eating and cried incessantly, and in a few days became incoherent and distracted when she would speak, which was not often. She would hide under the bedclothes or resist attempts to view her, became inattentive to her toilet and surroundings and developed automatic movements. With changed environment this psychogenous attack subsided within a few weeks. The next month was utilized to instruct both parents and daughter, and in the four years since this has happened no further attacks have occurred.

Either hysteric or schizophrenic is hardly appropriate to such an episode and I would prefer to regard it as a reaction to an experience in the sense which Jaspers uses it. "It is immaterial," as he puts it, "whether such a reactive psychosis occurs with a psychopath, a schizophrenic or an organically diseased individual. The variability of the reactions depend primarily upon the psychic constitution of the individual upon the nature of the psychic experience and upon the structure of the reactive states." It would seem, therefore, that in addition to the progressive type of dementia præcox with deterioration and with the attacks occurring without any connection with exogenous factors, that clinically we cannot ignore a reactive type with recovery without noticeable deterioration and with unmistakably psychogenetic etiology. A reactive type in this sense as a part of the dementia præcox group would not be recognized by many. Some seem to regard nonprogressiveness and non-deterioration as irreconcilable with dementia præcox. To the writer, however, the psychogenous psychoses cannot always be separated clinically from the dementia præcox group in the beginning of the attacks.

Bleuler's study of autism and of negativism as a distaste reaction with its two divergent impulses from the normal type through the hysteric to the schizophrenic, is a great help in making this clear. The separation by Kraepelin of the paranoid form of dementia præcox from the other types as paraphrenia, is a very acceptable one to me because it helps to make more understandable the tendencies of Kraepelin to consider clinical symptoms as entities without endeavoring, as does Bleuler, to delve into the mechanism of their origin. To the former the loss of the finer feelings, of shame, of pity (Zerstreutheit and Stumpfheit), etc., is the keynote of the disease; to the latter, Sperrung, Spaltung and Autismus represent the important conditions. His conception is a wider one and tends to connect all the psychogenous diseases

with schizophrenia rather than to separate them as does Kraepelin. Likewise, it allows, therefore, for recoveries or rather readjustments.

Bertschlinger formulates this very neatly in asserting that the symptoms in dementia præcox types vary with the mode of onset of the breakdown, and the nature of the adjustment that ensues directs the course of the disease.

Adjustment according to him marks the beginning of recovery and may result:

1. By a process of belated sublimation.

2. By a process of desymbolization, i. e., sub-conscious thoughts being brought into accord with the facts of external reality. 3. By a transfer of the complex (temporary recovery).

attempt to formulate a broader conception of psychic mechanism in the psychoneuroses includes a fundamental principle which relates to the dementia præcox types as well. Adler regards the effort not to feel inferior, to rise to the level of his companions, an important influence in determining the psychic life of an individual. He lives in this way mentally an unwholesome life, represses everything which does not enable him to act out his purpose. There results an inability to recognize the real; bizarre impulses and actions, as well as ideas, result. Constitutional inferiority of function is, therefore, the basic factor which causes efforts of psychic compensation around which are woven phantasies and motor reactions and which causes stimuli to arise in an effort to develop compensatory increase or hypertrophy of function. This even more than Bleuler's conception of autism reminds one of Janet's descriptions of perte de la fonction du réel and of his sentiment de incompletude. It is a psychic factor which often occurs, but is a result and not a cause, and not a universal one either.

Adler's hypothesis again brings out the factor of reaction to environment as one which cannot be ignored. Psychic reactions do occur from repressed desires and result in true and secondary actions; the latter occurring as symbols or as sublimation. All psychic life is, however, "not deterministic nor need there always

8

Bertschlinger: Dementia Præcox: Allg. Ztschft. fuer Psychiatrie. LXV, 1911, pp. 209-222.

'Adler: Den Nervösen Character. Bergman, 1912.

be an unconscious connection between the symbolic expression and the complex."

66

With Jaspers we can conceive of this as an as if " or out-ofconsciousness connection, i. e., understandable but not explainable. A reactive psychosis fulfilling the wish complex of the individual develops, therefore, from experiences in life, subjectively shows itself through the manner of content, phantasies, verbigerations, mannerisms, etc., and points the way to mechanisms and personality alterations ejected from consciousness and yet influencing the individual, depending upon his make-up whether psychopathic or schizophrenic. The two cases I have cited illustrate the occurrence of reactions from environmental experiences upon a schizophrenic background. Such reactions are not spontaneous or continuous, are deterministic in origin" and may recede, leaving the patient practically as before. Only the psychology of Freud and Bleuler can explain such types. There still remains, however, among the dementia præcox group, those types which have no environmental factors as a causal influence, but in whom chemical, pathological or genetic causes are alone at play. These are the true types of Kraepelin's dementia præcox, the origin of whose symptoms the future must clear up.

cases.

DISCUSSION.

DR. Wм. A. WHITE.-I was very much pleased to hear Dr. Mayer's paper. There was one thing suggested by Dr. Mayer's paper and also by Dr. Hoch's paper, and which should be emphasized; that is the question of our attitude towards this class of patients; whether the time has not arrived when we can take a more optimistic view as to the future of these There are two extremes; one is known as the reactive type, of which Dr. Mayer has spoken, and the other the constitutional type. The reactive types complex lie near the surface and so are more capable of removal. Many of our prææcox cases get well, and they belong to the reactive type. The constitutional types are productive and deteriorating and the therapeutic outlook is much worse; and yet with the constitutional types something can be done, and something happens whether we do anything or not. It is a matter of observation that those cases who do not get well in the hospital automatically go down to lower levels and when they get to a level at which they are capable of making an adjustment, there they will stay. We should always bear in mind that every patient presumably has a level at which he can get along and live at considerable ease, and so an effort should be made to fit an environment to him, so to speak.

10 K. Jaspers; loc. cit. Practically abstracted.

1

RECENT TRENDS IN THE PSYCHOPATHOLOGY OF

DEMENTIA PRÆECOX.

BY ISADOR H. CORIAT, M. D., BOSTON, MASS.

The evolution of the conception of dementia præcox furnishes one of the most interesting chapters in psychiatry. The modern ideas concerning a special deterioration psychosis which usually reaches its culmination or complete development at puberty or adolescence has been the result of a slow evolution, which reached its culminating conception in Kraepelin, whose successful attempt at unifying these various disease pictures, which terminated in dementia, must ever be considered as one of the triumphs of sound clinical observation in psychiatry. The name dementia præcox was first suggested by Pick, although some years previously under the name of katatonia, Kahlbaum had described a pubertypsychosis associated with special muscular symptoms and rapid mental deterioration. In the editions of Kraepelin's "Lehrbuch der Psychiatrie" previous to the sixth, dementia præcox was classified under the special category of disorders of metabolism, in common with myxedema, cretinism and dementia paralytica. Further observation, however, led to a breaking away from this traditional conception and gave to the disorder a special generic grouping, although with a somewhat artificial sub-classification. into three different types of the disease. At first the disease was interpreted as a profound disorder of the cortex, and only partially recoverable. More recent advances, however, have led to a considerable modification of this anatomical conception. refer particularly to the condition described as " allied to dementia. præcox," to the partial or complete recoveries or the remissions in the disease and to the marked improvement that may be noted in early cases through a complete psycho analysis, which procedure lays bare the unconscious disturbing complexes. These results would be impossible if the disease were due to actual physical changes in the nerve cells of the cortex.

One of the most prominent riddles of the entire condition lies. in the fact that the symptoms of the disease frequently develop

parallel with puberty. At first this led to a vague conception that perhaps the basis of the disorder might be an autointoxication from sexual products, a view which was later demonstrated to be utterly erroneous. In addition, dementia præcox frequently shows many features strongly resembling hysteria, such as the delirious episodes, the irrelevant replies to questions, stupor, vasomotor disorders and peculiar disturbances of consciousness. Many of the features of katatonic stupor resemble hypnosis, a phenomenon which led Evenson to conceive dementia præcox as due to a narrowing of the field of consciousness, thus making its mental mechanism correspond to the current French view of the psychogenesis of hysteria. On the other hand, from the standpoint of autointoxication from ductless glands, there is occasionally seen, particularly in katatonic stupor, an enlargement of the thyroid gland, rapid pulse and a myxedematous thickening of the skin, features strongly resembling hyper or hypothryoidism. However, the indifferent results of thyroidectomy in dementia præcox speak strongly against the disease having any connection with perversions in the secretion of the thyroid gland. I was able to demonstrate a few years ago that intestinal toxic products through absorption, are unable to produce the disease, as the hyperindicanuria so frequently found in the akinetic states of dementia præcox was merely an index of the accompanying intestinal torpor. In fact, when by the use of intestinal antiseptics the indican diminished to normal or almost completely disappeared, no parallel improvement took place in the symptoms of the disThe chemical examination of the cortex in cases of dementia præcox has likewise yielded nothing of value, at least so far as bearing upon the etiology of the disease process.

ease.

Various theories have been proposed concerning the pathogenesis and psychogenesis of dementia præcox, from vague statements of a special predisposition at puberty, especially in cases with an hereditary taint, the hazy autointoxication concept, and, finally, the psychopathological theories. It is with these latter that this paper is particularly concerned. The chief feature in the evolution of the conception of the disease process has been the change from the general clinical view, with prognosis as its chief criterium, to the modern individual psychological analyses. Probably the most important question in contemporary psychi