Clinical Psychiatry.

CLINICAL DEMONSTRATIONS.

BY CLARENCE B. FARRAR, M. D.,

Assistant Physician and Director of the Laboratory, Sheppard and Enoch Pratt Hospital; Assistant in Psychiatry, Johns Hopkins University.

II.

DEPRESSIO AFFECTUS.

First attack in a young woman of 25. Unhappy marriage three years before. Long prodromal period with episodes of "nervousness," indigestion, insomnia, crying-spells. Duration of depressive phase, six months. Convalescence initiated by a hypomaniacal syndrome. Recovery.

As we enter the ward for acute cases our attention is at once arrested by a young woman who approaches slowly, with even measured steps and eyes cast down, looking neither to right nor left, a feminine personification of Il Penseroso. The picture is so characteristic and so striking that it is likely to remain long fixed in the memory of the beholder.

As she draws near we see an attractive girl of about twentyfive, well developed and in fairly good flesh, but with complexion cloudy and marred by acne, suggestive of disorders of digestion and assimilation. Her facial expression indicates a real and dominant tone of consciousness, a fixed sadness without emotion and a degree of hopeless resignation. She is properly and neatly clad, and yet her coiffure gives unmistakable evidence of a certain lack of interest in her personal appearance.

Unless we accost her she passes without lifting her eyes, without interrupting the heavy rhythm of her tread. To our salutation she replies in a low monotone, scarcely audible, hardly raising her glance, and continues on her way; but if we say that we desire some words with her she pauses and attends.

In our attempts at conversation the first conspicuous fact with which we are impressed is the meagerness of the information which the patient furnishes. This is due first to a diminution and difficulty of the associative processes; to think and to speak cost obviously an unwonted effort. Added to this is a degree of indifference which characterises the condition,—an indifference which is rather apparent than real, and which is at the same time a feature of the patient's affect-depression and a consequence of the increased difficulty of her psycho-motor functions. As a result of these factors her voice is low pitched, of little tone, scarcely varying in inflection, and almost without accentuation. She replies to questions often after a little delay, slowly and briefly, answering short and simple questions much better than those involving more psychic activity. As we should expect there is little play of facial expression; yet her features reflect adequately the content of consciousness, and the gloom which is seated in her mind overshadows likewise her countenance. Nevertheless a slight sad smile appears as she shakes her head to our observation that she will soon improve.

Even these few moments' interview serves to show that the fundamental lesion in this case is in the realm of the feelings, that we have to do in other words, with a primary affectpsychosis. The mental processes are to be sure deranged, but their primary change is a quantitative one which may be denoted by the term hypopsychosis, the qualitative changes which we shall presently notice being rather dependent upon this quantitative change and the accompanying depressive affect-tone.

To state the subject schematically, we have first a functional interference with the natural ready succession of the psychic elements. This interference expresses itself in an affect alteration in which the euphoria of health is replaced by a dysphoriaa vague oppressive feeling that all is not well. The mental horizon becomes overcast and the spirit is borne down by a formless gloom. This stage represents a real Melancholiac limbo, and it is through this limbo that our patient has just been passing,— and her daily course would suggest that she has not yet reached the lowest level of the valley of the shadow through which she must pass. Before her she sees only a wall of ominous clouds which at first were without form, unpeopled by the creatures of an active

fancy. (“I am not like other people-I shall never be myself again-Some awful end awaits me-I can never see my mother again.")

As will be seen the disturbance is here chiefly in the autopsychic sphere of consciousness. Allopsychically the patient is tolerably clear. She knows her whereabouts, correctly identifies those about her, gives the calendar date and the approximate duration of her stay in the hospital as well as the time (about two months previous to her admission) when the conspicuous symptoms of her present illness appeared.

We learn from her that she was at this time staying with her husband at a boarding house in Brooklyn. For at least eight months previous to this she had been in rather delicate health, troubled much with insomnia and gastric irritability, often vomiting her food shortly after eating. These symptoms however had not been constant. In the Brooklyn pension the patient formed the acquaintance of a physician's wife who seems to have taken a good deal of interest in her case. This lady gave her some pills (perhaps laxative) together with talks upon spiritualism. The soil was just ripe for the developing psychosis, and the first definite sign of alienation came to light as a suspicion which soon became an unreasoning belief that the physician's wife had acquired a mysterious influence and power over her and that her entire personality had been changed through the agency of the medicine which this individual had given her.

Here we see a symptom which is repeatedly encountered in patients of this type,—an unhappy attempt to explain their condition by misconstruing the relations of cause and effect. First come the ill-feelings. These they cast about to interpret, and the insufficiency of the associative faculty already mentioned, allows them to fix upon some circumstance near or remote, which may be of trifling significance, and to trace to this circumstance all the misfortunes of their illness.

In the depressive psychoses of later life this assumed causative factor is very commonly some long forgotten pecadillo of youth, and the patient declares that in his misery he is only paying the just wages of sin.

In our patient however there is no suggestion of auto-accusation, and ideas of sin and retribution do not enter the reckoning.