Jules Cotard (1840-1889)

Reseña histórica y homenaje a Jules Cotard.

Nacido en Issoudun (Indre) en 1840. Estudió Medicina en París y fue discípulo de Charcot y de Vulpian*. (Nota: De la paralysie agitante "De la parálisis agitante" (Charcot et Vulpian, 1862): Edición bilingüe de Rafael González Maldonado, 2013).

Tesis doctoral sobre: “Étude sur l'atrophie partielle du cerveau” (Estudio sobre la atrofia parcial del cerebro). A través de Lasègue fue colaborador de Falret, quien dirigía el manicomio de Vanves.

En 1880 presenta: “Délire hypocondriaque dans une forme grave de la mélancolie anxieuse” (Delirio hipocondríaco en una forma grave de la melancolía ansiosa).

En 1882 y 1884, publica en los Archives de neurologie: « Du délire des négations » (Sobre el delirio de las negaciones) y « Du délire d'énormité » (Sobre el delirio de enormidad) en los Annales médico-psychologiques.

En 1889 redacta el artículo: « L'Hypocondrie » del Dictionnaire Dechambre.

En 1889 murió en el propio psiquiátrico de Vanves de difteria.

En 1891 aparece su obra póstuma, prologada por Jules Falret: “Études sur les maladies cérébrales et mentales”.

Recordar también a su hijo Lucien Cotard, nacido en el manicomio de Vanves, quien fue interno de Féré y Séglas, y autor en 1908 de su tesis: “Étude sémiologique sur le psittacisme” (Estudio semiológico sobre el psitacismo, ecolalia), muerto en 1910 siendo adjunto del asilo de Dijon.

Emmanuel Régis (1855-1918) propuso nombrar al delirio de negación "Síndrome de Cotard", epónimo con el que honraba al psiquiatra que lo había descrito. Sería esta perspectiva sindrómica la que terminaría imponiéndose, hecho al que contribuyó con sus numerosas aportaciones Jules Séglas.

Ver: Historia de la psiquiatría. « Nouvelle histoire de la psychiatrie » de Jacques Postel y Claude Quétel. Ed. F.C.E. de México. Año 1983.

Obras principales:

Cotard (J.). "Étude sur les maladies cérébrales et mentales" [Estudio sobre las enfermedades cerebrales y mentales], Prólogo de Jules Falret. París, Baillière et fils, 1891.

Referencias principales:

COTARD J., CAMUSET U., SÉGLAS J. "Du délire des négations aux idées d'énormité" [Del delirio de negaciones a las ideas de enormidad], prólogo de J.‑P. Tachon, París, L'Harmattan, 1997.

BOURGEOIS M. "Le syndrome de Cotard aujourd'hui" [El síndrome de Cotard hoy], Annales médico‑psychologiques, 1964, p. 534‑544.

CZERMAK M. "Signification psychanalytique du syndrome de Cotard" [Significación psicoanalítica del síndrome de Cotard], en Passions de l'objet, París.

TRÉMINE T. "1880‑1980 : centenaire du syndrome de Cotard” [1880-1980: Centenario del síndrome de Cotard], L'Évolution psychiatrique, 1982, 47, p. 1021‑1032.

BERRIOS, G. E. The History of Mental Symptoms [La historia de los síntomas mentales], Cambridge, Cambridge University Press, 1996.

Jules Cotard (1840‑1889). Studies on Cerebral and Mental Diseases.

 "ON NIHILISTIC DELUSION"  1882

 ver texto original, traducción al inglés. Anotaciones de J. L. Día.

**sólo para estudio fenomenológico en el curso de lecciones de psicopatología.

- "The important paper in which Lassegue, in 1852, separated persecutory delusion from the diverse forms of melancholia, was a point of departure for complementary works which made this form of derangement one of those best known in its symptoms, in its progression and in its outcome.

Charles Lasègue, 1809-1883

 In 1852 he described persecutory delusions and their evolution. In 1873 he described hysterical anorexia, and in 1877 he introduced and described with Jules Falret the concept of “folie à deux,” fully describing the psychological mechanisms (1). This term continues to be employed to this day in the international psychiatric vocabulary.

Corraze J: Charles Lasègue: de la folie à deux à l’hystérie et autres états. Paris, L’Harmattan, 1998

- We need do no more than recall the names of Lassegue, of Morel, of Foville and Legrand de Saulle, and in particular that of M. J. Falret who presented to the Société médico‑psychologique the fullest possible picture of the successive phases and of the evolution of that disease.

- As regards the other varieties of melancholic delusion, our knowledge falls far short of this relative perfection. Simple melancholia, melancholia with stupor, anxious melancholia have been described with care; it is known that these forms are often intermittent, that they sometimes become continuous and finally chronic, but the characteristics and the successive phases of the delusion which culminate in this chronicity have not, to my knowledge, formed the subject of any study equivalent to that which has been done for persecutory delusion.

I propose, in this paper, to describe a particular delusional evolution, which seems to me to be characteristic of a considerable number of these non‑persecuted melancholics, more particularly those who are anxious, and to be based above all on negative dispositions which are very habitual in these patients.

Generally, the deranged are negators: the clearest of demonstrations, the most authoritative of affirmations, the most affectionate of assurances, leave them incredulous or ironic. Reality has become to them foreign or hostile. But this negative disposition is particularly marked in certain melancholics, as has been remarked by Grieseinger.

«... it seems to the patient that the real world has completely vanished, has disappeared or is dead and that there remains nothing more than an imaginary world in the midst of which he exists in torment.»

- I propose the name nihilistic delusion… to designate the state of those patients to whom Griesinger alludes in these lines and in whom the negative disposition is carried to the highest degree. Ask them their name? they have no name; their age? they have no age; where they were born? they were not born; their father and their mother? they have neither father, nor mother, nor wife, nor children; whether they have a headache, a stomach ache, pain at some point in their body? they have no head, no stomach, some even have no body; show them some object, a flower, a rose, they reply: that is not a flower, that is not a rose. In some, the negation is universal, everything has ceased to exist, they themselves have ceased to exist.

These same patients who deny everything, also oppose everything, resist everything that they are called upon to do. Certain madmen, says Guislain, present an opposition which it is impossible to conceive when one has not seen them closely. It requires the greatest efforts to persuade them to change their linen, they refuse to go, to bed, refuse again to rise, are opposed to everything they are asked. This is the madness of opposition.

In this madness of opposition, Guislain –ver trabajo de Giné y Partagas- includes mutism, the refusal to eat and that singular disposition of certain deranged persons who force themselves to retain their urines and their excrement. However, he does not refer to nihilistic delusion, of which the madness of opposition is, so to speak, simply the moral aspect. The same is true of most: of the authors and it seems strange that so marked an intellectual lesion has not attracted more attention. Even the cases where the fact is simply described, are rare. Only the hypochondriac form of the nihilistic delusion has been commonly observed since the work of M. Baillarger.

It is in Leuret –ver tratamiento moral de la locura.- that I find the most characteristic observa­tion. Below is a summary of the questioning process.

François Leuret  "Du traitement moral de la folie"  Chez J.-B. Baillière, 1840.

"El tratamiento moral de la locura". Ed. Asoc. Esp. Neuropsiquiatria. 2001

‑ How are you, mistress?

‑The person of myself is not married, call me Miss, please.

‑ I do not know your name, would you tell me?

‑The person of myself has no name: she wishes you not to write it.

‑ I would nevertheless like to know what you are called or rather what you were formerly called.

‑I understand what you mean. It was Catherine X....,we must no longer speak of what took place. The person of myself has lost her name, she gave it away on entering the Salpêtrière.

‑ How old are you?

  ‑The person of myself has no age.

‑ Are your parents still living?

‑The person of myself is alone, very alone, she has no parents, nor ever had.

‑ What have you done and what has happened to you since you have been the person of yourself?

  ‑The person of myself lived in the asylum of ... Physical and metaphysical experiments were performed on her and continue to be performed. This work was not known to her before 1827. There is an invisible being descending, she has come to unite her voice with mine.

Leuret's patient presented, in addition to the most marked nihilistic delusion, numerous hallucinations: she was tormented by invisible beings, by physics and metaphys­ics, in short, she manifested symptoms of persecutory delu­sion. Complex cases where, as here, the two delusions coexist, are not rare; I will provide examples of them later. Usually, however, these two forms of delusion are observed in isolation in different patients.

The true persecuted individual passes through all the phases of his delusion, from the hypochondria of the beginning to megalomania, without his negative disposi­tions exceeding that which is commonly observed in the deranged; he denies out of mistrust, out of fear of being deceived, or else because he is entirely dominated by his delusional conceptions and his hallucinations, and has there­fore come to live in an ¡imaginary world, but his negative dispositions are quite different from the systematised nihil­ism of which 1 wish to speak here.

In general, the persecuted present neither the profound depression, nor the groaning anxiety of the true melan­cholics; there does not seem to be in them that profound disorder of the moral sensibility, which Griesinger considers to be the fundamental element of melancholia. It is on this terrain, however, after a variable period and following a particular delusional process, that systematised nihilism seems to develop. However, it is not unusual, in states of advanced chronicity, for the nihilistic delusion to continue, so to speak, beyond the general early disorders, and for patients, like that of Leuret, no longer to present either apparent depression or anxious agitation.

          I have just identified the dual origin of nihilistic delusion as melancholia with depression or stupor, and agitated or anxious melancholia. However different these two forms of melancholia may be in their external manifestations, one cannot but recognise their delusional similarities, similar­ities which are particularly striking in cases where the depression and the anxious agitation succeed each other or alternate in a single patient, without significant alteration to the delusion.

These forms are dominated by anxiety (according to Grie­singer, a frightful internal anxiety constitutes the fundamen­tal state of melancholia with stupor), fears, imaginary terrors, delusions of guilt, of perdition and of damnation; patients blame themselves, they are incapable, unworthy, they bring misfortune and shame on their families; they will be arrested, condemned to death; they are to be burnt or cut into pieces. 

These fears of imprisonment, of condem­nation and of torture should not, - as M. J. Falret has often remarked- , be confused with true persecutory delusion, which is relatively rare in patients of this type. Quite other than the persecuted, they blame themselves; if they are to undergo the ultimate penalty, that is only just, they deserve no less for their crimes.

From this point of view, two main classes of melancholics can be distinguished: those who blame themselves and those who blame the outside world and above all their social sphere. The latter are the persecuted, previously described by Guislain as the accusatory insane.

This division of the melancholics largely corresponds to the division into melancholia with general disorder of the intelligence and into sad monomania (Baillarger), and to the division into general lypemania and partial 1ypemania (Foville).

The true mel­ancholics blame themselves, while the sad monomaniacs blame others. However, it is not unusual to see, on the one hand, the persecuted adopt, during a paroxysm, the charac­teristics of general, depressed or anxious melancholia; and on the other hand, the melancholics with delusions of guilt, having reached a fairly advanced period of their disease, adopt the physiognomy of the sad monomaniacs.

 No doubt, behind these external manifestations, which vary from stupor to anxious, quasi‑maniac agitation, there exist more profound morbid dispositions in which resides the essential difference between the persecuted and the other melancholics.

Perhaps it is in the tendencies of patients, which I mentioned earlier, either to blame themselves, or to blame others, that we shouted seek the most immediate manifestation of those intimate dispositions which consti­tute the true ground of the disease.

These tendencies often exist many years before the ob­vious emergence of the delusion; to a very attenuated degree they are encountered in many men of sound mind, amongst whom they form, two quite distinct categories.

Long before they become truly deranged, the persecuted are suspicious and distrustful, more severe with regard to others than to themselves; likewise, certain anxious persons, long before they experience a clear attack of insanity, are scrupulous, diffident, self‑effacing, more severe in their own regard than in that of others.

I stress this division of the melancholic delusions, which have been confused by most authors. Marcé  (citado por J. Seglás ) seems implic­itly to acknowledge it; he describes, in true melancholia, originally only the delusions of ruin, of guilt, etc., indicates the sub­sequent hypochondriac delusion and assigns the persecutory delusions to monomania; however, he does not otherwise emphasise this distinction, which anyway appears too abso­lute, since certain persecuted individuals present the char­acteristics of true melancholia and other patients with delusions of ruin and guilt resemble the monomaniacs.

 Jules Seglás:  De la Melancolía sin delirio1 . Melancholy without delusion. Rev. Asoc. Esp. Neuropsiq. v.26 n.2 Madrid  2006 (traducción de: H. Astudillo del Valle)

Let us now examine by what evolution of delusion the self‑accusing melancholics arrive at nihilistic delusion:

 In their most attenuated form, these characteristics are those of the variety of melancholia described by the names simple melancholia or melancholia without delusion and, more exactly, by the name moral hypochondria, by M. J. Falret, who has described it with meticulous precision.

 Jean-Pierre Falret (1822)  De l'Hypochondrie et du suicide   (hypochondria involved a moral weakness and declared that it is primarily a mental disorder)

The so‑called melancholics without delusion in fact: suffer from a sad delusion affecting the state of their moral and intellectual faculties, and which already exhibits a marked negative form.

- "They feel shame or even horror at their own person and despair at the thought that they will never be able to recover their lost faculties ...

- "They regret their vanished intelligence, their extinguished feelings, their faded energy"

- "They claim to have no heart, no affection for their relatives and their friends, nor even for their children:"

Delusions of ruin appear often, and seem to be negative delusions of the same nature: at the same time as his moral and intellectual riches, the patient believes himself to have lost his material fortune; he has nothing which constitutes human pride, neither intelligence, nor energy, nor fortune.

It is the opposite of the delusion of grandeur where the patient claims immense riches together with every talent and every ability. This moral hypochondria is based in the common ground of melancholia and in a state of vague and indeterminate anxiety;

«patients feel that all has changed both within them and outside, and are distressed no longer to perceive things through the same prism as formerly."  J.P.. Falret.)

In these mild cases, it is already as if there existed a veil through which the patients perceive reality only in a con­fused manner; everything seems transformed. As the mor­bid state becomes more intense, this veil becomes thicker and, in cases of stupor, comes completely to mask the real world. The patient is then, as M. Baillarger has justly point­ed out, close to the dream state.

Not only from this point of view, but in every respect, there seems to be nothing but a difference of degree between these states of moral hypochondria and melancholic disor­ders with delusions of guilt, ruin, damnation and systema­tised negation.

Moral hypochondria is a sketch; by simply accentuating the outlines and deepening the shadows, the picture of these latter forms of melancholia can be complet­ed.

Self‑disgust culminates in the delusion of guilt and dam­nation, fears become terrors; external reality, transformed and confusedly perceived, is finally denied.

Certain forms of nihilism may even appear very early in the moral hypo­chondriacs; they deny the possibility of cure, of any relief for their suffering; this is one of the first negations of these patients, some of whom will later go so far as to deny the external world and their own existence.

It is important to make a clear distinction between this state of moral hypochondria and ordinary hypochondria.

Although cases of melancholia without delusion must, according to M. Baillarger, be acknowledged, it is neverthe­less important to be on one's guard with regard to certain hypochondriacs who, in appearance, exhibit a close resem­blance to the melancholics in question here.

The true mel­ancholic is in a state of general depression ... Nothing similar occurs in the hypochondriac, who may at any time be drawn out of his supposed prostration, his nullity, his impo­tence, etc. by a simple disposition.

Ordinary hypochondria, of which M.Baillarger is speak­ing here, is comparable in several respects to persecutory delusion, of which it is often simply the first stage, and it is above all the diverse evolution of the two hypochondrias which justifies M. Baillarger's distinction.

In general, it may be said that moral hypochondria is to the delusion of ruin, of guilt, of perdition and of negation, that which ordinary hypochondria is to the persecutory delusion.

          When nihilistic delusion is established, it applies either to the actual personality of the patient, or to the outside world.

          In the first case, it takes a hypochondriac form simi­lar to the particular delusion reported by M. Baillarger in paralytics: patients have no entrails, no brain, no head, they no longer eat, no longer digest, no longer dress, and in fact they resolutely refuse food and often retain their faecal matter. Some imagine that they will never die.      

          This idea of immortality is found above all in cases where anxious agitation is predominant; in stupor, the patients are more likely to imagine that they have died.

          There are even those who alternately experience the delu­sion of having died and of being unable to die, depending on the alternation of their states of anxious agitation or stuporous depression.

Hypochondriac delusion, largely moral at the onset becomes, at a more advanced stage and especially when the disease attains the chronic state, both moral and physical.           Patients who initially have lost both heart and intelligence, end by having no body.

 Some, like Leuret's female patient, speak of themselves only in the third person.

In the perse­cuted patient, the contrary takes place. The hypochondria of the outset is above all physical; but at a more advanced phase, patients are preoccupied with their intellectual fac­ulties; they are being transformed into half‑wits, prevented from thinking, being told nonsense, having their intelli­gence removed, etc.

These two hypochondrias differ not only in their pro­gress:

The hypochondria of the anxious bears the stamp of humility; they have nothing and are worth nothing; they are rotten; suffering from ignoble diseases; some believe they have syphilis, a delusion which Fodéré had already noted to be connected with the delusion he calls demonomania.

Traité du délire. Tome 1 / , appliqué à la médecine, à la morale et à la législation

Fodéré, François-Emmanuel (1816).... Plusieurs formes d'extase et de démonomanie (Fodéré)

The persecuted hypochondriacs are entirely different:

They in general have a very good opinion of themselves and of the strength of their constitution in sustaining so many ills; they blame external influences, the air, the humidity, the cold, the heat, food and especially medicines. If they have syphilis, it is not the syphilis, but the mercury which is the cause of all their suffering.

They finish by blaming the doctor and enter a state of confirmed persecu­tory delusion.

           The persecuted individual feels himself exposed to these injurious influences, which converge on his person from outside.

          The anxious individual by contrast believes he is the source of them, and that it is he who is responsible for spreading them all around; he imagines that he brings misfortune on those who approach him, on the doctor who treats him, on the servants who attend him; he will infect them with fatal diseases, compromise them or dishonour them; the house in which he lives will be cursed; walking in the garden, he causes the trees and the flowers to perish.

 The sensibility:  Anaesthesia and  hyperaesthesia

Semiología de los trastornos de la  percepción. 

Hypochondriac nihilistic delusion is often linked with alteration of the sensibility. Anaesthesia is frequent in stu­por, and has been reported by all the authors; it is also encountered in certain anxious melancholics; in others, by contrast, it appears that there is an hyperaesthesia, patients do not permit themselves be approached; they cry out as sort as they are touched and constantly repeat: "Do not hurt me !"

In what measure do these alterations of the sensibility contribute to the development of hypochondriac nihilistic delusion? I shall confine myself to report­ing them as a differential characteristic of the two hypo­chondriac delusions; common in the negators, they are very rare in the persecuted.

When the delusion relates to the outside world, patients imagine that they have no family, no country, that Paris has been destroyed, that the world no longer exists, etc.

Religious beliefs, and in particular belief in God, often dis­appear, sometimes very early. Griesinger has reported the lugubrious, negative ideas, by which the patients feel them­selves invaded, their anxious agitation rendering them inca­pable of meditation and of prayer.

A rapid description of the nihilistic delusion and of its diverse forms would not be sufficient to prove that this delusion is a particular species of melancholia. I wish to show that, in conjunction with this delusion, there exist numerous symptoms, closely associated in such a way as to constitute a veritable disease, distinct in its characteristics and its evolution.

 We can employ the persecutory delusion as our type.

It is above all by identifying the differences and contrasts between him and the persecuted type, that I seek to depict the negator.

I have already begun this parallel by marking the differ­ence between moral hypochondria and ordinary hypochon­dria, between the anxious melancholic who blames himself and the persecuted who blames the outside world. When the disease becomes more intense, or takes a more severe form from the start, there occur, in addition to the symp­toms indicated in moral hypochondria and to ordinary delu­sion of ruin and of guilt, new phenomena which merit attention due to their special characteristics: these are the hallucinations.

Tipos de alucinaciones y síntomas psicóticos.

These hallucinations are especially frequent in states of stupor, but they are also observed in the anxious form:

Patients believe themselves to be surrounded by flames, they see precipices at their feet, they imagine that the earth is about to swallow them up or that the house is about to collapse, they see the walls waver and believe that the house has been undermined; they hear preparations for their pun­ishment, the guillotine being prepared; they hear the roll of drums, explosions of firearms, they are about to be shot; they see the rope intended for their hanging, they hear voices accusing them of their crimes, announcing their death sentence or repeating that they are damned. Some have hallucinations of taste and smell and imagine that they have become rotten, that their food has been transformed, that they are consuming garbage, faecal matter, human flesh, etc.

In general, hallucinations in patients with ideas of guilt belong to that category of hallucinations, established by M. Baillarger, which reproduce the existing preoccupations of the patients. A melancholic, this author states, who blamed herself for imaginary crimes, was obsessed night and day by a voice which announced her sentence of death and described the punishments reserved for her.

Another patient, whose history is reported by Michéa, believed her­self guilty, pursued by the police and under sentence of death. She was placed in an asylum and a few days after, the lypemania being at its height, she saw almost constantly before her eyes the rope which would strangle her and the coffin prepared to receive her corpse.

Patients believe themselves damned and see the fires of hell, they hear gun shots and believe that they are going to be shot. Guislain has pointed out the close connection between demonophobia, suicide and the type of hallucina­tion where patients see flames, fires all around.

Melancolía según Giné y Partagas (J. Guislain) s

The hallucinatory state of anxious, stuporous or agitated melancholics is totally distinct from that of the persecuted, first because of the visual hallucinations which are rare in the persecuted, and second by the character of the auditory hallucinations. Like the visual hallucinations, the latter sim­ply reflect the delusions and it is sometimes difficult to distinguish one from the other; in the anxious, the halluci­natory phenomenon does not have this independence which, in the persecuted, lends it such distinctness together with a very particular evolution.

The persecuted individual gradually arrives at a dialogue, he can be seen to listen, to answer his imaginary interlocu­tors with impatience or anger. Nothing similar in the anxious patient; if he speaks, he constantly repeats the same words, the same phrases, the same groans, his loquacity takes the form of a monologue, of a litany, while that of the persecuted is a dialogue.

Nor is there observed in the anxious patient the reper­cussion of thought, the echo, nor that special vocabulary by which the chronic persecuted can be recognised after a few moments of conversation.

I stated, at the beginning of this paper, the systematic opposition and resistance of individuals suffering from nihil­istic delusion; they often exhibit a muscular rigidity and tension which reveals that their inertia is only apparent and that their resistance is not simply passive.

As soon as one attempts to change their position, to bring some motion to their limbs, they powerfully contract their muscles in order to resist and to maintain their habitual position.

I do not wish to linger on the trembling reported in some anxious subjects, on the cataleptiform accidents in stupor cases, but 1 cannot omit the suicidal impulses and mutilation so common in anxious patients, especially when they are dominated by religious ideas, which establish yet one more difference from the persecuted in whom suicide is much less frequent, and mutilation very rare.

Anxious patients with ideas of damnation are those most disposed to suicide; even though they may believe them­selves dead, or in the impossibility of ever dying, they none­theless seek to destroy themselves; some desire to burn. themselves, fire being the only solution, others wish to be cut into pieces and seek by every means possible to satisfy this morbid need for mutilation, for destruction and for total annihilation.

Some show themselves violent towards the people around them; it appears that they wish to dem­onstrate that they are the most vicious beings, wholly devoid of moral sentiments; often they curse, blaspheme; for the damned and devil’s cannot do otherwise.

The rejection of food, so closely linked with madness of opposition, also possesses certain special characteristics in negators. In general it is total and applies without: distinction to all food; patients refuse to eat because they have no entrails, because "meat and other nourishment falls into the skin of their belly," because the damned do not eat, because they cannot afford to pay. Some, however, dominated by a less intense delusion of guilt or of ruin, select their food: out of penance, they eat only dry bread or eschew dessert.

The persecuted patient, on the other hand, carefully examines his food, seeks out what appears good, rejects what appears suspect; when by chance he encounters food which he supposes free of any poison, he eats voraciously. In general, the rejection of food is partial in the persecuted.

The course of the disease.

          The persecutory delusion is essentially remittent or, if one prefers, continuous, with paroxysms; the disease generally begins early, develops in a slow and progressive manner and lasts throughout life. This remittent course is already appar­ent in the hypochondria of the beginning; it is equally so where the sickness does not seem to evolve beyond that embryonic form.

The condition has a quite different appearance in the negators: it strikes suddenly, often around the middle period of life, in people whose moral health had previously seemed good; when there is a cure, it is sudden, like the onset; the veil is torn and the patient awakens as if from a dream.

The mildest forms, it goes without saying, are also the most curable.

So‑called melancholia without delusion, moral hypochondria, and anxious states with delusions of ruin are usually cured. But the condition is subject to relapses at

varying intervals, and takes on the character of the inter­mittent insanities. This intermittent character is sometimes revealed, even in incurable cases, by awakenings: of short duration in which it seems that the patient has entirely recovered his lucidity.

I once saw, says Griesinger, in a patient suffering from profound melancholia (she imagined herself to have com­pletely lost her fortune and believed herself destined to die of hunger) a perfectly lucid interval, of approximately one quarter of an hour, which occurred for no obvious reason and likewise suddenly disappeared.

In the forms where stupor is predominant from the beginning, a cure is often observed despite the intensity of the delusion and its absurdity. However, it is not unusual, after intense and prolonged anxious agitation, with hallucina­tions, panophobic delusion, etc., for patients to fall into a kind of stupidity which is too often mistaken for dementia and which continues indefinitely. These patients often show madness of opposition to the highest degree, they are mute, some repeating over and over again nothing but the word “no”.

The prognosis is also unfavourable when the intensity of the general melancholic disorder is seen to diminish, while the delusional ideas and the negations persist to the same degree. Patients arrive at a state of systematised nihilistic delusion which is rarely curable; in most cases they too exhibit madness of opposition, the unfavourable prognosis of which has been reported by Guislain.

By its course, by its onset, by its sudden termination, when it is cured, nihilistic delusion belongs to the group of fitful or intermittent insanities and to cyclical derangement. Even if the name nihilistic delusion is reserved for cases where this delusion has attained the degree to which I refer­red at the beginning of this study, it can be said that nihil­istic delusion is a state of chronicity specific to certain intermittent melancholics whose disease has become con­tinuous.

I wish only to state a point which seems to me to establish a difference between the negators and other intermittent conditions which are close to cyclical states.

When the ante­cedents, the character of the patients, are examined, one often learns that they have always been a little melancholic, taciturn, scrupulous, devout, charitable, always ready to perform a service; some are endowed with the most distin­guished moral qualities.

Their diseased state, their delusion of humility are not in complete contrast with their former manner of being and are simply a morbid exaggeration of it. In short, these patients are not entirely in alternation, in the way of cyclical and certain intermittent patients, whose healthy state is in absolute contrast with the fits of melan­cholia.

This characteristic in the negators also makes it possible to separate them distinctly from most hereditary patients, amongst whom they form a special category; this is because they are distinguished by an exaggerated development, if one may call it so, of those same moral qualities, the absence of which in other hereditary patients explains their disordered life, their profound egoism, their pride, their undisciplined character, their offences and their crimes.

If the nihilistic delusion seems to belong, in many cases, among the intermittent delusions, I must add that it is not unusual to see it develop on a ground of hysteria; nor is it unusual to encounter it as a symptom of diffuse perien­cephalitis. The delusion of smallness, reported in this condi­tion by Dr Materne, seems very close to nihilistic delusion and can coexist with it; we will see an example of it in the observations which follow.

Delusions of belittlement. Others have the delusion that they have become dwarfed, or that some part or organ of their body has become far smaller than normal. This condition, which I term delusions of belittlement ; which is often called micromania, but for which a better name, than the latter, was the one originally proposed by Dr. Materne "delire des petitesses," rarely exists alone; is usually of not very long duration, and easily escapes observation unless patients are closely examined