REACTION IN FOUR CASES OF DEMENTIA

PRÆCOX.*

By WM. BURGESS CORNELL,

Assistant Physician, Sheppard and Enoch Pratt Hospital, Towson, Md.

The dementia præcox group seems ever widening to include increasing numbers of variations from the three older sub-types, hebephrenic, catatonic and paranoid. The clinical method of Kraepelin has been of an undoubted value in the comprehensive consideration of symptoms and description of the case as a whole, as well as in the grouping together of these cases to form a nosological entity upon which in a practical manner prognostic, diagnostic and therapeutic measures can be based.

The application of Wernicke's psychological analysis has lent further assistance in the description and study of single symptoms. Wernicke distinguishes primary and secondary identification or sensation, and assumes that secondary identification, which comprehends all the functions implied in mental grasp and elaboration, is the seat of disorder in all mental disease. Secondary sensation is divided into auto-, allo- and somatopsychic fields, or subjective consciousness as relates to the ego, its projection and environment, and its reciprocal relation to the body. Furthermore, disorders such as occur chiefly in the sensory sphere are termed psychosensory, those of thinking, intrapsychic and those mostly involving the motor mechanisms, psychomotor.

The elaboration of such methods has led to an individual psychology, which makes each case of mental disorder a variant from others, and through which Breuer and Freud, and later Bleuler and Jung, have inaugurated a new epoch in psychiatry by such works as the "Diagnostische Association Studien," "Affectivität, Suggestibilität, Paranoia," "Psychopathologie des Alltagsleben" and "Die Traumdeutung."

Tiling as well as Freud came early to the conclusion that the importance of the individuality in the origin and the formation of

* Read at the sixty-fifth annual meeting of the American MedicoPsychological Association, Atlantic City, N. J., June 1-4, 1909.

the psychosis was almost boundless. Proceeding along these lines, Jung, in studying the association in dementia præcox, has come upon important and far-reaching facts and has even attempted to explain the etiology on psychological grounds. He has found an identity in the psychological mechanism of hysteria and dementia præcox. Both show an association complex which the individual tends to elaborate in every direction until he is forced out of all adaptation to his environment. In hysteria Jung is sure of the causal connection between the complex and the disease, but not so in dementia præcox. In the latter the complexes become more tenaciously fixed and he further postulates that the complex produces, in addition to its psychological effects, an "X" or metabolic toxin which completes the psychic mutilation. Yet Jung does not deny the possibility that the "X" may primarily result from other than psychological reasons.

As for the main facts in the psychopathology of dementia præcox, various observers preceding Freud have all called attention to the existence of a central disturbance, although different terminology has been used, such as apperceptive dementia" (Weygandt), dissociation and abaissement du niveau mental (Janet), tendencies toward fixation (Masselon, Neisser) and affect dementia (Kraepelin).

Then came the demonstration by Freud of the presence of splitoff series of ideas, their repression and subsequent reappearance and fixation as complexes.

Interesting and far-reaching as are the theories of Bleuler, Freud and Jung, it is apparent that the psychoanalytic method apparently does not disclose a complex in every case of dementia præcox to which the dissociation may be attributed. Especially is this true in the hebephrenic and catatonic forms. It is also apparently true in the four cases whose abstracts follow.

In considering etiology in such types as these one is more inclined to consider the "X" or toxin is of primary importance, rather than secondary to a psychological complex. The nature of such a toxin and the method of its action remain to be disclosed by a better chemistry and histopathology of the future.

CASE I.-Male, 19, single. Family history is bad on both sides. Both parents are intelligent and highly educated. Father was alcoholic at the

time of patient's conception, and has remained so since; at the time of the patient's admission to the hospital he was going through an attack of delirium tremens. Mother had some sort of psychosis at 18, lasting six months.

Patient is the sixth of seven children; the oldest is a talented musician, but erratic and eccentric; the third has probably an aborted form of dementia præcox; the others are said to be well. Our patient, up to the age of 14, was considered to be the most healthy and brilliant of all the children. In most of his school work he had difficulties, but at a precocious age he read Darwin, Spencer and Huxley. He was also musically talented, and at one time gave great promise as a violinist. He has always been of an argumentative turn of mind, and delighted to enter into weighty discussions on philosophical and metaphysical subjects; his sexual life was normal, as far as could be ascertained. Personal history in other regard is negative.

About 14 he contracted a fever, which may have been typhoid, though not identified as such. During convalescence he refused to eat and was very thin; he lived mostly on milk. He improved somewhat, but later, on reading some books on physical culture, he decided he would be stronger if he lived on a very limited diet. He was in a very nervous condition. After a few months' schooling his health demanded his withdrawal and he was sent to Florida, where he improved and was able to enter school the following fall. Soon he was again compelled to leave. His condition steadily grew worse, and at 17 he was sent to a sanitarium. Later he improved and again attempted school. He grew sluggish and indifferent mentally and was once more taken out.

In the spring of 1908, at the age of 19, he was sent to northern Maine for the summer. He then complained of a loss of feeling for things in general and of a general sense of unreality. He expressed himself volubly and intensely. He complained of the uncongeniality of his home surroundings. On his return from Maine the feeling of unreality was more marked; he complained of a general sense of vagueness, said at times he could not distinguish between his right and left hand. All mental processes seemed slow. There was a tremor of the lips, some cutaneous cyanosis, tongue coated and breath foul. Mental condition showed variability. He would suddenly change from an apparently bright and normal state to one in which he became confused and retarded, and at times impulsive.

Shortly after admission the following interrogatory was taken with the aid of a stenographer:

Dr. How do you feel to-day? Pt. I feel, I don't feel. Dr. Why don't you feel? Pt. (pause). Well, I don't know enough to tell you why I don't feel-I don't-it would take a man who knows a great deal, a very great deal about physiology, psychology and everything else to tell you the exact reason why I don't feel (pause). Don't you think it would (smiling)? Now, if you want me to talk I will talk all you want

(smiling). Dr. You told me last night you thought you were going to sleep. Pt. O, yes, I am, I gradually went to sleep last summer (pause), gradually went to sleep-deadened-poisoned-poison forming from malassimilation, and the poison is the result, not the cause—that is, the cause of the cause is primarily the deadening of all these nerves through here and the inability of these nerves to tell the brain that there is a pain in here (pointing to stomach), and that's as near as I can tell you. That is a month ago, six months ago, in the spring, when I would havemy food wouldn't really digest properly-there would be no pain and, of course, gradually grew worse-deadened. Osler could tell you what is the matter with me. What's this for, to see whether I am sane or insane (looking at stenographer and smiling)? Dr. No, I want to get a description of what you think. Pt. I could have told you perfectly two weeks ago, but since then I have deadened very much, all associations and memory, association and memory and (pause) various other things that go to make up what you choose to call self have gone; the idea of possession, that my arms and legs belong to me, that's gone-I don't feel anything at all I appear to other people, I am not self at all. Dr. You feel that you have changed? Pt. No, I am nothing now, I have lost myself, I cannot go back, I cannot look back-there is no memory, really. Dr. Then you have changed? Pt. Of course, I have changed. Dr. How do you mean? Pt. I gradually stopped-I was 18 then, and weighed 80 pounds. I went on a milk diet and went up from 80 to 145 poundsgained 50 pounds in two months-9 pounds in one week-most I ever gained; and while I was gaining that I gradually deadened, that is, there was a loss-I got fat, but the legs would get all swollen up, with water, I think. My brother and I went to school and I couldn't do any real studying; in other words, I got fat, but I didn't get strong. There is no real, there is no real motor energy about my-whatever you choose to call it-no nervous energy. Then in the spring, after going to school, and I was very tired, I had been tired all that winter-all the winter beforeslept all the time, wanted to sleep and I (pause) gradually went more and more to sleep, and felt as if my head was made of rotten blood (pause). I have lost all memory and associations and ability to go back, and inner feeling, lost all that entirely, and all retention of anything, for instance, when I go to, go up (pause), go on a fishing trip to the lake and come back, I couldn't retain it. I don't retain scenes, ideas of position. Dr. You remember them though? Pt. Yes, I can remember, all that's good, but suppose you have a lot of intellect, but haven't any feeling, what then? Well I gradually deadened in the summer and a (pause) kept on getting as much sleep as possible, and when I would go to sleep my whole arm, this arm (showing physician) would go to sleep; I would have to take this arm and hit it and wake it up, but there is no real memory. Dr. You have periods in which you feel real stupid? Pt. Stupid! I am stupid all the time. Dr. You are not this afternoon. Pt. I am not? Well, what is it? Suppose you are the most intellectual