some cases these changes may recede either temporarily or even permanently.

Dementia præcox appears in many forms that are difficult to classify. In Germany, following Kraepelin, three principal forms are distinguished: hebephrenia, catatonia, and paranoid dementia. Delusional types of hebephrenia resemble paranoid dementia so closely that it is often impossible to determine to which of these groups a given case is to be assigned. It seems more convenient for practical purposes to describe separately the following three forms: simple dementia præcox without delusions; dementia præcox of the catatonic form; and dementia præcox of the delusional form.

We shall study first the psychic and somatic symptoms that are common to all forms.

SYMPTOMS COMMON TO ALL FORMS.

Psychic symptoms.1 All the psychic functions are not equally affected. While orientation and memory are often preserved or but little affected, attention, association of ideas, the emotions, and the reactions are always markedly impaired.

Lucidity and orientation. These very frequently remain intact, although the appearance of the patients would scarcely lead one to think so. Many patients appear to be ignorant of what occurs about them, yet they will give rational and correct replies

1 Masselon. Psychologie des déments précoces. Thèse de Paris, 1902.

to questions concerning the date, their surroundings, and even the important events of the day. We shall return to this question in connection with the study of catatonia.

Memory. Like the lucidity, the memory is but slightly affected, at least in the majority of cases for a considerable number of years. Old impressions remain well defined, and the knowledge acquired during youth and childhood is often astonishingly well preserved. An old asylum inmate, a typical case of dementia præcox, who had been in the institution for fifteen years, was still able to name without hesitation and in their proper succession all the French rulers from the time of Clovis.

Actual occurrences impress themselves quite durably upon the memory. Many patients are able to relate events that have taken place since their commitment, and can often even name the physicians and attendants that have followed each other on the service during several years.

However, when the affection is of long standing it is rare for the memory not to have become impaired to some extent. Anterograde amnesia is the first to appear; the power of fixation becomes diminished. Retrograde amnesia appears later and is usually less marked. Little by little old impressions grow fainter and may even become entirely effaced.

Attention. This faculty is always weakened. Any labor requiring some degree of concentration becomes impossible.

Association of ideas. These are sluggish and often occur without any apparent connection,1 giving rise to speech which may reach the extreme limits of incoherence. We have given a very typical example of such speech. These incoherent phrases are uttered quietly and without the volubility which characterizes flight of ideas of the maniac. On superficial examination this phenomenon may create the impression of a profound state of dementia or mental confusion, which in reality does not exist. The patient whose incoherent speech we have quoted as a typical specimen is perfectly oriented and possesses good memory.

The affectivity and the reactions are greatly impaired from the beginning. Indifference constitutes an early and very prominent symptom of dementia præcox. The patient takes no interest in anything, expresses no desires, makes no complaints. Often even hunger determines no reaction. If the patient is accidentally forgotten at meal time he evinces no surprise and makes no protest. As in all conditions of dementia, this disorder of affectivity is not a conscious one.

Occasionally, especially at the onset of the illness, this habitual state of indifference is interrupted by explosions of anxiety or of anger, for which there is often no apparent cause.

A priori the emotional indifference of dementia præcox would be expected to lead to a reduction of

1 See page 61.

the voluntary and normal reactions. Observations upon patients show this, indeed, to be the case.

On the other hand, the automatic reactions are often exaggerated. They manifest themselves under all the forms studied in the first part of this work, General Psychiatry: pathological suggestibility, negativism, and impulsiveness (stereotypy of movements and of attitudes, verbigeration, grimaces, unprovoked laughter, etc.).

Mental deterioration. - When, as is most often the case, the disorder of attention, the sluggish formation of associations of ideas, and the impairment of affectivity and of the will, or in other words, when all the symptoms which we have described above have become definitely established, we have mental deterioration.

The degree of deterioration is variable. In some cases it apparently affects all the psychic functions to so pronounced a degree that all mental activity seems to have disappeared, and, from this point of view, the patient cannot be distinguished from an idiot or from an advanced general paretic. Such cases are exceptional, and often enough the dementia is much less complete than it appears to be from a superficial examination, as is shown by the following case:

Theresa C., formerly a school teacher, at present (1905) a patient at the Clermont Asylum, age thirty-four years. The disease came on at the age of twenty-five. For several years this patient has lived in a state of apparently complete unconsciousness, incapable of carrying out the simplest commands or of answering the most ele

mentary questions. The facial expression is silly. The patient spends most of her time sitting in a chair or wandering about the court-yard, talking incoherently, her utterances showing marked stereotypy. The word "mystery” keeps recurring in the manner of a Leitmotiv: “To digest the nature of mystery, Claude of mystery, Matthew of mystery, Joseph of mystery. It is a conflagration, it is a petticoat, it is an oblation, resurrection, when will you wake up, like the brutes. Mystery, of mystery, forty-eight of mystery," etc. Totally indifferent to everything, she manifests not the slightest emotion when spoken to about her family, or when offered her release. She is filthy in her habits. And yet, when a pen is put in her hand she will write disconnected words or fragments of sentences without a single orthographical error. No example could illustrate more clearly the dissociation which characterizes dementia præcox in which total ruin of some faculties is compatible with perfect conservation of knowledge acquired previously.

1

Somatic disorders. These are present in all the three forms of the disease, though they are perhaps most marked in the catatonic form.

Motility. -The disorders of motility consist in hemiplegias and monoplegias that are slight and of short duration; convulsive hysteriform or epileptiform seizures; and fainting spells. The contractures often observed are usually the consequence of negativism.

Sensibility. One must be guarded against attributing the absence of reaction to pricking, which results from negativism, to anathesia. True disorders of sensibility are, however, far from being

1 Sérieux et Masselon. Les troubles physiques chez les déments précoces. Soc. méd. psych., June, 1902.