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Worthington, J. H.: Case of prominence of eye-balls with disease of thyroid gland and heart. Am. Jour. of Insanity, 1856-7. Vol. XIII, pp. 36-38.

Ziemmsens Cyclop., Vol. XIV.



BY ERNEST JONES, M. D., M. R. C. P. (Lond.),

Demonstrator of Psychiatry, University of Toronto.

The psycho-analytic methods developed by Freud in the past fifteen years have been singularly neglected by workers outside of German-speaking countries, as is illustrated by the fact that no psycho-analysis carried out in any other country has up to the present been published. Yet these methods are unquestionably destined to have a far-reaching influence not only in the case of the psycho-neuroses but in much wider fields, and particularly in that of insanity. Already in dementia præcox Jung' has applied Freud's principles to the elucidation of the mental changes present in this obscure malady, and in spite of the great technical difficulties encountered has met with such brilliant success as greatly to encourage workers in this and allied spheres of investigation. Up to the present no psycho-analysis of a case of manic-depressive insanity has been recorded, for the only one published under that name, by Otto Gross, was almost certainly, as Jung and others have pointed out, a case of dementia præcox. The same objection may be open as regards the case presently to be described, but in the writer's opinion the evidence seems here definitely to point against the diagnosis of dementia præcox.

Before detailing some of the results of the study carried out by the Freudian methods, I will first give an account of the case as observed on ordinary lines.

'Jung: The Psychology of Dementia Præcox. Translated by Peterson and Brill. Journal of Nervous and Mental Disease, Monograph Series, 1909. See also two excellent analyses by Brill, Journ. of Abn. Psychol., Vol. III, p. 219, and Amer. Journ. of Insanity, Vol. LXVI, p. 53.

'Otto Gross: Das Freud'sche Ideogenitätsmoment und seine Bedeutung im manisch-depressiven Irresein (Kraepelin's). 1907.

Previous History. The patient, S. T., is a woman aged 39. Her father died of pneumonia at the age of 55. Her mother, aged 78, is still alive; she is said to have suffered from "hysteria." One brother died of an aortic aneurism at the age of 35; two others are alive and well. There was no instance of insanity known in the family.

The patient was brought up in the country, in a Northern American State, and was at home until she married. At school she was unusually quick in learning. She began to menstruate at the age of 14, and had no dysmenorrhoea. She married at the age of 19, and in the next year bore a son, who is still alive and well. A year or two later she had a miscarriage; this was followed by pelvic complications, evidently of a septic nature, which kept her in bed for five months. In 1892, when aged 23, she underwent double ovariotomy. This operation had no effect on her menstruation or on her sexual feeling. Ill health persisted, and she suffered much from painful sensations in the top of the head. Three years later her uterus was curetted for this. A period of depression followed and she was given electrical treatment for six months. In the succeeding years she was well for varying periods, and in the intervals suffered much from weakness, malaise and pelvic pain. In the summer of 1904 her health again badly broke down, and she was in hospital for three months of that year and for six months of the next. In June of the latter year (1905) she had a broad ligament cyst removed; it was at the time noted that the ovariotomy had been complete. Since this last operation she has rarely been free from sleeplessness, lack of appetite and other symptoms, though these greatly varied in intensity from one time to another. Two months before her admission to the asylum a marked exacerbation of them took place, as will presently be detailed.

At different times during her married life she had entered into irregular relations with men, which lasted for varying periods. Her husband, who was a commercial traveller, was aware of this. He attributed it to irresponsible eccentricity caused by her markedly erotic temperament, and took the view that his duty was to forgive, and, wherever possible, to guide her. His attitude towards his wife was one of exceptional patience and fondness,

and domestic scenes between them were rare and insignificant It should be mentioned that the patient had always from a girl been religious, but only to a reasonable extent.

Present Illness.-For two months before admission the patient had been restless, irritable, depressed and excited, varying greatly in mood from one day to the next. She had conceived an aversion towards her husband and son, and thought they were conspiring to harm or destroy her. She imagined that various clergymen were in love with her, that people were discussing her reputation, and conspiring to injure it. Her food was being poisoned, and she refused to eat it. Electricity was being pumped up through the floor to hurt her, and there were strange odors in the room. The house was full of men and spirits. The front of the house was transparent, so that everything could be seen from the street.

She tried to throw herself out of the window, and to run out into the street undressed. She became violent, uttered loud screams, and had to be forcibly restrained. Throughout, however, she seemed to have considerable insight into her condition; she realized that her mind was sick and that she was going insane.

First Admission.-She was admitted to the asylum on January 30, 1907. From the note taken during her stay the following points may be added to the account given above. Her attention was easily gained, and was well maintained. There was no clouding of consciousness. She was well oriented. She cried readily. She was fretful and, later on, depressed. She made a good recovery and was discharged on March 27, 1907.

Second Admission.-The patient was readmitted on September 27, 1908, with the story of having suffered from a very similar attack to the previous one. The symptoms had developed only a week ago, and had ensued on another gynæcological operation to which she had recently been submitted. They began with considerable depression, which was soon followed by excitement. The same erotic delusions were present as on the previous occasion. She was exceedingly restless and excited, gesticulated wildly, swore, sang, wandered from room to room, and threw things out of the window. She would toss herself about in bed until she reached an ecstasy of excitement, banging the walls with her fists,

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