THE CYCLIC FORMS OF DEMENTIA PRÆCOX.* BY WILLIAM RUSH DUNTON, JR., M. D., Assistant Physician, Sheppard and Enoch Pratt Hospital, Towson, Md. In a paper read before the American Medico-Psychological Association in 1907,' I drew attention to certain forms of dementia præcox which had been described by De Sanctis, Dercum, and others, and I feared at the time that I might be accused of having a classifying mania. My friends have been too considerate to make this charge concerning me, but I may run some further risk with my present paper. Perhaps the statement of my belief that the dementia præcox group is susceptible of much further division. may be an excuse for the advocacy of another form. During the past winter in one of our staff conferences Dr. Cornell applied the term cyclic dementia præcox to the case then under discussion and this seemed to me to aptly describe certain cases which I had mentally grouped and I therefore have adopted it. So far as I know its use is original with Dr. Cornell. It will perhaps be best to first give abstracts of these cases in order that it may be clearly understood what is included by the term, and especially as I am fully aware that there may be some who will disagree with my diagnosis. The first two cases (Case 1, No. 541, and Case 2, No. 547) which I wish to bring to your attention have so recently been reported by Dr. Barnes' that I shall not give abstracts but will merely call attention to the fact that while for a number of years they were regarded as typically cases of folie circulaire, which I believe is generally included in the maniacal-depressive group, yet there has been a gradual change and the excitement has become less typically maniacal; there has been a less marked flight of ideas and in the woman evidences of stereotypy, while in the man the excitement * Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909. 'The Forms of Dementia Præcox. Proceedings, 1907. has been replaced by periods of mutism and catatonic rigidity. There is undoubtedly mental deterioration in both of these cases, which was not present in the only other case of circular mania which I have observed over a considerable term of years. Here the cyclic course is undoubted and the only point on which disagreement may occur is whether they may be properly placed in the dementia præcox group. A close study of their symptoms makes such disagreement unlikely. The course of these cases is best shown by the annexed charts, 1 and 2, which illustrate the duration of the abnormal and normal periods of these cases for a part of the time which they have been under observation. Case 3, No. 1295, is a man, single, aged 23, who was admitted to the Sheppard Hospital, July 6, 1905. His family history is negative as is his personal history. He was of a quiet, even disposition, and that he had considerable mental ability is shown by his being one of 12 out of 170 who passed a civil service examination in 1903. At times he complained of his work as stenographer being hard. It is said that two months before admission he was told by a physician that he had heart trouble and should get on a drunk for it. This frightened him and he consulted a life insurance examiner who told him his heart was normal. The first mental symptom noted was the expression of grandiose ideas to his father on June 15, 1905, he declaring that he would be Secretary of State, that he was to negotiate a treaty of peace between Russia and Japan (these two countries having then suspended hostilities), and on this day he sent a telegram to the Papal representative at Washington, concerning the peace negotiation. From the beginning there has been a cyclic course, several days of excitement being followed by several days during which he was rational. He has shown some insight. Soon after admission he became so impulsive as to necessitate his removal to the disturbed ward. He showed many religiose delusions, fewer grandiose, also visual, tactile, and auditory hallucinations. On September 21, he was transferred to a quieter ward and on this day admitted that all of his delusions were unreal. On October 1, he became noisy, saying he shouted because some one told him to do so, and this condition lasted until October 10, when he again showed good insight. A less severe attack lasted from October 24 to 31, and in the attacks which followed it was noted that they began with elation and refusal of food, then came a condition of confusion after which he would gradually become clear and his insight would return. Ordinarily much interested in baseball and playing a good game, when confused he would have nothing to do with it. After showing a slight improvement he was discharged on a trial visit home February 9, 1907, and has remained there ever since. During the greater part of this time he has had attacks which are described by his physician as follows: The stuporous condition usually begins the latter part of the month, about the 20th or 23d, preceded by a mild exaltation, the patient becoming talkative and somewhat restless, followed within a few hours by a stuporous, negativistic condition, during which he will not talk, is unable to attend to his usual occupation, and sits in his room unresponsive in every way. During this period he eats and sleeps as usual. This period usually lasts from ten days to two weeks, and recovery is noted by the patient becoming more aggressive, agitated (psycho-motor restlessness), and at times has struck his father or sister. Within a few hours the patient has regained his normal self and returns to work. Between the attacks the patient is bright, industrious, and to the casual observer is perfectly normal. During the depressed period the patient will sit in a chair for hours at a time with a silly grin, holding a book on his lap and repeating silly phrases over and over again. He will oppose any passive motion and refuses to talk. He has a clear recollection of all that transpired during the period and is able to relate incidents that occurred. It will be noted that the word depressed is above used to qualify the abnormal period, and for a considerable period after his discharge from the hospital his physician was of the opinion that he was suffering with a folie circulaire. In our opinion, however, the patient showed some mental deterioration at the time of his discharge. I recently saw the patient for a few moments and noted that he had changed considerably in physical appearance. Our conversation being limited to ordinary greetings was not of a nature to bring out any mental symptoms but his manner was not suggestive of any mental disturbance. He was asked to write an account of illness and sent the following: DEAR DOCTOR: In accordance with your request to the best of my knowledge hereby state as to periods of unconsciousness and cataleptic state duration of same. Since I have been out of asylum, Feb. 1, 1907, 8 months succeeding each month a slight indisposition and one or two exaggerated affairs during the whole period. Since about Oct. 15, '08, until now, a bad period every month always of either 10 or 14 days duration induced by almost every attack by disagreement with same on some usually trivial subject this state of mind acting adversely on the condition of my head. I add at no period of this time have I been able to study speedy short hand work on account of these interferences. At the time I was under your care, as I then reported, these periods extended from about 12th or 14th of each month until 24th or 26th. Gradually the period has changed, the attack consistently occurring almost to a day (for the last 6 months on the 20th and lasting until the 2d or 4th of the following month. Last month (May) shifted to the 25th, but it was the same period of duration, 14 days. Respectfully, R. E. O'MARA. This last case and the two previously reported by Dr. Barnes show typically the cyclic character of the disorder. The character of these periods is similar in the three cases there being first a period of excitement in which an element of confusion is present, this last increasing as the excitement subsides until finally a stupor occurs from which the patient gradually emerges. The woman has shown this cycle more consistently than have the other two and shows but little variation in the character of her abnormal periods from those which she had years ago with the exception that they are apparently becoming longer. During the early excitement, which does not suggest that of manic-depressive insanity, there is a good deal of stereotypy shown by her singing the same phrases over and over and by the repetition of " this, this, this " very constantly, as well as other phrases not so constantly. An example of her production has been given by Dr. Barnes, but for comparison is reproduced here, it representing 8 minutes spontaneous production: "Sign yourself, sign yourself (laughs), nothing, nothing, nothing. Yes, you do it yourself, do it yourself. How many more? How many more of them? How many more are there? I am tired of these things (blood smears were being made)-my father took it out-eight o'clock-no, nothing. What's that in your mouth? (blood pipette). Transactions—put that in your mouth. Can you see? Who is this? I don't know. How many more is there? How much of that trash have you got there? How many more of them? I will get up on the stage. How many more of them are there? How many more? How is your stomach (laughs)? Blue flag (looking at physician's blue necktie-laughs) yes, yes, yes (laughs), good-bye (this to the nurse who leaves the room). (Q. Are you happy now?) perfectly." In the man, Case I, the attacks formerly always began with logorrhoea, an example of which taken in 1905 by Case III, who, it will be remembered, was a stenographer, is as follows and represents the spontaneous production for one minute: "Moss was the name of a colored employee on the Light-house Board. Moss attempt-got most of it—and he is a damned lie, becauselook here. I cannot be beat with, I can't go out with, and if I'm not working after that-what the-he work with-he crack-doing the wrong kind of business on the ground and a coffin nail is gone. Such things and you have got to get like little babies and suck your nose, but they going off so of these days themselves, that is all right, bees and you." The above is very similar to that noted by Dr. Barnes in 1908, and in all of these we note there is marked dissociation. Case III also showed a logorrhoea in the initial stage of the abnormal period but less markedly than the others and frequently taking the form of writing. I regret that I have no record of his speech but the following is a copy of two pages of note paper written by the patient and illustrates the character of such logorrhoea as well as his ideas: 3 The Sabbath day was Friday, August 18, 1905. Robert Emmett O'Mara' is the Pope of the Holy Catholic Church. Rev. T. H. Barter is a Cardinal. Zink is a Cardinal. Merry del Val is a Cardinal. Merry del Val is Papal Secretary of State. Lewis Weber is a Bishop of the Holy Catholic Church. Walter Elmer is a Bishop of the Holy Catholic Church. This is [scratched] Tuesday, August 20, 1905. The Pope is the servant of God on earth. The Papacy of the Holy Catholic Church cannot be transferred. (Second page.) The Sabbath is the day of God. There are 10 Commandments of God. I. Thou shalt not have strange gods before thee. 2. Thou shalt not take the name of God in vain. 3. Remember thou keep holy Sabbath day. 4. Honor father and mother. 5. Thou shalt not kill. 35 These indicate names which have been altered from the original, being the patient, former friends and fellow patients. |