Correspondence

NOTE ON THE MECHANICAL IRRITABILITY OF THE FACIAL NERVE IN DEMENTIA PRÆCOX.

Editors American Journal of Insanity:

In 1902, in a report of a case of dementia præcox, published in the American Journal of Medical Sciences, Vol. XXXIII, p. 109, I mentioned among other symptoms that the patient showed marked mechanical irritability of the facial nerve. Later in the same year in a paper entitled Some Points in the Diagnosis of Dementia Præcox, published simultaneously in American Medicine and in the American Journal of Insanity, I drew attention to the diagnostic importance of this symptom. In this I stated: "As yet I do not feel that I have investigated this phenomenon sufficiently to make any very positive assertions concerning it. It is not present in all cases, and sometimes when I have most expected to find it, it has been absent. It seems to be most pronounced in the later stages and unless pretty constantly present as an early symptom will not prove of much value from a diagnostic standpoint. So far I have been able to obtain it in most but not in all early cases. Later I hope to obtain more conclusive data, and meanwhile I should be very glad if others would investigate this phenomenon and would publish their results, or communicate the same to me."

Not long after this, in conversation with Dr. D. J. McCarthy, he drew my attention to the fact that this symptom was often found in cases who had indulged in excess of tobacco or alcohol, and he therefore believed it to be frequently toxic in origin. I was subsequently able to confirm this opinion and from further observations I believe that in my paper I gave undue prominence to this symptom, and that it must simply be considered in connection with the exaggeration of other reflexes and the hypertonic condition of the muscles, as probably a toxic condition. It must be remembered that the physical signs of dementia præcox are

multiform and it is usually a mistake to give undue prominence to any one symptom, which mistake I believe I made in my paper. The general hypertonus of the muscle as shown by the exaggerated tendon reflexes and resistance to passive movements like the mechanical irritability of the facial are probably all indications of a toxic condition which is the cause of the dementing process. That dementia præcox is the result of a toxic condition has been the opinion of several writers for a number of years.

It had been my intention to publish this note earlier, but as no one seemed to attach any special importance to the diagnostic value of the mechanical irritability of the facial but myself, I allowed the matter to rest. However, having recently noticed that Dr. Daniel R. Brower in a paper in the Alienist and Neurologist for May, 1905, mentioned this symptom, quoting me, I have thought best to give my later opinion on this point.

WILLIAM RUSH DUNTON, JR.

Sheppard and Enoch Pratt Hospital.

AN INQUIRY IN REGARD TO MENTAL PHENOMENA CONNECTED WITH ANESTHESIA.

Editors American Journal of Insanity:

While in the deeper stages of anesthesia mental processes are usually so entirely submerged as to fall beyond the possibility of record, in the lighter stages and in the period of approach to, and most favorably of all, in the period of recovery from more complete anesthesia, the power of response to outward stumuli is sufficient to afford ample opportunity for a series of observations which furnish the motive to the present inquiry. The cooperation of surgeons and anesthetizers is invited to secure data that bear upon any of the questions summarized below, or upon the general problem thus suggested. Special attention is directed to the importance of tracing relations between the phenomena recorded during anesthesia and normal, waking, mental traits of the subject. Indeed, the former can in many cases be interpreted only in the light of the latter; and observations become of value

in proportion as the subject is able to account for the mental experiences of the unusual state by references to the normal source and trend of his mental processes. To determine these, skilful questioning controlled, where possible, by ingenious tests, will be the most effective instrument of inquiry.

1. Analogies between the Lighter States of Anesthesia and Hypnosis. Of these the chief trait is increased suggestibility: Will the patient carry out automatically with enfeebled consciousness suggestions given by the operator to do thus and so, to feel or neglect certain sensations, to follow a train of thought, to carry out a code of signals between subject and operator? Is obedience to such suggestions apparent by facial expressions, involuntary cries, nods, etc., after more controlled forms of reaction have disappeared? Is there evidence that patients respond to similar suggestions not directly addressed to them? Do they react to the conversation of the attendants, to a vague knowledge of their surroundings, to interpretations, correct or incorrect, of what is actually going on? Are there any of these responses that reflect the normal habits, idiosyncrasies, etc., of the waking condition? Do they belong to the experiences immediately preceding or to a more remote past?

Next in importance are the automatic activities. Illustrations are desired of automatic talking, mechanical acts, and simple tricks of manner, of the type so common in sleeping persons who walk and talk in their sleep, answer questions without awakening, make movements as of knitting, counting money, etc., or other betrayal of their subconscious thought. In very favorable instances it may be possible to place a pencil in the patient's hand and secure by questioning a subconscious answer or scribble or drawing that throws interesting light upon what is going on in the mind, even when there is but partial consciousness of surroundings or direction of mental processes. Such observations have especial value and should be accompanied by the actual records.

2. Analogies between the Lighter States of Anesthesia and Dream Life.—If the patient be questioned as to what occupied his mind up to the moment of losing consciousness and again during the regaining of full consciousness, there will inevitably result a valuable collection of data regarding the waning and waxing

states of consciousness. Many of these phenomena will be dream-like, and should, like dreams, be recorded with ample detail to make them intelligible. The nature of the impressions, whether visual or auditory, acted or felt, and most of all, the connections between the dreams and the recent or remote experiences of waking are important items. Just as ordinary dreams become interesting when they are connected with normal experiences, so in the dreams of anesthesia the patient alone can give adequate personal detail to give significance to the narrative.

3. Other Points of Interest.-The specific points enumerated are intended to make the matter definite rather than to limit the scope of the inquiry. Evidence is desired that bears in any degree of pertinence upon the general problem thus suggested. As additional points of interest may be mentioned the following: In cases of repeated anesthesia, after rather brief intervals, is it possible to elicit evidence that in the approaching or receding consciousness, details are remembered (or recallable by suggestion) which though beyond the control of the waking consciousness, are shown to connect one state of abnormal consciousness with another similarly caused? The analogous fact is that in hypnosis the subject will tell in a second hypnotization what happened while he was formerly hypnotized, but cannot recall in the waking interval; or again, in changes of personality the relapse into the altered personality will bring with it the control of memories of the last states of abnormal personality, which were not recallable in the normal state. Dreams and the actions of drugs show similar phenomena. Where records of this kind are available through anesthesia, they should be recorded in detail, and a conclusive set of questioning and tests be made to elicit how far the two states are connected.

A further point of interest is the correlation of different types of mental states with different degrees of anesthesia. For this purpose it is desirable that some physiologic sign of the degree of anesthesia be recorded as evidence in general of the depth of anesthesia during which the mental phenomena were observed. The variations of susceptibility to an anesthetic are such as to make it important to estimate the susceptibility in each case, as well as to give such general data as the age, sex, occupation, condition in life, physical state, temperament, purpose for which the

anesthetic was administered, length of period under its influence, degree of nervous shock accompanying the same, and so on.

The general use to which the data will be placed will be that of formulating a consistent account and interpretation of the range of subconscious mental states, including simple states of distraction, absentmindedness, reverie, trance, hypnosis, dreams, the actions of drugs, alterations of personality, lapses of memory, states of confusion, and the reactions to anesthetics. It is hoped that a sufficient series of data will be elicited by the present inquiry to throw important light upon processes as yet imperfectly understood, and the analogies of which to such artificially induced states as those accompanying anesthesia are of especial importance. The psychologist has naturally but little opportunity to observe these phenomena, and must thus appeal to those who are professionally engaged in their production, to step aside from their main interests to supply in a spirit of cooperation the data so valuable to students of a different and yet not unrelated science. Full credit will be given to all contributions, and no direct or personal use will be made thereof in print without distinct permission. Those to whom this circular letter is addressed are hereby invited to send records of such observations and to further the purposes of this inquiry in such ways as may lie in their power. The undersigned will appreciate, both personally and professionaly, favorable action upon this request.

Madison, Wis.

JOSEPH JASTROW.

The University of Wisconsin: Department of Psychology.