IS DEMENTIA PRÆCOX THE "NEW PERIL" IN

PSYCHIATRY?1

By J. T. W. ROWE, M. D.,

First Assistant Physician Manhattan State Hospital, Ward's
Island, New York.

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The few local observations on this popular psychosis presented here suggest the trite old couplet:

"Tis the sad complaint, and almost true,

Whate'er we write, we bring forth nothing new."

The advent of dementia præcox, like other exotics received with enthusiasm, has resulted in an eruption of articles on that entity. While it did not, like the young Lochinvar, come out of the west, many of the recent articles describing it exhibit the vigor and breeziness of that region. Some have the force and dogmatic utterance of the small clinic and the smaller general practice. Others savor of the larger asylums, not wanting so much in population, as in a larger purview of the subject. Some of the cases illustrated combine all the types in one, so allembracing is it to the chroniclers; while others again exhibit a wealth of detail which could never have been met with, except in the pages of the foreign text-book. Still other cases are made to demonstrate every sign and symptom of classic requirement. What new ones they contain can only be conceived, for they have been made to exhibit all the phenomena established as proper to dementia præcox. The same monotonous and inexpressive jargon meets you in each appearing article. The paucity of actual observation and clinical material is equalled only by the bibliographical zeal.

To begin with, I think much harm may be done by the unfortunate term, as well as by the gloomy prognosis of those in a position of authority to speak. Dr. Jones, the superintendent of the

'Read at the sixty-second annual meeting of the American MedicoPsychological Association, Boston, June 12-15, 1906.

London County Asylum, said in an ex-cathedra tone, " dementia præcox is now so common that it may almost be described as the scourge of our asylums, for it attacks prematurely our most promising youth. It is practically incurable, and will fill our asylums of the future with the hopelessly insane." The cloud, fortunately, has a brighter lining, for the British asylum statistics do not bear him out in his fears. We do not know whence his evidence is derived, but we do know that in our own clinical experience the educated and more enlightened, and even the mentally hard-working, are not the groups from which the most of the hospital inmates are recruited. These quickly seek medical advice, which can frequently ward off the impending danger.

With our wealth of clinical material, it must follow that the disease, dementia præcox, is frequently met. As a matter of fact, we have the best clinical types to be found in any asylum in the world. We have this disease in all its gradations, from the almost speaking clinical picture to that exhibiting a group of morbid symptoms so slight that to discover sufficient justification for stamping it dementia præcox is an almost hopeless task to our zealous young clinicians at staff meetings.

As in great waters are found fin and feather in infinite variety, why should we not at this hospital, fed by a huge cosmopolitan metropolis, teeming with the flotsam and jetsam of human wreckage, have the greatest variety of psychoses known to alienists? But if we are frank, we cannot subscribe to the teaching that dementia præcox is paramount or in the ascendant here. The doctrine is not sound. We must dissent. I think the more we see of undoubted cases of dementia præcox, the better the outlook is for the patient and statistics. Scores of cases so closely resemble dementia præcox in symptom-complex and termination that it is surprising more are not stamped as such and transferred from active observation to the rubbish-heap from which the psychiatrical "finds" have been extracted, to get well as best they may. The long list of morbid mental states just on the border line, embracing adolescent dementias, the depressions with confusion and stupor, post-alcoholic psychoses, hypochondria and neurasthenia, the great variety of neuroses and psychoses associated with imbecility, if these cases are checked in their progress, they respond quickly to treatment, but the care must be unceasing. Then

most of them will get well, as they would have done had they received proper medical care outside, and thus made the certificate of insanity unnecessary. These forms of insanity are often the result of exhaustive and toxic states, and neuroses unrelieved.

I cannot understand why continental thought should set the pace for the rest of the world, more especially for this country. With an admission of nearly two thousand patients annually, examined under the most exacting system of analysis, and subjected to the criticism of a large medical staff, we are still influenced and guided by the dictation of foreign savants and writers, and we are asked to bolt unquestioningly the conclusions they have derived from sometimes very limited fields of observation. It is high time we made our own the predominating statistics in this country, and stood by them. Any others are likely to be at variance with the conditions and environment prevailing here. The question is too often asked at court and clinic, "Have we read what Prof. von So-and-so writes or has observed," which soft impeachment we have to deny, and by our confession of ignorance are, I suppose, placed quite outside the pale. If we have been locked in some pent-up Utica," is it not time that we emerged into the freer atmosphere of independent thought and our own conclusions?

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There are no new forms of insanity that I am aware of. This much most of us are agreed upon, except in the newspapers and novels, and finesse in diagnosis is not so important as saving from classification, as dementia præcox, the cases closely resembling it, but which escape the unfavorable prognosis imposed by the name and surprise us by a return to a condition of mental health. The question arises then, What shall we consider dementia præcox? I would confine the name to those groups of insanity occurring in the adolescent period and tending to dementia. I would restrict it to a period not later than the adolescent age, and I would make it a sine qua non that the inclusive stages of mental deterioration be reached rapidly. Psychical enfeeblement, with relative integrity of memory, disappearance of the effective feelings or emotional tone, apathy, dissociation between memory and judgment, and a primary normal mental condition ending in early breakdown.

The physical signs in dementia præcox are not reliable and

should not be taken too seriously. They are seen in other forms of insanity, and may be indefinite or accidental. When we have a case appearing at the period of pubescence, or a little later, with languor and inattention, the mental powers too sluggish to assist the patient in recognizing his condition or surroundings, with hallucinations of hearing and the progressive character of the mental deterioration demonstrated, we are reasonably safe in diagnosing it dementia præcox. But I would stand firmly for the psychical enfeeblement, diminished attention, and dominating apathy, and as a clinical picture is necessary to a concept of the disease, I would urge that dementia præcox should imply a dementia that is primary and present from the beginning of the disease, although its recognition may be obscured by transitory episodes. Some of these may be only faintly discerned. Then the patient is entitled to the benefit of the doubt. Many of the cases we see are not degenerative cases. They show but little disturbance of attention and impairment of judgment, and such as it is, may be secondary to some acute psychical disease of which we have no knowledge. We should not try to fit the patient to the diagnosis. The materies morbi is necessary, for the true precocious dement is to the manner born. In many the age of adolescence has long been passed.

As for the anatomical stigmata of degeneracy,-what do they indicate? They may be seen at any gathering of people of all ranks, in the pulpit or in the prize ring. At this stage of life almost any mental weakness may reveal itself,-derangement of function, the strain of development special to some, the explosive emotional states, boastfulness and sexual depravity of the illbalanced-a tremendous amount of insanity that is not dementia præcox comes to us. The entire gamut of symptoms peculiar to dementia præcox may be found in imbeciles, the constitutionally defective, tramps with stigmata suggesting the workhouse or prison, the ill-balanced lad blowing off the emotion of youth. The boy who can never learn at school and is inclined to wander away, who cannot settle down to any kind of occupation, is likely an imbecile. Some exhibit intense stupor closely resembling dementia. Many are harmless and industrious, and although too deficient mentally for much initiative or progress, are capable of useful employment and of earning their own living. Why saddle

upon these the term " dementia præcox"? It hampers their convalescence, puts a taint upon them, and keeps them in the background. They are mentally unstable, but under careful supervision, if their young manhood be passed in an orderly and systematic manner, in employment adapted to their capabilities, recovery and escape from future attack may be fairly assured.

It is not the most intellectual classes or those who are hardworked mentally who supply us with morbid conditions. They don't supply the dementia præcox cases, or those so-called "allied" cases. The flower of our youth may give us the true psychoses, well cut and definite, if any. Our cases of defect and deterioration come largely from foreigners, soft, undeveloped, the flotsam of congested agrarian districts and poverty-stricken surroundings, unaccustomed to active competition at home. The sundering of home ties, followed by wretchedness and homesickness, is the first step in their decline. Then you have these poor peasants coming into competition with the fittest, living in confined quarters with insanitary environment and reeking of filth. The want of proper adjustment of forces and work results in nutritive and nervous exhaustion, insomnia, indigestion, autointoxication, and the pace kills or turns to insanity.

A propaganda should be urged to deal vigorously with this blight so peculiarly incidental to youth and adolescence. I firmly believe that if the conditions causing insanity were fought as vigorously and determinedly from the press and platform as are those of tuberculosis, alcohol, and syphilis, and the co-operation of the general practitioner and of organized charity, was obtained to prevent it in its incipiency, there would be no need for the large and increasing appropriations so regularly asked for. The steady and alarming increase of insanity would cease, the breadwinner would be preserved to his family, and he and they would be spared the stigma of mental incapacity and the horrible fear of transmitted disease. The State would be spared the task of maintaining the patient, and the family escape the degradation of becoming the subject of public or private charity.

The truth is that men, women, and children are overworked. They live amid struggle and stress unknown to other times. These conditions predispose to nervous disorders which become progressive. Stress and medical neglect do the rest. We see