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the working of the hands in the same invariable way certainly points to a separate and distinct disease. Notable among the mannerisms are the peculiar physical feats which these patients sometimes perform. Dr. Christian reports a case that always, when he enters the ward, tips up to him, lightly touches his shoulder, and then recedes to his corner again, assuming the same staring stuporous vegetative attitude and apparently oblivious to things about him. I recall among my cases one that looks at the ceiling constantly while making a characteristic gesture; another who has rubbed her nose for years in the same constant routine way. The impulsive acts of the precocious dement embody within themselves an element that is highly differential and peculiar to the disease. It is in this impulsive fit that this class of patients are most dangerous, and frequently commit acts of violence and even homicide, without any after-memory of what they have done. The act seems to be one of imperative motor excitement, as the volition takes very little part in the performance. Cases are on record in which patients under this imperative influence have wandered away and found themselves in new and strange surroundings. They are never able to tell why and how they got there. Admitting the epileptiform and apoplectiform phases of dementia precox, it is quite probable that this sudden unconscious wandering of patients represents a type of psychic epilepsy, which in all probability is nothing more than dementia precox itself.
Dunton says it is easy to differentiate the impulsive acts of the precocious dement from those of paranoia and mania. In the former the sudden violence usually occurs without warning, is motiveless, and comes like a "clap of thunder from a clear sky." The patient is unable to give any reason for his act, and therefore denies it. In mania
or paranoia impulsive acts, with attempts at violence, emanate from a delusion or provocation, and the patient endeavors to explain and justify his motive. One of the most striking physical phenomena is the marked negativism displayed in nearly every case. Negativism has been defined "as the silly, purposeless resistance to every external impulse." It is almost impossible to get the co-operation of these patients in any way. They do not see, as a general thing, the necessity of any procedure you may make in their interest, and hence, offer a certain amount of resistance to every effort to elicit their true condition. Of great interest is the peculiar condition of muscular rigidity which is characteristic of the katatonic type. In this instance negativism seems to be suspended, and the limbs are allowed to remain in whatever position placed for quite a while. The stupor is to be mentioned here as a very impressive phase of the disease. In this state patients may sit or stand for days in certain positions without apparently the slightest interest or knowledge of their surroundings.
Strange to say, however, before the period of dementia sets in, they are perfectly appreciative of the external conditions about them, and hence, their orientation is undisturbed. Attention is very much impaired, as it is almost impossible to educe answers to questions, and when answers are obtained they seem to be more automatic and motor than volitional. Memory for past events is very good, but these patients are unable. to elaborate in any way, and their ability for technical work is greatly reduced. The deep reflexes are nearly always exaggerated, being more active in some cases than in others. There is no special change in the pupils, some of my cases have shown a sluggish reaction to both light and accommodation. Sensation appears to be disturbed
to a marked degree in a large per cent. of cases, but whether or not this is a true afferent disturbance is hard to say. Special mention is made by several authors of the irritability of the facial nerve; slight percussion over the facial causing in some cases sharp, quick contractions of the obicularis-palpebrarum. I have elicited this symptom clearly on several occasions. At the time the patient is on the downward scale in nutrition marked desquamation of the epidermis is sometimes observed. Great quantities of ropy mucus is either excreted from the mouth or stomach in certain cases, and the buccal cavity is usually found to be full, with constant driveling. The pulse is generally irregular, rapid and of low tension. The fingernails are often eaten deep into the matrix. The appetite is quite variable, but is generally poor, and often tubal feeding has to be resorted to in the beginning of the attack.
Trommer and Christian make the following summary of symptoms:
The tendon reflexes are increased; the pupils may be equal, dilated or irregular; saliva is increased; constant appearance at puberty or adolescent state; a peculiar confusion in speech, writing and demeanor; the tendency to the production of anomalies in gait, gesture, mien and action; weakness of judgment; various delirious symptoms at the beginning; constant sudden impulses; a rapid termination in a peculiar dementia.
DIAGNOSIS AND PROGNOSIS.
The above symptomatology covers the simple or hebephrenic and katatonic forms. I will merely mention in passing the paranoid type of dementia precox. Here the disease assumes the peculiar characteristics of paranoia, but is different from paranoia in its early tendency towards dementia. Idiocy and imbecility may be confounded with certain stuporous phases of dementia precox, but
in the former there are usually the marks of physical defectiveness and congenital mental deficiency, while if you look well into the history of dementia precox you will see the glimmerings of a once active intellect. A few months' observation will generally enable you to differentiate the stuporous types of melancholia from dementia precox.
The prognosis is bad. Kreplein gives eight per cent. of apparent recoveries in the hebephrenic form. While thirteen per cent. of the katatonic forms he claims recover sufficiently to resume their avocations.
Some authors regard this as entirely too high. Christian states that no case ever makes a complete recovery. The further special differential diagnosis is too voluminous to enter into here. I will only state in conclusion that dementia precox is a chronic progressive psychosis with a peculiar tendency towards dementia, and having its determining features represented in a peculiar chain of symptoms of excitement, delirium, stupor, mannerisms, negativism, verbigerations, stereotopy and cera-flexibilities.
1. Christian, dementia precox, abstract by Dunton and Farrar, Amer. Jour. Insanity, Vol. LVIII, No. 2, 1901.
2. Christian, dementia precox, abstract by Dunton and Farrar, Amer. Jour. Insanity, Vol. LVIII, No 2, 1901.
3. Dunton, report case dementia precox with autopsy, Amer. Jour. Insanity, Vol. LIX, No. 3, 1903.
4. Points on diagnosis, dementia precox, Amer. Medico-Psychological Proceedings, 1902.
DISCUSSION ON DR. MOBLEY'S PAPER.
Dr. Martin Cooley, of Savannah: I think the excellent paper of Dr. Mobley should excite interest among us. Its presentation should attract the interest of the profession generally. Psychiatry is a complex subject,
and, unfortunately, up to this time our nomenclature has been confused in our study of cases, and it is only recently that men have gone into psychiatry and have brought to it the same clinical study that has been given to typhoid fever or any other disease, and it is through the excellent work of Kreplin and the Germans that we get a most excellent idea of psychiatry, giving us a rational prognosis.
These cases of dementia precox are most interesting indeed, because we must recognize that they are going to be misinterpreted. There is liable to be confusion. Let us take the simple psychoses or melancholia, which we think would recover, but which does not. These cases occur, in my experience, in young people of a considerable degree of intelligence, the so-called bright people who develop a paranoiac idea. It is usually called paranoia by the general practitioner. They get ideas of persecution and go all to pieces.
A patient was sent to me from Charleston who sustained a slight injury in childhood, without any bone injury. There was simply a scar. There was no epilepsy or any evidence of fracture, but a surgeon nevertheless insisted on trephining the skull. Six months after that it was decided that the trouble was reflex, and the ovaries were removed. I saw the girl two months thereafter, and her condition was one of dementia, and since then has been extreme. She was sent on my advice to a sanitarium, and has recovered. It was negligence on the part of the surgeon. She had a condition which was beyond his care.
I think Dr. Mobley's paper should excite considerable attention, and point out the important fact that the general practitioner should strive to recognize these cases early. Psychiatry to-day is receiving much more attention than it has in the past. A good many men are taking it up.