There is no clear-cut symptomatology but rather certain deviations from the normal which can be definitely defined. It has its origin principally from hereditary factors, viz., insanity in parents, feeblemindedness, epilepsy, consanguinity neuropathic and psychopathic strain in the lineage. It is well to mention here that the word psychopathic is used synonymously with constitutional.

This paper is a feeble attempt to make a brief survey of mental disorders near the stage of insanity or not definitely insane.

There is no satisfactory definition of insanity. To give some idea of what character of cases we wish to exclude, we will not consider cases that in their environmental reaction modify or pervert the actual which amounts to a flight from reality. A more generous concept of insanity might be those cases demanding custodial care because of their mental incapacity for social adjustment. Thus, we will consider maladies under which the patient is able to perform the essentials for everyday living but cannot satisfactorily adjust himself to his requirements for a normal life.

Two groups will include almost all the cases for our consideration, viz., the constitutional and the psychoneurotic types.

The first type lacks moral sensibility, emotional control and the inhibitions of the will. As implied in the term constitutional type it is an imbalance of the mental traits on a constitutional basis. On the other hand it is not a disordered function, something superficial in character.

There is no clear-cut symptomatology but rather certain deviations from the normal which can be definitely defined. It has its origin principally from hereditary factors, viz., insanity in parents, feeblemindedness, epilepsy, consanguinity neuropathic and psychopathic strain in the lineage. It is well to mention here that the word psychopathic is used synonymously with constitutional.

It is suggested by some that the ill health of the mother during pregnancy, including the toxaemias, septicaemias and various infections, is of definite importance. Some symptom pictures similar to the hereditary causation are acquired from long continuance of the toxic effects of drugs and poisons or from the imbalance and dysfunctioning of the endocrines. Also the vitamin deficiencies in the diet may play a part, if they are not the whole cause, in bringing about the psychopathic state. Finally any disease that is capable of affecting the brain of the young and adolescent may leave a cerebral defect resulting, in later years, in character deviation.

The symptom pictures will simulate in appearance a manic minus the spirited emotional element and the hysteric, the neurasthenic, the psychasthenic or the obsessive when present on a constitutional basis.

From an instinctive source we have specialized drives, viz., the pathological liar and the persistent thief or kleptomaniac. Then there are the swindlers who have attractive fly-by-night schemes that fool a part of the people a part of the time. The cranks and eccentric individuals are sometimes brilliant promoters of projects only to have their plans peter out from lack of purpose or capacity to reach their goal. The sexual instinct gives an erotic expression in the homosexual, onanist, sadist, masochism, fetichism, etc. The reactive or situation cases are found among persons in close confinement as in our penal institutions. These may be in character hysteric, catatonic, paranoid, manic or depressed according to the inherent tendency of the individual. And as we may naturally expect, these reactive states disappear upon removal of the rigorous incarceration.

There are cases called constitutionally inferior which are ofttimes associated erroneously with the psychopathic personality. In the psychopath, the inferiority status is in the driver or an uncontrolled will but the intellect level may be normal, or as sometimes is the case, supernormal. The reverse is true in the constitutional inferior where the mentality is subnormal, frequently with physical anomalies. The emotions are proportionately limited with the lowering of the intellect level as from the moron, the subnormal level, to that of the idiot.

In due respect to these constitutional inferior cases they are considered among the borderland ones when they are a menace to society. They almost invariably manifest physical, intellectual, instinctive and emotional defects early in life. In advanced years they will develop reactive psychic disturbances because of the insufficiency of their inferior physical and psychic equipment to meet the normal adult social standards. The symptoms are varied and ill defined and generally labelled behavior disorders.

In summing up the constitutional or the psychopathic type of case, we may well say that there is a constitutional drive featured in the imbalanced state of the mental mechanism.

The psychoneuroses or the disordered functional group have maladies that are not frequently committed to state mental institutions. This is the broadest field to mental disorders taxing the resources of the general practitioner.

It is well established that the mechanism of the neurosis dwells on the psychological plane. From a mental standpoint the individual either fails or lacks the ability to select and control the thoughts coursing through the mental processes, accompanied by an emotional stress or by an inadequate energy output.

Although he is abnormal mentally, he is capable of knowing that this is so and for the time being he feels helpless to master his difficulties. He reacts to conditions in his environment as being real but inadequately so. The symptoms are mentally projected into the physical, the sensory, the motor and the visceral fields. In some instances, these are all combined as in hysteria.

Compulsion neurotics, as a rule, are superior persons striving inefficiently to attain to high ideals. They frequently have fears, doubts and persistent abstract ideas: misophobia (fear of infection), syphiliphobia (fear of syphilis), claustrophobia ( fear of closed places), aerophobia (fear of high places), pyrophobia (fear of fire), agoraphobia (fear of open spaces). A compulsion of doubt may mean a person beset by two courses of action: after the gas is turned out before going to bed, he is seized with the doubt, while in bed, as to whether he really did or did not turn out the gas; to satisfy himself he must make personal investigation.

Persistent ideas are prevalent at night, on going to sleep. Imperative ideas or obsessions are a form of compulsion neurosis, or classically termed psychasthenia. The compulsive phenomena has many varied motor, sensory and sexual symptoms. Impressions from sexual experiences of early childhood give a large number of compulsive disorders later in life.

If there is any feature in a physicians practise that throws him into a state of anxiety, making him a neurotic for the time being, it is the oldest of neuromental phenomena, hysteria. The etiology is not definitely known. Freuds theory continues to possess the field, viz., that hysteria is due to the operation of buried sexual complexes. There has been a repression by diversion and suppression of infantile sex desires into the subconscious by meticulous environment. Thus we have a buried complex. The tension of the desire continues to enervate the more subtle psychic forces, when under an emotional stress the now erotic fantasy emerges upon and through the various physical components. Thus we have what Freud terms a conversion of the effect of the complex into physical symptoms. Furthermore, he declares this is the essential feature of hysteria.

The patients in true hysteria are suggestible and they will become increasingly dramatic when sympathy is extended to them. The symptomatology is very complex. It is grouped about the motor and sensory functions to simulate practically every known neurological syndrome of disease.

Here it is well to bear in mind that the complex of symptoms are not constant but suddenly changeable in location and vary with different periods of observation. There are all degrees of expressed hysteria from the universal distribution of the symptoms in the motor, sensory and visceral fields to a mild delirious state. It may be narrowly confined to a special function as that of smell. Bear in mind, this phenomena is purely mental and it is impossible to define its limits with any degree of accuracy.

The last and undoubtedly the most widespread form of neurosis is neurasthenia. Fatigue is the keynote. The patient has a sense of weakness or exhaustion. Rarely does organic disease exist. What is most prevalent is abnormal physiology. The immediate influence of the fatigue is to lessen the psychic tension and diminish the physical energies. Mentally, there is inattention, especially to things in his environment. When effort is exerted to center his thought processes toward some particular objective irrelevant thoughts intrude against his wish at the exclusion of thoughts which are related and logical to the objective. Thereby he lacks concentration and he makes inadequate contact with things of the external world.

The first stage of fatigue in neurasthenia is the inverted attention on the subjects physical body interests. Fatigue may be either pathophysiologic or psychogenic. If physiologic, there are metabolic changes or changes from lack of nutrition or from emotional stress as fear and physical exertion. If psychogenic, it is a case in which some desire or ambition has been suppressed and unconsciously it is disguised by the attention featuring and complaining of feelings of fatigue. With the lack of concentration to outside interest and with the awareness of fatigue, the individual become self-conscious.

V. T. Carr