GENTLEMEN,You have before
you to-day a strongly-built and well-nourished man, aged twenty-one, who
entered the hospital a few weeks ago. He sits quietly looking in
front of him, and does not raise his eyes when he is spoken to, but evidentlv
understands all our questions very well, for he answers quite relevantly,though
slowly and often only after repeaeed questioning. From his brief
remarks, made in a low tone, we gather that he thinks he is ill, without
getting any more precise information about the nature of the illness and
its symptoms. The patient attributes his malady to the onanism he
has practised since he was ten years old. He thinks that he has thus
incurred the guilt of a sin against the sixth commandment, has very much
reduced his power of working, has made himself feel languid and miserable,
and has become a hypochondriac. Thus, as the result of reading certain
books, he imagined that he had a rupture and suffered from wasting of the
spinal cord, neither of which was the case. He would not associate with
his comrades any longer, because he thought they saw the results of his
vice and made fun of him. The patient makes all these statements in an
indifferent tone, without looking up or troubling about his surroundings.
His expression betrays no emotion; he only laughs for a moment now and
then. There is occasional wrinkiing of the forehead or facial spasm.
Round the mouth and nose a fine, changing twitching is constantly
observed.
The patient
gives us a correct account of his past experiences. His knowledge speaks
for the high degree of his education; indeed, he was ready to enter the
University a year ago. He also knows where he is and how long he
has been here, but he is only very imperfectly acquainted with the names
of the people round him, and says that he has never asked about them.
He can only give a very meagre account of the general events of the last
year. In answer to our questions, he declares that he is ready
to remain in the hospital for the present. He would certainly prefer
it if he could enter a profession, but he cannot say what he would like
to take up. No physical disturbances can be definitely made out,
except exaggerated knee-jerks.
At first sight, perhaps,
the patient reminds you of the states of depression which we have learned
to recognise in former lectures. But on closer examination you will
easily understand that, in spite of certain isolated points of resemblance,
we have to deal here with a disease having features of quite another kind.
The patient makes his statements slowly and in monosyllables, not because
his wish to answer meets with overpowering hindrances, but because he feels
no desire to speak at all. He certainly hears and understands what
is said to him yery well,but he does not take the trouble to attend to
it. He pays no heed, and answers whatever occurs to him without thinking.
No visible effort of the will is to be noticed. All his movements are languid
and expressionless, but are made without hindrance or trouble. There
is no sign of emotional dejection, such as one would expect from the nature
of his talk, and the patient remains quite dull throughout, experiencing
neither fear nor hope nor desires. He is not at all deeply affected
by what goes on before him, although he understands it without actual difficulty.
It is all the same to him who appears or disappears where he is, or who
talks to him and takes care of him, and he does not even once ask their
names.
This peculiar
and fundamental want of any strong feeling of the impressions of life,
with unimpaired ability to understand and to remember, is really the diagnostic
symptom of the disease we have before us. It becomes still plainer
if we observe the patient for a time, and see that, in spite of his good
education, he lies in bed for weeks and months, or sits about without feeling
the slightest need of occupation. He broods, staring in front of
him with expressionless features, over which a vacant smile occasionally
plays, or at the best turns over the leaves of a book for a moment, apparently
speechless, and not troubling about anything. Even when he has visitors,
he sits without showing any interest, does not ask about what is happening
at home, hardly even greets his parents, and goes back indifferently to
the ward. He can hardly be induced to write a letter, and says that
he has nothing to write about. But he occasionally composes a letter
to the doctor, expressing all kinds of distorted, half-formed ideas, with
a peculiar and silly play on words, in very fair style, but with little
connection. He begs for 'a little more allegro in the treatment,'
and 'liberationary movement with a view to the widening of the horizon,'
will ' ergo extort some wit in lectures,' and 'nota bene for God's sake
only does not wish to be combined with the club of the harmless.'
'Professional work is the balm of life.' These scraps of writing, as well
as his statements that he is pondering over the world or putting himself
together a moral philosophy, leave no doubt that, besides the emotional
barrenness, tbere is also a high degree of weakness of judgment and flightiness,
although the pure memory has suffered little, if at all. We have
a mental and emotional infirmity to deal with, which reminds
us only outwardly of the states of depression previously described.
This infirmity is the incurable outcome of a very common history of disease,
to which we will provisionally give the name of Dementia Praecox.
The development of the illness
has been quite gradual. Our patient, whose parents suffered transitorily
from 'dejection,' did not go to school till he was seven years old, as
he was a delicate child and spoke badly, but when he did he learned quite
well. He was considered to be a reserved and stubborn child. Having
practised onanism at a very early age, he became more and more solitary
in the last few years, and thought that he was laughed at by his brothers
and sisters, and shut out from society because of
his ugliness.
For this reason he
could not bear a
looking-glass in his room. After passing the written examination
on leaving school, a year ago, he gave up the viva voce, because he could
not work any longer. He cried a great deal, masturbated much, ran
about aimlessly, played in a senseless way on the piano, and began to write
observations 'On the Nerve-play of Life,' which he cannot get on with.'
He was incapable of any kind of work, even physical, felt 'done for,' asked
for a revolver, ate Swedish matches to destroy himself, and lost all affection
for his family. From time to time he became excited and troublesome, and
shouted out of the window at night. In the hospital, too, a state
of excitement lasting for several days was observed, in which he chattered
in a confused way, made faces, ran about at full speed, wrote disconnected
scraps of composition, and crossed and recrossed them with flourishes and
unmeaning combinations of letters. After this a state of tranquillity
ensued, in which he could give absolutely no account of his extraordinary
behaviour.[ The patient afterwards returned to the care of his family unchanged.]
Besides the mental
and emotional imbecility, we meet with other very significant features
in the case before us. The first of these is the silly, vacant laugh,
which is constantly observed in dementia praecox. There is no joyous
humour corresponding to this laugh; indeed, some patients complain that
they cannot help iaughing, without feeling at all inclined to laugh.
Other important symptoms are mahing faces or grimacing, and the fine muscular
twitching in the face which is also very characteristic
of dementja praecox. Then we must notice the tendency to
peculiar, distorted turns of speech--senseless playing with syllables and
words--as it often assumes very extraordinary forms in this disease.
Lastly, I may call your attention to the fact that, when you offer him
your hand, the patient does not grasp it, but only stretches his own hand
out stiffly to meet it. Here we have the first sign of a disturhance
which is often developed in dementia praecox in the most astounding way.
As the illness
developed quite gradually, it is hardly possible to fix on any particular
point of time as the beginning. In such cases, the change which is
taking place is easily referred to some culpable looseness of morality,
which it is sought to combat by educational means. Onanism in particular,
which is very common in our patients, is usually held to be the source
of the disease, so that cases of this kind were formerly spoken of as the
insanity of onanism. I am nevertheless inclined to see in onanism
a symptom, rather than the cause, of the disease. We often see the
whole severe mental and physical condition arise, without any striking
degree of onanism, and we also know degenerate onanists who present quite
different symptoms. Hence there cannot well be any question of a
regular causal connection between onanism and dementia praecox. Besides,
the disease is just as common among women, in whom the weakening effect
of onanism must be much slighter. Lastly, it is to be observed that
the disease often sets in quite suddenly, another circumstance not exactly
adapted to confirm the supposition of its onanistic origin [Kraepelin,
1968, 21-4].
Bibliography
of Kraepelin's works.
Eugen Bleuler [1857-1939] introduced the term Schizophrenia
into psychiatry.
He was born in a suburb of Zurich, Switzerland. After finishing his medical
training he took a position as a resident at the Waldau mental hospital
near Bern. He left there to study with Charcot and Magnan in Paris, to
travel to London and Munich and then join the staff of the Burghölzi
Mental Hospital, which was then directed by August Forel [1848-1041].
In 1886, Bleuler was appointed medical director of the Rheinau mental hospital.
For the next twelve years he lived closely with his patients, spoke their
dialect and made every effort to understand their 'senseless' utterings
and delusions. In 1898 he succeeded Forel as the director of the Burghölzi.
Bleuler was the personification of work and duty. He demanded a strenuous
amount of work and devotion to patients. Abstinence from alcohol was imposed
on everyone. Among his staff, after 1900, was Carl Gustav Jung. Although
Jung does not mention Bleuler in his autobiography and says that 'the psychology
of the mental patient played no role whatsoever' at the Burghölzi,
this is unanimously contradicted by everyone else who worked with Bleuler
[Ellenberger,
1970, 666-7.
Bleuler was favorably impressed by Freud and asked Jung to report on Freud's
Interpretation
of Dreams to the Burghölzi staff in 1906. for a brief time Bleuler
became a member of the budding psychoanalytic organization. He attended
its 1908 international congress and founded, with Freud, the Jarbuch für
psychoanalytische und psychopathologische Forschung [Yearbook for Psychoanalytic
and Psychopathological Research], with Jung as editor. Bleuler wrote a
small volume in defense of Freud's psychoanalysis, which appeared in 1911,
by which time Bleuler had already parted company with the movement on the
basis of what he considered to be Freud's excessive emphasis on infantile
sexuality [Stone,
1997, 147].
In 1911
Bleuler published book Dementia Praecox or the Group of Schizophrenias.
The title of the book reflected the fact that Bleuler did not like the
term Dementia Praecox. He felt that it was misleading both because it implied
deterioration, which he did not think was inevitable, and because it suggested
the presence of a true dementia like senile dementia, which was not the
case. Nonetheless Bleuler and Kraepelin had the same case material in mind
and Bleuler never intended to oppose Kraepelin's views.
Kraepelin's view
at first did not find much acceptance outside the circle of his co-workers,
and in fact encountered much resistance. This did not change until the
appearance of Eugen Bleuler's book . This book, and the greatly enlarged
8th edition of Kraepelin's textbook in 1913 broke the deadlock and brought
general acceptance not just in Germany but in the world--except in France
[Hoenig,
1995, 342].
Kraepelin's Dementia
Praecox and Bleuler's schizophrenia, however, differ in more than the implications
of their names. Kraepelin's Dementia Praecox always included psychotic
symptoms, Bleuler's Schizophrenia did not. Kraepelin's approach is purely
observational and empirical. He avoids any kind of theorizing about his
observations.
Bleuler is guided by the theory that an unknown cerebral disease
process expresses itself through primary or fundamental symptoms, often
referred to as the four A's: altered
associations, altered affectivity, ambivalence and autism. Bleuler
insisted that 'once the schizophrenic anomalies of association have been
proven, the diagnosis is assured [Bleuler, 1911,283]. The secondary
symptoms such as hallucinations and delusions were not due to the disease
process, but to life experiences.
Ellenberger has suggested
that this distinction was probably inspired by Pierre Janet's concept of
psychasthenia, which has a primary physiological process of lowered psychological
tension and a secondary elaboration of specific symptoms. For Bleuler the
primary symptoms of schizophrenia were due to a loosening of the tension
of associations, as occurs in dreams [Ellenberger,
1970, 287].
Kraepelin
insisted that Dementia Praecox was a single disease, even though he thought
that no single symptom occurred in every case. Bleuler identified primary
symptoms, which he felt occurred in every case, yet he spoke about the
'Group of Schizophrenias.' Bleuler's expanded notion of schizophrenia led
to the creation of subtypes. Simple schizophrenia, for example, could be
diagnosed in patients who showed only the fundamental symptoms. Bleuler
argued that there are people who have 'the disease' while having no schizophrenic
symptoms, not even the fundamental ones. These he regarded as having
'latent schizophrenia,' which he believed was 'the most frequent
occurring form even though it comes under treatment the least often.' [Hoenig,
1995,341-2]
While in recent
years Bleuler's definition of Schizophrenia has been regarded as too broad
to be useful for classification, its inclusiveness did encourage therapeutic
optimism. Because Bleuler thought that Schizophrenia could be stopped or
reversed at any stage, he made an active effort to treat his patients.
He would resort to early discharge of apparently severely ill patients,
or to unexpected transfers to another ward. He organized a system of work
therapy and arranged for leisure time activities for has patients [Ellenberger,
1970,288].
'Dear Mother: Today I am feeling better than yesterday.
I really don't feel much like writing. But I love to write to you. After
all, I can tackle it twice. Yesterday, Sunday I would have been so
happy if you and Louise and I could have gone to the park. One has such
a lovely view from Stephan's Castle. Actually, it is very lovely in Burgholzli.
Souise wrote Burgholzi on her last two letters, i mean to say on the envelopes,
no, the 'couverts' which I received. However, I have written Burgholzi
on the spot where I put the date. There are also patients in Burgholzi
who call it 'Holzliburg.' Others talk of a factory. One may also regard
it as a health-resort.
'I am writing on paper. The pen which
I am using is from a factory called 'Perry & Co.' This factory is in
England. I assume this. Behing the name of Perry Co. the city of London
is inscribed; but not the city. The city of London is in England. I know
this from my school-days. Then, i always liked geography. My last teacher
in that subject was Professor August A. He was a man with black eyes. I
also liked black eyes. There are also blue and gray eyes and other sorts,
too. I have heard it said that snakes have green eyes. All people have
eyes. There are some, too, who are blind. These blind people are led about
by a boy. It must be terrible not to be able to see. There are people who
can't see and, in addition, can't hear. I know some who hear too much.
One can hear too much. There are many sick people in Burgholzli; they are
called patients. One of the I like a great deal. His name is E. Sch. He
taught me that in Burgholzli there are many kinds, patients, inmates, attendants.
Then there are some who are not here at all. They are all peculiar people...'
About this example Bleuler comments: 'A non-schizophrenic
informant would tell us what in his immediate invironment affected
him; what may have made him feel comfortable or uncomfortable; or, perhaps,
something that might interest his reader. There is complete absence of
any such purpose here. The common denominator of all of the patient's ideas
rests in the fact that they are present in his awareness, but not because
they have any close relation to him. ... Although nearly all the ideas
expressed are correct, nevertheless the letter is meaningless. The patient
has the goal of writing, but nothing to write about [Bleuler,
1911/1950, 17-8].'