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dream analysis, as in the strict neuroses, is the best method to arrive at the real conflicts. By keeping sharp watch of the dream content one can usually judge whether or not the analysis is being pushed too rapidly; that is, if it is too fast, stress and suicidal symbols begin to present themselves as resistance to the treatment. Only one of my patients feebly attempted a suicidal act.

As might be expected, the transference is extreme in analyzing these depressants, but this need concern one but little, as the normal, or the hypomanic, state will quickly remove it. The retarded depressant rarely or never leans upon the physician as the neurotic may after incomplete analysis. It is perhaps unfortunate that severe depressants are not analyzable and that not many even in their mild hypomanic states can be treated in this manner. The beginning or the ending of a severe depressive period are the most accessible states for treatment. The latter part of the depressive episode is possibly preferable, as one then has the whole historical present to work upon. Sooner or later, however, the whole life of a case must be gone into minutely if the treatment is to be fully successful. In no case have I failed to find Hoch's general principles of the mechanisms for retarded depressions which he has laid down in his “ Study of the Benign Psychoses." *

In conclusion I would reiterate that an intensive analysis should be made in every carefully selected case of retarded depressions encountered in intra- and extra-mural practice. I feel convinced that by so doing many such individuals will make a sounder recovery from the specific attack and recurrences in the after-life will often be avoided. Physicians in sanatoriums and in private practice are particularly urged to try this method in the milder types of the disorder, which often masquerades under such designations as benign depressions, neurasthenias, and the like. Finally, I hope state hospital physicians will undertake this analytic plan more extensively in their severer cases, especially so soon as convalescence is well established. I am sure the extra-mural life of these depressants after discharge will be the better for such treatment.

* Hoch, Johns Hopkins Hospital Bulletin, May, 1915. For those who may be unacquainted with his views, the original paper may be consulted, or a summary digest of it may be found in my second paper upon retarded depressions, Some Therapeutic Considerations of Periodic Mental Depressions," Med. Record, Feb. 9, 1918.

A CRITICAL REVIEW OF THE PATHOGENESIS OF DEMENTIA PRÆCOX, WITH A DISCUSSION

OF THE RELATION OF PSYCHO

ANALYTIC PRINCIPLES.*
BY MICHAEL OSNATO, M. D.,

Captain M. C., U. S. A. The absence of any material advance in the elucidation of the problem of the pathogenesis of dementia præcox is discouraging. This statement does not hold good if one is satisfied with the psychological explanations advanced. Nevertheless, the psychologist, who is also a student of pathology, anatomy and physiology, will find it hard to be perfectly content with the various psychobiological explanations given for the precipitation and continuation of the psychosis which we know as dementia præcox. The importance of clearing up the problem of the cause of this disease cannot be too emphatically stressed. Centering about it are numerous related problems concerning difficult and abnormal mental states which will be solved by a satisfactory clearing up of the dementia præcox situation. I refer particularly to hysteria, various compulsion—and psycho-neuroses, some types of alcoholic psychoses and other toxic mental states in which manic-depressive insanity may be included. The difficulty of beginning an investigation into the pathogenesis of dementia præcox is readily realized when we stop to think that within this classification are usually placed a number of widely different mental and related physical reactions, which necessitate subdividing the great group into eight or nine subgroups, all more or less indefinite in their clinical manifestations. Few of these subgroups have definite pathological or clinical criteria which can serve as a basis for diagnosis. No specific serological, bacteriological or other laboratory tests can aid us in placing any given mental reaction in the group of dementia præcox or in any of its subgroups. Post-mortem examinations also fail to establish absolute diagnostic criteria, so that we are necessarily driven to the application of certain clinical standards for the diagnosis of dementia præcox. In order to

* Read by title at the seventy-fourth annual meeting of the American Medico-Psychological Association, Chicago, June 4-7, 1918.

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begin from a definite premise, it is necessary for the purposes of this discussion to state what it is that we understand as dementia præcox. The definition offered by Meyer" is advanced. This includes “those types of defect and deterioration which show the existence or the development of fundamental discrepancies between thought and reaction, defects of interest and affectivity with oddities; dreamy, fantastic or hysteroid or psychasthenoid reactions, with a feeling of being forced, of peculiar unnatural interference with thought, frequently with paranoid, catatonic or scattered tantrums or episodes."

The main points, therefore, which require stressing in order to obtain a conception of what is meant by dementia præcox are three: First, the discrepancy which is so characteristic between the thought processes and the emotional and volitional reactions of the individual; second, the defects in the fields of interest and affect, and third, the feeling of being influenced in the performance of acts or thought processes. Any one of these symptoms or any combination of them are absolutely essential to the diagnosis of dementia præcox. The character of the mental or physical reactions will determine whether the case should be called one of the paranoid, catatonic, schizophasic, hebephrenic or paraphrenic type. Some deterioration, particularly of the will, affect and interest, must be present in every case aside from the delusional trends and hallucinatory episodes. It can be readily seen that these considerations are a matter of personal observation, deduction and evaluation on the part of the individual psychiatrist. Therefore, they cannot serve as absolute criteria. Admitting this fact, nevertheless, it is not helpful in the elucidation of this problem to refuse to recognize dementia præcox as a clinical and pathological entity entirely. This the psychoanalysts of various schools have seemed to do. I have searched in vain through the writings of Freud, Jung, Brill, White, Wells and others for any attempt at clinical classification of their observations in the so-called functional psychoses. The terms dementia præcox, hysteria, psychoneurosis, psychosis, neurosis, etc., are used with no attempt at definite conceptions for any of them. It is not my intention to discredit the psychological investigation of these problems, but surely the teachings of medicine in other fields where progress has been made by empirical grouping of symptom complexes should not be disregarded in psychiatry. It is true

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that many things have been placed in the classification with dementia præcox that should not be there but this is no reason to widen the breech any further by clouding our conceptions of this disease entirely.

Perhaps it has been because of this difficulty of finding a common ground upon which the clinician and anatomist on the one hand and the psychologist on the other can meet that so little has been done to bring about a real advance in an understanding of this psychosis. It is characteristic of this to find that in a discussion of the pathogenesis of dementia præcox, there are two groups, the views of whose members must be given unquestioned weight and authority but who take diametrically opposed stands in this matter, some of them allowing for the possibility of no middle ground. In order to arrive at an understanding as to what should be the attitude of psychiatrists towards the various schools of psychoanalytic endeavor in the treatment of this disease, it seems important that those who adhere to the theory that dementia præcox is primarily an organic disease and the adherents to the dogma that it is primarily a distortion and perversion of the personality of the individual, the organic changes being secondary, should be brought to the realization of the fact that neither one of them may be right. It seems important that all fair-minded men should be willing to start in the investigation of this problem without preconceived notions. Of late years, the anatomical work done in the pathology of this disease has certainly gained very little attention in this country. This matter was recently referred to by the writer in a discussion of this question which appeared in the Neurological Bulletin of Columbia University (Vol. 1, No. 3, p. 106, March, 1918). I take the liberty of briefly quoting from the article mentioned so that we may be placed in the proper frame of mind towards this subject :

Meyer dismisses the neuro-pathological evidence in dementia præcox as being meager and refers particularly to the work of Kleist. He says, “The isolated facts of the frontocerebellar disorders, tremors, reflex alterations, dermatographia, seborrhoea, and the eye symptoms appear like elements in the general process but not like helps for an explanation.” Referring to the histological data, chemical findings and the work of correlation of the clinical symptoms in dementia præcox with the organic changes found in the brain, the author dismisses these as being merely incidental or due to defective oxidation or possibly the consequence instead of the cause of the symptoms. Meyer emphasizes the psychobiological viewpoint, ascribing the difficulty in this condition to habit deteriorations and tantrums which, he says, are pathologically unfavorable to the maintenance of a normal mental balance. He speaks of complexes, habit conflicts and all the other psycho-analytic mechanisms as the essential causative factors. The symptoms of the disease, he says, are due to peculiar attempts which have been made at balance and reconstruction. He admits, however, that undoubtedly a large number of cases are “beyond complete analysis and understanding."

Jelliffe' as an exponent of the view just presented by Meyer

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says:

I freely admit that we are still much at sea in this matter and am fully prepared to follow Meyer in part in a more functional interpretation of certain of the dementia præcox reactions.

In attempting to recognize a fundamental personality, he says:

I am directly opposed to a too dogmatic pathological interpretation. Our pathological findings may represent atrophies of unused association tracts which have resulted from the, so to speak, petrification of bad habits of mental adjustment.

Taken alone, this may appear as a definite statement of a mental attitude but in the same article from which this is quoted he also says:

So that to the more striking mental signs are added physical signs of almost as definite a character as those met with in paresis. The clinical pictures are bound to begin in a slightly different manner, according to the anatomical localization of the processes. The course will vary by reason of the same factors of variability in contact with the pathological alteration and the general end level will be reached largely as is paresis by the more or less general diffusion of the processes in the areas of special predilection.

From which we can see that this author is certainly not clear in his own mind as to the genesis of the symptomatology of dementia præcox, nor is he prepared to give the psychobiological interpretation the place of prime importance in the production of the symptoms of this disease.

Hoch' perhaps takes the most decided stand of any of these three exponents of the functional theory of dementia præcox. In the same monograph with Jelliffe and White, he says:

While these findings, upon which rests the claim that dementia præcox is an organic disorder in the same sense as is general paresis, cannot be neglected and represent a most important field for research, there is another set of data furnished by an analysis of the constitutional factors in these cases, of the development of the symptoms-data which would

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