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Of the various psychoanalysts in this country who have been attempting to find a middle ground upon which views such as those expressed by Adler and the views of those who hold to the theory of organicity can meet, William A. White of Washington is probably the most prominent. Dr. White has written the introduction to Adler's book. He dilates in this introduction on the healthy tendency exhibited by Adler in approaching his subject from the organic rather than the functional side. I am afraid that Dr. White will not endorse at least one of Adler's views. In this paper I have deliberately drawn several analogies, particularly one between the characteristic dissociation of the mental with the emotional reactions as it exists in dementia præcox with the same sign exhibited in pseudo-bulbar palsy and other diseases of the basal ganglia. Concerning reasoning by analogy Adler says that it is very important in the development of the neurotic constitution and is a characteristic of the general inferiority of the neurotic psyche. Whitesays that “reasoning by analogy is not only a legitimate form of reasoning but it is the best of all reasoning." Agreeing with Dr. White are Jung's views on this subject. It is only an instance of the danger of accepting without question the views of some exponents of psychoanalysis, that even in the camps of the most prominent of them, such wide differences of opinion are found about so important a point. The entire subject of symbolism on which the whole fabric of psychoanalysis is built is admittedly done by analogic thinking. Yet we are told by Adler that thinking by analogy is a trait of the neurotic, therefore, an inferior psyche.
In conclusion, it is my opinion that a decision of the questions herein discussed must be soon attempted. The only method available is to apply the therapeutic test to the principles laid down by psychoanalysts. On the other hand, we must require carefully kept records and published scientific data with tabulated results. If, after ample opportunity for investigation, they fail to give us this data, we then must regard psychoanalytic principles as they relate to the study of dementia præcox as impossible of application and confine ourselves to anatomical, pathological and physiological investigations as a means of discovering the pathogenesis of dementia præcox.
BIBLIOGRAPHY. 1. Adler: The Neurotic Constitution, Moffat Yard & Co., 1917. Trans
lated by Glueck & Lind. 2. Adler: Thinking by Analogy Strongly Developed in the Inferior
Neurotic, p. 18, lines 20-22; also p. 24, line 28. 3. Alzheimer : Beiträge zur Kenntnis der pathologischen Neuroglia und
ihrer Bezeihungen zu den Adbauvorängen im Nervengewebe.
Nissl u. Alzheimer. Histol. u. Histopathology, Arbeiten 3, 3, 1910. 4. Dercum: A Manual of Mental Diseases, second edition. W. B.
Saunders & Co., 1917, p. 124. 5. Hoch: Proc. Amer. Med.-Psychol. Assn., XVII, p. 227. 6. Hoch: Psy. Bull., Jan. 1917, p. 81. 7. Jelliffe, Meyer & Hoch: Dementia Præcox, 1911, Badger, Boston. 8. Jung: Psychology of the Unconscious, 156. 9. Kirby: Psychiat. Bull., July, 1916, Vol. 9, No. 3, p. 356. 10. Kleist: Dementia Præcox, 1911. Quoted by Meyer. 11. Kraepelin: Clinical Psychiatry, 3d edition, 1914, p. 22. 12. Kraepelin: N. Y. State Hosp. Bull., Vol. VII, No. 2, Aug. 1914, p. 276.
Quoted by Kirby. 13. Meyer : Psychiat. Bull., 1908, V, p. 257. 14. Morse: Thalamic Gliosis in Dementia Præcox. Amer. Jour. of In
sanity, Vol. LXXII, 1915, pp. 103-123. 15. Neuburger: Archives f. Psychiatrie, Vol. 53, p. 521. 16. Nissl: N. Y. State Hosp. Bull., Vol. VII, No. 2, Aug. 1914, p. 276.
Quoted by Kirby. 17. Rosanoff: N. Y. State Hosp. Bull., Vol. VII, No. 2, Aug. 1914, p. 200. 18. Ross: Archives of Internal Medicine, 1914, Vol. 13, pp. 889-903. 19. Schneider: Psychiat. Bull., Jan. 1916, Vol. 9, No. 1, p. 25. 20. Sioli: Histologische Befunde bei Dementia Precox. 82. ordentl.
Generalvers. des psychiat. ver du Rheinprovinz am 14. Nov., 1918,
in Bonn Zentralbl. f. Nervenh. u. Psychiat., XXXII, 1909. 21. Southard: Proc. Amer. Med. Psychol. Assn., XVII, p. 261. 22. Tanzi: Textbook of Mental Diseases, 1913, p. 633. 23. Teal: Amer. Jour. of Ophthalmology, Mar. 1918, Vol. 1, No. 3, p. 185. 24. Tilney: Jour, of Nervous & Mental Diseases. Vol. 39, No. 8, Aug.
1912. “Pseudo Bulbar Palsy, Clinically and Pathologically Con
sidered with a Clinical Report of Five Cases. 25. Walter & Krumbach: The Vegetative Nervous System and Dementia
Præcox. Zeitschrift f. d. g. Neurologie und Psychiatrie, Vol. 28,
p. 232. 26. White: "Mechanisms of Character Formation." Macmillan Co., 1916,
27. Wilson: Brain. Vol. XXXIV, Part 4, 1912, p. 446.
THE REHABILITATION IN THE COMMUNITY OF PATIENTS PAROLED FROM INSTITUTIONS
FOR THE INSANE.* By SAMUEL N. CLARK, M. D., CHICAGO, ILL. The subject broached by the title of this paper is too vast to be discussed here except in very general terms, but a broad survey may serve to open the topic for further and more specific investigation.
The needs for the return of all recovered patients to life outside the institution are too well known to recount and yet a special word here may not be amiss. The community and the individual are best served by the fullest expression of activity of which the individual is capable. It must be remembered, however, that the ability of the individual to withstand stress is not always easy to estimate. Adequate reaction to a difficult situation for a few days, weeks or months may be followed by excessive oscillation of mood or by the substitution of a false trend of ideas or fantasies for stern reality. Once such disorientation is accomplished the services of the individual are lost to the community probably for considerable time. Obviously it would be better were such case required to meet only situations to which he is able to react repeatedly without mental capitulation. It is most important that this idea be comprehended and one must remember that it is diametrically opposed to the belief rather widely held that everything is possible if only the individual is willing to make the necessary effort.
The fact that a mental disorder has occurred strongly suggests that thereafter there must be a compromise between the efforts of the patient and those of the ordinary individual. The question of degree of compromise necessary in a given case is difficult, but upon it depends the future welfare of the patient and an attempt to solve it must precede the restoration of the patient to life outside the institution.
The ability to answer the question in the preceding paragraph is dependent upon knowledge of the factors which have in the past caused more or less marked mental upset. These are not only the
* Read at the seventy-fourth annual meeting of the American MedicoPsychological Association, Chicago, June 4-7, 1918.
unusual stresses to which the patient has been subject; acute or constitutional illness, psychic trauma, etc., but also and even of more importance those habitual tendencies on the part of the patient to react to certain situations in a harmful manner.
The way in which ordinary problems are met is portrayed in the usual behavior of the individual. At times the reaction to certain everyday situations is of a sort which fails to pass the censorship of the social code. In other cases no unusual manifestations are noted until an unusual situation arises, be it the death of a friend, financial upheaval or actual change in structure of the brain. Even in such case it is not the situation which constitutes the immediate need for social supervision, but the behavior under the existing conditions.
In speaking of etiological factors of mental disorders the writer refers to the conditions which cause any of the disturbances of behavior commonly spoken of as insanity. It is easy to refer to etiological factors in general terms but often difficult to say specifically what things should be avoided. Of course, carefully taken anamneses will aid greatly in pointing out probable pitfalls, but occasionally these are difficult to obtain. In such case one must look elsewhere for guidance. The fact that there is doubt as to the sort of problems or situations which may be considered probable factors does not excuse one from making an attempt to outline the activities of a recovered patient. ' If a patient is placed under the jurisdiction of a department there is no choice but to use the data available in an effort to safeguard him even if interpretation of the data is somewhat open to question. The experience one has had with other cases will be of aid. There is food for thought in the frequency with which cases improved following acute episodes of the dementia præcox type of disorder, show an apparent narrowing of interests and a disclination for any but the more automatic sorts of industry. It may be presumed that this fact has a general application to all disorders based upon a difficulty in adjustment and that it points to the need of caution in returning individuals no longer manifesting acute evidences of mental disorder to active life. If one may surmise that the apparent inclinations of these patients are actually preservative, one may say that the characteristics which are conspicuously absent in the improved dementia præcox case, are ones which the patient cannot assume without risk. Among these characteristics are the assumption of