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lowing this he began to drink, and gradually fell off. He had become jealous of his wife and an old gentleman who had been helping to care ior the family.

Orientation was correct. No impairment of memory. No evident deterioration. No hallucinations. Complained of one of his ears being blocked, and that he had niore or less stomach trouble. Emotionally somewhat depressed. Physical examination negative.

He remained hypochondriacal until about a month before leaving the hospital on March 17, 1917, when he began to improve, to do some work, and to talk less about himself. He went home on March 17th, and on March 22d was brought again to this hospital by the police, because of an attempt at suicide on that day. He was said to be very despondent, as he believed he would become a burden for his wife and children, since he thought he had had attacks of paralysis.

It appears that on the morning of the 22d, while his wife was out, patient beat himself on the head with a cold chisel. When he did so it did not hurt him any more than “if his head were a block of wood." He had linear lacerations, ten in number, which did not extend through entire thickness of scalp. There were also two parallel superficial scratches running transversely across the neck.

At the time of the admission he said that, “all the mucous membrane is gone in my mouth. I can talk and think all right, but my body is dead, all except my heart, my saliva is gone, and I have pus instead." He took off his shoe and stocking to show that the foot was dead and cold, although it was warm and of a normal appearance. He was correctly oriented. Realized that he was despondent, thought he was very weak, not strong physically, had not been unconscious. Felt somewhat depressed because he thought he had gotten himself into serious trouble, at the same time laughed about it. While he felt that his body was dead he knew that it was unreasonable, and could not be true, nevertheless it seemed to be so. He could be temporarily reasoned out of his ideas, but at once would begin to feel again that they were real. No memory defect. No other abnormalities. Mental level that of a normal adult. Continued to do fairly well, and was committed to a hospital because of his attempt at suicide. Patient denied ever having been nervous before he began to drink; found that drinking affected him very much. At times felt as though he were very light in weight. Complained at times that his head did not have the proper control of his body. Explained the pus as due to some local condition in his nose. Did not sleep very well; tired very easily.

The discussion of the diagnosis brought out that the differential diagnosis between manic-depressive psychosis and psychoneurosis is rather unsatisfactorily presented.“ Neurasthenic symptoms cani


be the first symptoms of different psychoses, chiefly of manicdepressive and dementia præcox. A neurasthenic patient shows irritability and depression, because he notices that his efficiency decreases. As soon as he takes a rest he becomes better. The manic-depressive case has uneasiness and depression without apparent reason, which cannot be changed by cheering him up. The neurasthenic is suggestible and will believe you; the manicdepressive remains pessimistic. Changes in the neurasthenic condition happen under the influence of outside factors; in the manicdepressive without definite reason." (Abstract from Kraepelin.)

The diagnosis lay between manic-depressive psychosis and psychoneurosis; if the latter, possibly a constitutional state lighted up by alcohol.

The symptoms seemed to be those of psychoneurosis, with secondary phenomena of depression—the whole making a state in which the patient was dangerous to himself, and practically inefficient.

Because of his suicidal attempt, and the very real danger to himself thus indicated, he was committed. At the hospital to which he was sent, the diagnosis was left unclassified. His condition has improved and he is working, but he has not yet recovered. It is possible that the neuronic damage due to his alcoholic excesses will prevent the return to a normal level of activity.

Case II.-A Jewish man, born in Roumania, was sent to the hospital by his physician on February 8, 1916, because he had been worrying for the past year, and had become very nervous and fretful. Suffered a great deal from headaches and dull pains over the face. He was removed from the hospital the next day so an adequate examination was not possible, but certain facts were obtained.

On January 1, 1916, patient took examinations for the bar for the fourth time. He was sure he had not passed because his head felt bad, but had not received notification. He had been very nervous, there was insomnia, and a good deal of headache; for a few days he had been rather depressed. Correctly oriented. Attitude of a depressed person. Denied hallucinations and delusions. There seemed to be no impairment of the memory. The first three times he took the bar examinations he had felt that he should pass, but he did not do so; the last time he took them he was quite certain he had not passed. Following this he became more and more depressed and worried.

The physical examination was approximately negative, aside from some tonsillitis and adenitis. Wassermann reaction on blood serum was negative. In March the patient was notified that he had passed the bar examinations. He became very active and joyful, and suddenly became blind. Treated for this at a general hospital, a diagnosis of “hysterical blindness" was made, and he was cured suddenly and completely by pressing a pencil against the eyeball, assuring him that when it hurt sufficiently he would suddenly see. He then continued his over-activity; engaged in the practice of law, hired expensive offices, but in May suddenly lost his speech. Sent then to a sanitarium where he was mute, except for the repetition of some incoherent syllables, although he observed very accurately, and attempted to explain things in pantomime. At first he could not write, but after several weeks he gradually began to do so, and in July could write coherently and extensively. A philanthropic woman, who had been much interested in him, came frequently to see him. To her he one day wrote on paper that if she would permit him to address her by her first name he thought he could talk. To this she finally consented and forthwith he spoke, and talked voluminously. On July 23d he left the sanitarium, and attempted to practice law again, entering a political campaign as representative of his ward.

During the fall he got along only fairly well, but in January, 1917, he had a crop of boils. During this period he would fall into deep and long slumbers. His parents then took him to the New York hospitals; he was observed at Bellevue, transferred to Central Islip, from there to the Manhattan State Hospital, and from there to the Psychopathic Hospital. At the Manhattan State Hospital physical examination revealed no neurological symptoms nor hysterical stigmata. No hallucinations nor delusional ideas, no symptoms in the fields of orientation, memory, intelligence, etc. He was reserved and evasive, at times somewhat anxious, admitted a previous period of depression, loss of eyesight, and a complete loss of speech.

Readmitted to the Psychopathic Hospital on March 27, 1917, at which time a fairly satisfactory history was obtained. Patient had worked very hard for his education; was married at twenty, and his wife helped him through law school. His loss of speech was first noticed in April, 1916, and continued until some time in July. In January, 1917, he realized that he had “ bitten off more than he could chew," as he stated.

The family history was essentially negative; otherwise the information is that which has already been given.

The patient's memory was unimpaired. He was somewhat depressed, but not markedly so. Gave a good history of his previous difficulties. His last depression came because he did not have as much business as he should. Began to fear he could not provide for his family. Became tired, slept a good deal. Went at his mother's suggestion to be examined at the New York hospitals. Made some trouble there because his mother left him. He was quiet, orderly, accessible, no evidence of hallucinations or delusions. Spoke of the bad influence of being with the insane; thought that this was hard on his mind. Was not especially egoistic; was somewhat worried, and cried easily, but later denied being depressed. Insight good; somewhat suggestible.

The diagnoses to be considered were dementia præcox and psychoneurosis. For dementia præcox there was very little, except that one sometimes got from him the impression of dementia præcox. The analysis of the facts of his entire life, however, would indicate that it was a psychoneurosis (hysteria). There had been no suicidal attempts, nor had he seemed to think of such. A diagnosis of not psychotic was made.

Patient was discharged to the out-patient department on April 5, 1917, and on April 17th committed suicide by hanging-evidently with a return of his depression.

Here, then, is a rather definite history of prolonged worry and overwork, with several obviously hysterical episodes. Secondary to the psychoneurotic manifestations came depression, and apparently to the return of such depression is to be ascribed the successful attempt at suicide. The case indicates clearly that where there is much depression in a psychoneurotic we should be very careful about releasing the patient from observation.

Case III.-A young man of twenty-four, whose father was Hungarian, and his mother (who was very neurotic) English, was born in this country; is single; a Protestant; a cler and music student. He came voluntarily to the hospital on June 15, 1916, suffering from insomnia, profound depression, and occasional thoughts of suicide. He was oriented; answered questions intelligently; had no delusions nor hallucinations and was not alcoholic. He had at times imagined that when he was playing the piano the audience commented unfavorably on his looks, character, or playing, or all of these. About three months before, while writing in the office, he became unable to go on. He felt something snap in his head, he trembled, and felt numb all over. This had been preceded by much worry over social, family and business affairs. There was

no memory disturbance. Patient graduated from the Mechanics Arts High School at eighteen. He was an accomplished pianisthad had to go to work because of his father's death, and had worked as a clerk. He had found his work distasteful, and had always worried about it. He had an attack of grippe in November, 1915, following which he was nervous, lacked energy, was less alert, and found his memory not so good. He had headache and some insomnia, and distressing dreams frequently of a sexual character. He became more self-conscious, felt that he did not play so well as formerly, and this caused him to worry and become more depressed. He expressed some ideas of reference (some of which have been stated above), and in addition he thought that his boss was down on him because he was uneducated, and feared that patient might get his position. He was sure his appearance had changed, and that people had noticed him on the street because of it. He showed emotional instability, weeping rather easily.

The physical examination was negative, except for a rather low systolic blood-pressure—104. There were no abnormalities in the neuromuscular system. Urine negative. Wassermann reaction on serum negative. Spinal fluid negative.

On the Point Scale he graded at normal, with no irregularities. He continued to worry some—to be rather unstable—was finally discharged to the out-patient department as not psychotic; psychoneurosis; (?) of dementia præcox.

On June 25, 1917, he returned voluntarily to the hospital. Imagined that he was dying, and shaking from the knees up to the chest. Thought his mother was dead. Said he had various kinds of mental diseases; that he heard people talking about him, and saying bad things about him. He was correctly oriented; there was no memory defect. School knowledge well retained. He still felt that people were criticizing him unfavorably when he was playing; that his playing was poor; and that he must look queer and excited, because he was so nervous. No delusions of persecution or grandeur. He named a great many types of mental diseases which he thought he had; thus, because of his numb feeling he was sure he had dementia præcox or general paresis. No actual delusions could be made out. He seemed depressed and fearful, wept easily. Rather restless, walking up and down a great deal. He remained in this state, rather weak and listless, complaining that his mentality was below par, that he was helpless; seemed depressed. No amount of explanation or suggestion could rid him of his ideas. His heart became weak, then he thought his organs were disconnected, that his existence was merely physical or mechanical, and he could not really be encouraged. It was necessary to commit him, and he is still in the hospital to which he was committed.

He was presented at staff meeting with the diagnosis of psychoneurosis. He had marked and variable somatic delusions, and difficulty in thinking, so that he felt at times that he had lost his mind. He explained, for the first time, that he had the fear that he had syphilis, and that this was what gave to him the fear of death; but reassurance that he did not have syphilis was not sufficient to break down the train of ideas.

The diagnosis was very easily reduced to dementia præcox, manic-depressive, and psychoneurosis. There were no definite hallucinations; there was a good deal of scattering of interests and mental processes; he was somewhat apathetic; not deteriorated; and without much impulsivity. The definite relation of the sexual ideas and disturbances and bodily sensations all seemed more likely referable to psychoneurosis. This diagnosis was compatible with the feeling of inadequacy, the absence of definite depression, and the ideas about his physical condition. On the other hand, his train of thought could not well be followed he had somatic and nihilistic ideas; he did not show the characteristic

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