding to the name and to the object will be awakened.
To illustrate our point, on seeing a man the visual sensation will give rise to a complexity of presentations and representations synthetized in the percept, ‘man.’ Furthermore, the name ‘man’ may come into consciousness, and this may give rise to the kinaesthetic representations manifesting themselves in the sound ‘man.’ This will further give rise to the visual symbolization of the auditory symbols, and if the kinaesthetic sensations are also awakened, we may write the word ‘man.’
We started here directly from the object. The process may, however, be started in the reverse order, instead of going from the percept to the symbol, we may go from the symbol to the percept. We open a book and see there certain signs m a n. These visual sensations awaken their corresponding visual representations of memories, associated with their related auditory and kinaesthetic representations which may be manifested in the word ‘man,’ and along with it all the synthetized representations, corresponding to the percept, are awakened, and we know that the word means ‘man,’ a certain object. This is especially clear in observing children learning to read and write and in the study of foreign languages. On seeing the word homo the first attempt is to pronounce it, then to associate it with some system of representations.
What will happen if in the occipital lobe the systems of neurons whose functional activity is concomitant with the psychic processes of visual representations of auditory symbols, i.e. reading or writing, is dissociated or destroyed? The patient will be unable to read. There will be a condition known as alexia. The patient will be able to see the letters, may even be able to imitate, to reproduce them but will not know their meaning.
Similarly in the case of writing, if the systems of neurons, the functions of which consist in the represensations of the kinaesthetic sensations of writing, be destroyed or dissociated, the patient will be able to see the word, to read it, will know its meaning, but will be unable to write it. This will constitute the state of agraphia.
There may be a complicated pathological process where the lesion occurs in the conducting fibers between the visual sensory word system of neurons and that of their associated representations. The result will be that the patient, on seeing written or printed letters or words, will be unable to read them. He will be, however, able to write, although he will be unable to read his own writing. The only way for him to grasp written symbols is by kinaesthetic sensations. He may pass his hand over the printed or written letters and may thus be able to know their meaning. Of course, this will require some education. This will constitute one of the forms of visual aphasia. If all the representations are gone then the patient will be unable by any means to grasp the meaning of the word or letters. The former may be termed relative visual aphasia, the latter absolute visual aphasia.
The same thing may happen in the case of writing. If the area of the graphic, sensory, neuron systems is injured or the fibres going to their associative representations are interrupted by a lesion, the patient will still be able to write correctly, but upon closing his eyes or attempting to write with his eyes closed, he will be unable to know whether he has written correctly or not. That is, the kinaesthetic sensations being absent or dissociated, the patient will not know what his hand has written. He will however be able to know what he has written by looking at the words. This may be termed relative agraphia.
Should, however, the kinaesthetic representations of writing also be injured he will be unable to write at all. This may be termed absolute agraphia. In the same way there may be absolute and relative apraxia.
We can realize now that there may be various forms of aphasia and apraxia, according to the number and function of the systems of neurons involved. Thus systems in the sensory area may become affected, or systems in the association areas may become dissociated, or different combinations of systems in the sensory and association areas may become involved.
In addition to these forms there may also be different forms of apraxia and aphasia due to lesions or pathological processes within the conducting fibers, either from the sense organ to the sensory area or in the fibres between the sensory area and association areas, or in the conducting fibers within the association areas. That is, the lesion may be subcortical, or cortical, when within the body cells themselves, and transcortical when within the fibers in the associative areas. These will give rise to various forms of aphasia. We may therefore classify the aphasias and apraxias physiologically, according to the location of the lesion as subcortical aphasia and apraxia, cortical aphasia and apraxia, and transcortical aphasia and apraxia.
There are some special forms of aphasia and apraxia that are of interest. Amusia is a name applied to a condition in which the patient, a musician, is unable to understand music when he hears it; or it may be of the visual form in which case he will be unable to read notes; or of the motor form, when the patient cannot sing or play; or it may be of the graphic form when the patient formerly familiar with musical composition lost the skill of writing notes.
As a rule amusia is associated with some other form of aphasia or apraxia. Frequently we find that aphasic patients more or less retain their musical knowledge, since music, the language of emotions, is more organized, more primitive than speech and writing.
Amimias are forms in which the patient has lost the power of expressing himself in gestures commonly used in life. Amimias may be either of the motor or sensory type. Expression by gestures is simple, acquired early in life and is associated with the emotions. Gestures are more stably organized than the rest of mental life and are therefore the last to succumb to pathological processes.
The process of disintegration in different systems of neurons may be of various degrees and intensities thus distorting the process of association. This may give rise to occasional wrong associations. Thus we may have paraphasia, if for instance, the patient inserts a wrong syllable in a word or a wrong word in a phrase, etc.; or in reading the patient may read incorrectly; or in seeing an object he may occasionally regard it as another object. For example, he may use a knife as a spoon, or try to cut with a fork. These various forms of paralexia, parpraxia, etc., may in their turn be cortical, subcortical, and transcortical.
The forms of reviewed aphasias may be of an organic nature, or of a functional psychopathic character which may closely simulate organic conditions.
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