acquisition and unchecked development of vicious mental habits or of abnormal "types of reaction" which ultimately replace by substitution healthy and efficient mental reactions such as are necessary in our constant acts of adjustment to our usual environment as well as to newly arising situations.

The importance of this view lies in its bearing on therapeutics and, to a still greater extent, on prophylaxis.

To quote from the original paper:1

"Every individual is capable of reacting to a very great variety of situations by a limited number of reaction types.'

"The full, wholesome, and complete reaction in any emergency or problem of activity is the final adjustment, complete or incomplete, but at any rate clearly planned so as to give a feeling of satisfaction and completion. At other times there results merely an act of perplexity or an evasive substitution. Some of the reactions to emergencies or difficult situations are mere temporizing attempts to tide over the difficulty, based on the hope that new interests crowd out what would be fruitless worry or disappointment; complete or incomplete forgetting is the most usual remedy of the results of failures, and just as inattention and distraction correct a tendency to overwork, so fault-finding with others, or imaginative thoughts, or praying, or other expedients, are relied upon to help over a disappointment, and, as a rule, successfully. Other responses are much more apt to become harmful, dangerous, uncontrollable a rattled fumbling, or a tantrum, or a hysterical fit, or a merely partial suppression, an undercurrent, an uncorrected false lingering attitude, or whatever the reaction type of the individual may be. What is first a remedy of difficult situations can become a miscarriage of the remedial work of life, just as fever, from being an agent of self-defence, may become a danger and more destructive than its source. In the cases that tend to go to deterioration certain types of reactions occur in such frequency

1 Adolf Meyer. Fundamental Conceptions of Dementia Præcox. British Med. Jour., Sept. 29, 1906.

as to constitute almost pathognomonic empirical units. I would mention hypochondriacal trends, ideas of reference, fault-finding or suspicions, or attempts to get over things with empty harping, unaccountable dream-like, frequently nocturnal, episodes, often with fear and hallucinations, and leading to strange conduct, such as the running out into the street in nightdress, etc., or ideas of strange possessions with hallucinatory dissociations, or the occurrence of fantastic notions. All these appear either on the ground of a neurasthenoid development, or at times suddenly, on more or less insufficient provocation, with insufficient excuse, but often enough with evidence that the patient was habitually dreamy, dependent in his adjustment to the situations of the world rather on shirking than on an active aggressive management, scattered and distracted either in all the spheres of habits or at least in some of the essential domains of adjustment which must depend more or less on instinct or habit. On this ground reaction types which also occur in milder forms of inadequacy, in psychasthenia and hysteria or in religious ecstasy, etc., turn up on more inadequate foundation and with destructive rather than helpful results. We thus obtain the negativism no longer as healthy indifference and more or less self-sparing dodging, but distinctly as an uncontrollable, unreasoning, blocking factor. We obtain stereotypies not merely as substitutive reactions and automatisms on sufficient cause such as everybody will have, but, as it were, as a reaction of dead principle in a rut of least resistance. We see paranoic developments with the same inadequacy of starting point and failure in systematization, and in holding together the shattered personality,

etc."

Therapeutically, this way of going at the cases will furnish the best possible perspectives for action. We stand here at the beginning of a change which will make psychiatry interesting to the family physician and practitioner. As long as consumption was the leading concept of the dreaded condition of tuberculosis, its recognition very often came too late to make therapeutics tell. If dementia is the leading concept of a disorder, its recognition is the declaration of bankruptcy. To-day the physician thinks in terms of tuberculous infection, in terms of what favours its development or suppression; and long before "consumption" comes to one's mind, the right principle of action is at hand-the change of habits of breathing poor air, of physical and mental ventilation, etc. In the same way, a knowledge of the working factors in de

mentia præcox will put us into a position of action, of habit-training, and of regulation of mental and physical hygiene, as long as the possible "mental consumption" is merely a perspective and not an accomplished fact. To be sure, the conditions are not as simple as with an infectious process. The balancing of mental metabolism and its influence on the vegetative mechanisms can miscarry in many ways. The general principle is that many individuals cannot afford to count on unlimited elasticity in the habitual use of certain habits of adjustment, that instincts will be undermined by persistent misapplication, and the delicate balance of mental adjustment and of its material substratum must largely depend on a maintenance of sound instinct and reaction type."

Meyer's views gain additional significance in the light of the more recent contribution of August Hoch,' who finds in a large percentage of his cases of dementia præcox (51-66%) evidences of a peculiar mental make-up which he has termed "shut-in personality." This make-up he defines as follows: "Persons who do not have a natural tendency to be open and to get into contact with the environment, who are reticent, seclusive, who cannot adapt themselves to situations, who are hard to influence, often sensitive and stubborn, but the latter more in a passive than an active way. They show little interest in what goes on, often do not participate in the pleasures, cares, and pursuits of those about them; although often sensitive they do not let others know what their conflicts are; they do not unburden their minds, are shy, and have a tendency, to live in a world of fancies. This is the shut-in personality." And he adds further: "What is,

1 Constitutional Factors in the Dementia Præcox Group. Rev. of Neurol. and Psychiatry, Aug., 1910.

after all, the deterioration in dementia præcox if not the expression of the constitutional tendencies in their extreme form, a shutting out of the outside world, a deterioration of interests in the environment, a living in a world apart?" For purposes of control Hoch has examined the histories of his cases of manic depressive insanity and failed to find plain evidences of a marked shut-in personality.1

Pathological anatomy.— Until recently most psychiatrists placed dementia præcox among the socalled functional disorders. The newer studies have, however, revealed fairly constant, though not pathognomonic, anatomical changes. Alzheimer and others working by his methods have found products of nerve cell degeneration within nerve cells, in the clear spaces around them, and especially in the perivascular spaces. Southard, having selected 37 cases of dementia præcox showing at autopsy no coarse complicating features like brain atrophy, intracranial arteriosclerosis, etc., has found in 19 foci of gliosis distinctly palpable in the fresh brains.3 Rosanoff, making use of an improved method for

1 Journ. of Nerv. and Ment. Dis., Apr., 1909.

2 Alzheimer. Beiträge zur Kenntniss der pathologischen Neuroglia und ihrer Beziehungen zu den Abbauvorgängen in nervösen Gewebe. Histologische und histopathologische Arbeiten über die Grosshirnrinde, 3, 1910. - Sioli. Histologische Befunde bei Dementia Præcox. Allg. Zeitschr. f. Psychiatrie, Vol. LXVI, p. 195, 1909. Orton. A Study of the Brain in a Case of Catatonic Hirntod. Amer. Journ. of Insanity, Apr., 1913.

3 Southard. A Study of the Dementia Præcox Group in the Light of Certain Cases Showing Anomalies or Scleroses in Particular Brain Regions. Amer. Journ. of Insanity, July, 1910.

measuring brain atrophy consisting essentially in observing the relationship between cranial capacity and brain weight, has found very close and constant correlation between the degree of mental deterioration observed clinically and that of atrophy found at autopsy in cases of dementia præcox; from this he has drawn the conclusion that "dementia præcox is associated in some way with changes in the brain which lead to atrophy."1

Treatment. Excitement, refusal of food, dangerous tendencies are treated, as they arise, by the methods already described in the first part of this book. An effort should be made to combat stereotypy in all its forms by suggestion and by diversion and occupation. Employment at useful labor is desirable also from the economic standpoint; precocious dements constitute a large proportion of institution workers and thus contribute toward their support.

1 Rosanoff. A Study of Brain Atrophy in Relation to Insanity. Amer. Journ. of Insanity, July 1914.