PART II — часть 6

An analysis of the number of cases of manic-depressive insanity admitted to American institutions is exceedingly interesting in view of the opinions expressed by Kraepelin. From 1912 to 1919 there were 49,640 first admissions to the thirteen New York state hospitals. Of these, 7,499, or 15.1 per cent, were diagnosed as having manic-depressive psychoses or allied conditions. During the years 1918 and 1919, when the Association's classification was officially used throughout, the percentage of manic-depressive psychoses was 14.57. In the fourteen state hospitals of Massachusetts in 1919 there were 3,011 first admissions. Two hundred and eighty-three, or 9.39 per cent, of these were manic-depressive psychoses. In twenty-one state hospitals in fourteen other states, practically all in 1917, 1918 and 1919, there were 18,336 first admissions. Of these 3,409, or 18.59 per cent, were cases of manic-depressive insanity. Thus, of the 70,987 first admissions reported from forty-eight hospitals in sixteen different states there were 11,191 cases of manic-depressive insanity, a percentage of 15.76. This may probably be looked upon as fairly representative of the incidence of manic-depressive psychoses in American institutions.

When it comes to an analysis of the various forms of manic-depressive psychoses reported, the indications are not so clear. In New York during 1918 and 1919 there were 1,980 cases distributed as follows:—

During the eight-year period referred to above in the New York hospitals there were 6,091 cases of manic-depressive and allied conditions, classified as follows:—

The fourteen Massachusetts hospitals reported 672 cases in 1917 and 1918, classified as follows:—

In the twenty-one hospitals in fourteen other states there were 3,409 cases of manic-depressive psychoses as follows:—

The total from all of these institutions, of 12,152 cases, was classified as follows:—

It will be noted that manic cases are more common than the depressive in New York, the number of the former being fifteen per cent greater than the latter. In Massachusetts the number of depressive forms is twenty-two per cent higher than the manic. In the other states the depressive types are less than five per cent higher than the manic. In all institutions the mixed forms are more common than the circular or stuporous. The stuporous forms constitute the smallest percentage reported in all hospitals, except in 1918 and 1919 in New York. We would be warranted, apparently, in the conclusion that in this country manic forms are the more common, the depressive being second in frequency, followed by the circular and stuporous types in the order mentioned.

The statement is, I think, also warranted that there is a considerable difference of opinion as to the classification of the different forms of manic-depressive insanity and that diagnostic procedure is far from being standardized. Many of these discrepancies are doubtless due to difficulties in differentiating between certain cases of manic-depressive psychoses and dementia praecox. The hospitals reporting lower percentages of the former usually show a much higher rate of the latter. Certainly there is room for an honest difference of opinion in many instances. It must be admitted, moreover, that our fundamental conceptions of these two great groups do not permit of a hard and fast line of demarcation between them in all cases.

CHAPTER XII

INVOLUTION MELANCHOLIA

In 1896 Kraepelin first definitely outlined his views on dementia praecox, to which he assigned hebephrenia, although he did not at the time include katatonia in his delimitation of that disease. He also described melancholia in his fifth edition, classifying it as an involutional or retrograde presenile process (Das Irresein des Rückbildungsalters). He had not as yet formulated his theory of the manic-depressive psychoses although he described manic and depressive forms of periodical constitutional disorders. In 1899 he discarded the mania and melancholia of other writers altogether or rather included them in his new manic-depressive group, but still retained melancholia as a distinct entity occurring in the involutional period of life only. As has already been shown, melancholia is a term which had been used for centuries and in a general way applied to depressions of any and all types. Kraepelin's manic-depressive psychoses and dementia praecox very largely destroyed the integrity of this old-time conception. It has been shown, furthermore, that depressive states often constitute an integral part of the picture of general paresis. Symptomatic depressions more or less distinct in character have been associated with a number of somatic diseases. Senile psychoses, epilepsy, various organic conditions, the psychoneuroses and the psychopathic personalities have depressive manifestations well recognized and readily classifiable.

Kraepelin, however, pointed out the fact that there was another group still unaccounted for—the anxious depressions of later life, which he included under the designation of involution melancholia and which did not belong to the manic-depressive group. This he described as being preeminently a depression associated almost always with anxiety and fear as prominent symptoms. Accompanying this condition there are usually ideas of poverty, sin, or impending danger of some kind. Delusions of self-accusation are quite common. Anxious restlessness or agitated excitement is to be expected in a majority of the cases. There is usually no clouding of the consciousness, although, as Hoch expresses it, "the mental horizon may be more or less narrowed to the depressive ideas." The memory as a rule is not impaired. Hallucinations of sight and hearing are often present. Somatic delusions of a hypochondriacal nature occur. Insomnia is usually marked. The tendency of the disease is towards deterioration. Retardation and psychomotor inactivity are not to be expected. Melancholia is to be differentiated from manic-depressive insanity by the prominence of anxiety and apprehension, the absence of any retardation or psychomotor inhibition, the unusual frequency of self-accusation with ideas of sinfulness, the clearness of the sensorium, the comparatively unfavorable prognosis and the great frequency of suicidal impulses. The age, and the absence of previous attacks, is, of course, exceedingly important in arriving at a diagnosis. The onset of the disease is usually between the ages of forty and sixty, but not infrequently it begins with the menopause in women, and Kraepelin states that sixty per cent of the cases occur in the female sex. He found a history of defective heredity very common. The precipitating factor is often some mental shock, the illness or death of friends, or disasters of various kinds. No distinctive pathology of the disease has been described by Kraepelin. He was uncertain as to the rôle played by arteriosclerosis in its etiology. Diefendorf[283] reported that about one-third of the cases made complete recoveries; twenty-three per cent were able to return to their previous surroundings; twenty-six per cent terminated in an advanced state of deterioration and nineteen per cent died within a period of two or three years.

In 1907 Dreyfus,[284] at that time an assistant of Kraepelin's, made an elaborate study of the cases previously diagnosed as involution melancholia in the Heidelberg clinic. During a period of fourteen years, a total of seventy-nine were reported. A thorough investigation by Dreyfus showed that two-thirds of these had made complete recoveries or improved to such an extent as to be able to go home. Only eight per cent showed a marked mental deterioration. He also found that over half of the series had more than one attack, usually depressions. One-third of the patients died and were thus eliminated from further consideration. The duration of the attack was over three years in one-third of the cases reviewed. Fifteen per cent recovered in from three to five years, nine per cent in from six to eight years, and eight per cent in from ten to fourteen years. He was of the opinion that after a careful study of the hospital records the symptoms found could all be explained on the basis of manic-depressive insanity, usually of a mixed form. Kraepelin had reported that forty-nine per cent of his cases deteriorated mentally. Dreyfus reduced this on further observation to only eight per cent. On analysis he found, in many instances, brief periods of manic elation, sometimes only a matter of hours or a few days, evidences of excitability, manic suggestion in the eagerness of the patient to communicate his troubles to others, and inhibitory processes indicated by a lack of interest, loss of affection or even difficulty of thinking. Dreyfus concluded that the depressions of late years were not so common as had been supposed and that a sufficient knowledge of their history showed that they had usually exhibited previous attacks. He thought that the long duration of the disease probably led to erroneous ideas as to its termination in deterioration.

Kirby [285] is of the opinion that Dreyfus based some of his findings on insufficient evidence, as shown by his published case records:—"In a considerable number of other cases the author's conclusion that manic-depressive symptoms were present is based on extremely meagre data. As an illustration one case may be referred to briefly. A man fifty-three years old had an agitated depression lasting over two and one-half years and terminating in recovery. The case record contains no statement of any objective inhibition or feeling of subjective insufficiency, neither are there any statements regarding flight of ideas, or unusual loquacity. The diagnosis, however, is made of manic-depressive insanity, with partial psychomotor inhibition and flight of ideas. The assumption that these symptoms existed is based entirely on the retrospective account from the patient, obtained three years after recovery from the psychosis. He then declared that during the attack he could not think calmly; it seemed that one thought "knocked the other down," one thought "hunted after the other." He also described a feeling as if there were a cap on his head, as if he were nailed down. These retrospective statements are interpreted to mean that there was partial psychomotor inhibition and flight of ideas. In many other cases the reasoning is just as forced and the deductions based on equally insufficient grounds.... The author's aim was to see if the symptoms present fitted into certain schematic formula and thus the analysis became rather a search for diagnostic signs supposed to characterize a definite form of disease. Such a method leads away from consideration of the mental disorder as a whole; a few minor features are emphasized in the picture and because the patient recovers these are raised to diagnostic importance—a little feeling of insufficiency or a slight change of mood in a disorder which ends in recovery are seized upon as evidence that a special kind of disease exists; as a matter of fact, we would hardly miss just such symptoms in many other psychoses. There is no attempt to get below the surface, to understand the evolution of the disorder, or to use the facts in the development in formulating the prognosis."

In the introduction to the book written by Dreyfus in 1907, Kraepelin nevertheless expressed the opinion that "These results show that for the most of these disorders which have been designated as melancholia there now exists no sufficient reason to separate them from manic-depressive insanity." This at the time was looked upon as definitely settling the fate of the melancholia concept and it was abandoned by some. As a general rule, however, the psychiatrists of this country seem to have accepted Kraepelin's original description of the disease as being thoroughly justified. To use White's words, "Many psychiatrists still believe, although Kraepelin himself accepts Dreyfus' conclusions, that there is still a place for involution melancholia distinct from the manic-depressive group."

In his eighth edition Kraepelin[286] discusses melancholia as a presenile condition and reviews the whole situation in considerable detail. He shows that symptomatic considerations alone did not guide him in his original conception of the disease. A great deal of weight was attached to prognosis and certain forms were separated out and differentiated from manic-depressive because they tended towards mental enfeeblement. He calls attention to the fact that Thalbitzer disputed the integrity of melancholia in 1905, classifying it as a manic-depressive reaction. After reviewing the findings of Dreyfus he admits that the conclusions of the latter are in the main correct and that involution melancholia as originally described cannot be retained as a definite entity. "The significant fact still remains," he says, "that single attacks of depression are disproportionately common in the involution period." Hübner, for instance, found twenty-one single attacks of melancholia after the fiftieth year of age to only two single attacks of mania. "The appearance of depressions, therefore, through the revolutions of this period of life seems to be favored to a special degree." He again states that he is unable to determine what rôle is played in the involutional depressions by beginning arteriosclerosis or the onset of senile conditions. He concludes, however, that a form of depression, earlier described as melancholia, is still to be separated from the manic-depressive psychoses although not entirely clear as to its significance or exact delimitation.[287]

These are the most severe and rapidly fatal forms of anxious excitements, as a rule developing suddenly and included now in his presenile group. "These cases are anxious, restless, sleepless, self-accusatory and show delusions of persecution." The delusional ideas are depressive, extravagant and hypochondriacal. "They have offended everybody; are eternally damned; Satan is coming and will take them; he is out there. Nature has changed, everything is different, no mercy can come from heaven; there are ghosts in the house; the patients find themselves in the infernal regions, are surrounded by hostile powers, are in a bewitched castle. They will be carried away, thrown into a fiery furnace, their arms and legs cut off, have their throats cut in the presence of a thousand students, and be buried alive. They have a cancer in the stomach, the husband is insane or has had a stroke." Suicidal attempts are frequent. Sometimes grandiose ideas are expressed, accompanied by hallucinations. Apprehension and orientation are usually not disturbed. This is ordinarily followed by a period of violent excitement with agitated wringing of the hands, striking the breast, tearing the hair, etc. Confusional conditions with clouding may appear, often terminating shortly in a pneumonia, erysipelas or heart failure. According to Nissl, widespread and well marked changes are to be found in the brain at autopsy. There is an extensive destruction of ganglion cells, although that cannot be definitely associated with the symptoms of the disease. Kraepelin leaves the question open as to whether this should be looked upon as some form of "acute delirium" such as manifests itself in the course of various psychoses. The disease is usually one of the sixth decade of life, much more common in the female sex, and cannot without further information be definitely excluded from the involutional processes. He concludes his discussion by saying that these conditions probably "have some relation to the similar delirious senile forms to be discussed later." This is, of course, a decided modification of his original views, although it is quite clear that he still feels that there is an involutional depression, now included, however, in the presenile group.

In his chapter on manic-depressive insanity three years later Kraepelin[288] referred to this question again as follows:—"Under these circumstances I thought at first that the involutional depressions described as special clinical forms, melancholia in the narrower sense, which seemed to show essential differences in its general characteristics, course, and to a certain extent in the history of its development, should be separated from manic-depressive insanity. At the same time I was aware of the fact that in a considerable number of the involutional depressions, both on account of their clinical form and their association sooner or later with manic states, their connection with manic-depressive insanity could not be questioned. I therefore made an effort to establish a practical differentiation, entirely without satisfactory results. Further experience has demonstrated, as was shown in the discussion of the presenile psychoses, that they do not constitute grounds for the separation of melancholia. Deterioration is explained by the development of senile or arteriosclerotic changes. Some cases were of long duration, showing manic symptoms before recovery. The frequency of depressions in advanced years we have learned to be a legitimate development of the involutional period of life. The substitution of anxious excitement for volitional inhibition has proved to be an occurrence which is found in advancing years in those cases which had an attack of the ordinary form in the decade before (as shown in our cases 1 and 2). Hübner has, moreover, made the observation that melancholia may show retardation in one attack and not in the next. There remains, therefore, no adequate reason for differentiating the involutional depressions heretofore described as melancholia from manic-depressive insanity."

Kehrer[289] has made a careful analysis of the facts brought out by Kraepelin's statistical diagram showing the various age groups represented by his manic-depressive cases. "From the fifteenth year of life, at which age manic and melancholic attacks are most frequent (about twenty-five per cent), the curve of the manic attacks falls steadily (with only two important rises at the thirty-fifth and the forty-fifth years) until it becomes less than five per cent at the seventieth year, while the curve of the melancholic conditions with equal constancy increases (with the exception of the fifty-fifth year only), especially between the forty-fifth and fiftieth years, from fifty-two to seventy-four per cent and finally to eighty per cent. On the other hand, the curve of the manic first attacks falls steadily from 28.5 per cent at the twentieth year to 3.5 per cent at the sixtieth, with a slight increase at fifty from 12.7 per cent to 13.4 per cent, while in the male sex the same curve shows no further increase after the thirtieth year, when it reaches its maximum (33.8 per cent) and even shows a particularly sharp fall, from 22.2 per cent to 5.9 per cent, between the fiftieth and sixtieth year.... Based on this diagram Kraepelin concluded that the depressions of the involutional period, which did not show special symptoms of some other disease entity, could not be differentiated from those of the earlier periods of life."

Specht,[290] Hübner and Stransky have subscribed to these views. Stransky expressed the opinion that "there is nothing in the form of these depressions, either with or without anxiety, by which they can be distinguished from those recognized as manic-depressive insanity and that neither the course nor the age of onset offer any convincing argument for their clinical independence." Rehm, on the other hand, held that there were depressions of the involutional period of life corresponding to Kraepelin's melancholia and not belonging to manic-depressive insanity. He described these as lacking the constitutional taint and characterized by a slow onset, without previous attacks, fatigability, outspoken egocentric conduct, hypochondriacal delusions of the deteriorative type and the appearance of hallucinations. Bleuler,[291] Bumke, Seelert, Albrecht and others still hold to the integrity of involution melancholia as a distinct entity. "These forms," as Bleuler expresses it, "have as a rule a much more protracted course. They progress slowly for one or two years, continue to be mild, reaching their height in several years, and decline slowly to their final conclusion. The inhibition is obscured by great restlessness, genuine agitated forms are common, they tend to recidivism much less than the others and show also much less heredity." Albrecht, in 138 cases of functional psychoses of the involutional period, only thirty-two of which were in men, diagnosed eighty-two as genuine involution melancholia. In none of his cases did he find an isolated attack of mania in that period of life. He differentiates this condition from agitated melancholia, leaving the question open as to whether this constitutes a pernicious form or is a presenile disease. According to Bumke, psychic causes are more prominent in involution melancholia than in the manic-depressive psychoses, the duration is longer and they do not make such complete recoveries, the most common termination being a depressive mental enfeeblement, with despondency and an anxious hypochondriacal mood. For the genetic interpretation of climacteric melancholia as well as the other involutional forms the intimate association, according to Bumke, of endogenous with exogenous factors is the point of greatest importance. "Involution only brings the barrel to an overflow; it only adds exogenous to the individual endogenous momentum so that the sum total leads to the outbreak of a manifest psychosis." Seelert goes still further with the endogenous exogenous theory of Bumke. "It depends on the type of the association whether the organic anxiety psychosis, a melancholia or the depression of a manic-depressive insanity develops in the later period of life. In one the endogenous factors predominate, in the other the exogenous and in melancholia (in its narrower sense) the two maintain a balance."

Although, as has been noted, no characteristic pathological changes have been associated with involutional melancholia, a condition to which attention was called by Adolf Meyer should be referred to here. In 1901, in an article in "Brain" on "The Parenchymatous Systemic Degenerations mainly in the Central Nervous System" he proposed the name "Central Neuritis" for a terminal affection previously described by Turner in 1899 and occurring more frequently perhaps in involutional melancholia than in any other psychosis:—"This alteration has been found to occur in peculiar forms of end stages of depressive disorders, near or after the climacteric period, alcoholic-senile and alcoholico-phthisical cachectic states, idiocy, and perhaps also general paralysis (Turner's case). Ordinary infectious and cachectic states do not, however, appear to form an important link in the causes."[292] The mental condition is usually anxious, agitated and apprehensive, often terminating in a delirium followed by a stupor. The disease may last for a few days ending in death or may recover after several weeks. It is accompanied by progressive weakness, loss of weight and wasting, a slight rise of temperature, and in many cases attacks of diarrhea. Characteristic are muscular tension with rigidity, twitching movements, incoordination and jactitation of the limbs. The reflexes are usually increased. The onset is often quite sudden, usually in the fourth, fifth or sixth decade of life. At autopsy a striking condition, described as axonal alteration, is found in the "Betz" and other large ganglion cells generally. The cell body is somewhat swollen, the stainable substance is reduced to a structureless powder and the nucleus is dislocated and appears conspicuously in the periphery. There is also some "Marchi" degeneration of the fibre tracts in the motor areas. The regions involved, according to Meyer,[293] are "the cortico-thalmic connections of the motor areas, the auditory radiation, the forceps, the pyramids, the fillet, the restiform body, and to a lesser degree, the posterior column of the cord, the intersegmental elements, and the segmental efferent motor elements."

In view of the attitude of the psychiatrists of this country as shown by numerous expressions of opinion, the statistical committee of the Association felt justified in retaining involution melancholia in its classification of psychoses for the present and collecting data for further consideration. The following suggestions were offered as to its delimitation:—

"These depressions are probably related to the manic-depressive group; nevertheless the symptoms and the course of the involution cases are sufficiently characteristic to justify us in keeping them apart as special forms of emotional reaction.

"To be included here are the slowly developing depressions of middle life and later years which come on with worry, insomnia, uneasiness, anxiety and agitation, showing usually the unreality and sensory complex, but little or no evidence of any difficulty in thinking. The tendency is for the course to be a prolonged one. Arteriosclerotic depressions should be excluded.

"When agitated depressions of the involution period are clearly superimposed on a manic-depressive foundation with previous attacks (depression or excitement) they should for statistical purposes be classed in the manic-depressive group."

In view of the history of the development of the conception of this psychosis an analysis of the hospital statistics on this subject is of unusual interest. We now have reports of over seventy thousand first admissions based almost entirely on the classification at present used by the Association. In 49,640 first admissions to the New York hospitals during a period of eight years there were 1,351 cases diagnosed as involution melancholia—2.72 per cent of the total. During 1918 and 1919, when the Association's classification was followed in detail, these hospitals showed 480 cases, or 3.45 per cent of 13,588 first admissions. Twenty-one public institutions in fourteen other states reported 378 cases, or 2.06 per cent of 18,336 admissions. Two and twenty-five hundredths per cent of the admissions to the Massachusetts state hospitals in 1919 were cases of involution melancholia. Reports from forty-eight different state hospitals show that involution melancholia constituted 2.53 per cent of over seventy thousand admissions. This shows a remarkable similarity in standards of diagnosis as far as this psychosis is concerned.

CHAPTER XIII

DEMENTIA PRAECOX

The dementia praecox of today, notwithstanding the numerous theories which have been advanced as to its etiology and pathology and the various fundamental conceptions which have been evolved in the interpretation of its mental mechanisms, is essentially the disease described by Kraepelin in 1899. The designation which he applied to this psychosis or group of psychoses was not new, having been used by Morel as early as 1860 and again by Pick in 1891. His views as to the delimitation of the disease were, however, altogether different from those of earlier writers and were destined to inaugurate a new era in psychiatry. The grouping which he proposed would include certain types of mania and melancholia and the psychoses of puberty and adolescence described by Hecker and Kahlbaum together with various paranoid states previously associated with paranoia, chronic delusional insanity, etc.

Kraepelin thus at one blow destroyed the integrity of mania, melancholia, terminal dementia and paranoia, entities which had been practically unquestioned for centuries. This radical departure from established psychiatric procedure was based on his observation that various definite characteristics were common to certain cases in all of these clinical groups and that they were of vital significance from a symptomatic as well as a prognostic point of view. He called attention to the fact that excitements and depressions often recurred or alternated in the same individual without any tendency towards mental enfeeblement. An analysis of the mental mechanisms and symptomatology of these cases led to his well-known conception of the manic-depressive psychoses. Other clinical groups equally well-defined, although not so sharply circumscribed, showed consistent and progressive tendencies towards mental deterioration. These were brought together and described as dementia praecox. This may be looked upon as a logical development of the progress made by the German school of psychiatrists. The first step in this direction perhaps was the recognition of hebephrenia by Hecker in 1871. He particularly emphasized the occurrence of this condition at the time of puberty or during the adolescent period. This has often been referred to as "silly dementia." The preliminary stage or onset in many instances was characterized by a gradual change in personality. This was evidenced by foolish behavior, silly actions and a failure of adjustment to the patient's surroundings often resulting in an abandonment of his usual occupation, with an evident gradual intellectual deterioration. Initial attacks of depression were frequent, usually with hypochondriacal ideas and only occasional hallucinations or delusions. Transitory periods of excitement were common sequelae. The emotional reactions were characterized by their shallowness, the train of thought by incoherence, the conduct by foolish and senseless acts and the intellectual reactions by an advancing deterioration. "The weakminded silliness of the disease picture," in the words of Krafft-Ebing, "is partly to be explained by the original weakmindedness of the patient, which Hecker emphasizes in the etiology of his cases."

A more decided step in the development of the dementia praecox concept was the description by Kahlbaum of katatonia in 1874. This may be ushered in by an early stage strongly suggesting hebephrenia but terminating usually in a depression followed by states of excitement, stupor and dementia. The characteristic features of the disease are the peculiar catatonic stupor so-called, and forms of excitement differing materially from those exhibited in the manic-depressive psychoses. Hallucinations and delusions are almost invariably present. The delusions are likely to be of a most absurd and extravagant type, accompanied by self-accusation in some instances but oftener by feelings of influence referred to others or somatic ideas. States of muscular tension appear early, with constrained attitudes and peculiar mannerisms. The stupor which is such a prominent feature in the picture is characterized by negativism shown by a resistance to all external influences, mutism and a refusal to accept food. This may be associated with rigidity due to extreme muscular tension which is often so marked as to be described as cataleptic. Automatism may manifest itself in the form of echolalia or echopraxia. The excitements are characterized by impulsive acts of violence. Verbigeration and stereotypy are frequent symptoms. Remissions are rather to be expected but the tendency of the disease is towards a marked mental deterioration in the great majority of cases.

Schüle in 1886 suggested the term dementia praecox as one applicable to the psychoses of adolescence. It remained for Kraepelin, however, to establish the entity of these disease processes by including still another type, the paranoid forms, which were left entirely unaccounted for in the conceptions of Hecker, Kahlbaum, Schüle, Morel, Pick, or any of the earlier writers. In this group he included cases with persistent hallucinations, more or less loosely systematized delusions of persecution and gradually increasing deterioration but with little or no clouding of consciousness.

In the last edition of his book Kraepelin[294] defines dementia praecox as including "a group of clinical pictures having the common symptom of a characteristic destruction of the internal associations of the psychic personality affecting particularly the emotional and volitional spheres".... "Although wide differences of opinion still exist on many points, the conviction seems to be gaining ground more and more that dementia praecox on the whole represents a well-defined disease entity, and that we are justified in regarding the majority at least of the apparently dissimilar clinical types here described as the manifestations of a single disease process." Many objections have been raised to the name applied to this psychosis by Kraepelin. It has been pointed out that complete deterioration is not always the termination to be expected in this group and that it is not always a disease of adolescence. All of this was conceded by Kraepelin. He employed the term as one answering the purpose "until a more thorough understanding would suggest an appropriate designation." His conception of the psychosis as described in the sixth edition of his book may, I think, be said to have received the rather general approval of the psychiatric world. While there has been no serious attack on his delimitation of the disease entity itself, there has been a decided controversy as to the psychological mechanisms involved and the fundamental principles upon which his conceptions were based. Certainly no textbook of recent years has failed to give a very serious consideration to the question of dementia praecox.

Stransky (1909) looked upon dementia praecox as the result of a lack of coordination of the intellect, the emotions and volition, which he expresses as an intrapsychic ataxia. This is illustrated by the displacement of the affect so common in dementia praecox and its association with an entirely incongruous idea. Thus, the patient laughs while expressing an exceedingly depressing delusional belief or cries while telling a joke. No emotion is displayed at the statement that he is being buried alive or torn apart by some outside agency. This would possibly explain the unprovoked rages of the catatonic and the discrepancy between the catalepsy and mutism of a patient who is found to be perfectly oriented as to his surroundings and the curious fact that he is often thoroughly clear as to the exact day and date.

Wernicke's theories regarding the elaboration of mental mechanisms have already been referred to. He saw in dementia praecox and other deteriorative processes the possibility of a dissociation of psychical reflexes due to an interruption or disturbance located in the psychomotor projection field, preventing its proper coordination with the intrapsychic elaboration mechanisms.

The psychological processes involved in schizophrenia as outlined by Bleuler[295] (1911) have a very important bearing on the interpretation of the symptoms of dementia praecox. The group which he described under this designation is a very broad one, including "many atypical melancholias and manias of other schools (as well as hysterical melancholias and manias), the most of the hallucinatory confusions, many of the amentias described by others (our conception of amentia is much narrower), some of the forms belonging to acute delirium, Wernicke's motility psychoses, primary and secondary dementias without special designations, the most of the paranoias of other schools, especially the hysterical paranoias and almost all of the incurable hypochondrias, nervousness, compulsions and impulsions." To these he adds the various "juvenile and masturbation forms," a large part of the degenerative psychoses of Magnan, many prison psychoses and the Ganser symptom complex. In view of the fact, as Bleuler[296] expresses it, that "The name dementia praecox, which neither leads to dementia nor is precocious in its origin, necessarily, gave rise to many misunderstandings," he suggested the designation schizophrenia as more appropriate. "Even if we cannot make a natural grouping, it would appear that schizophrenia is not a disease in the narrower sense but a group of diseases somewhat analogous to the organic group, which includes paralysis, the senile forms, etc. Schizophrenia should therefore be spoken of really in the plural. The disease pursues a chronic course or progresses in attacks and may come to a standstill at any stage or may even regress but never to a complete restitutio ad integrum. It is characterized by a specific type of alteration in thinking, feeling and relation to the outer world encountered nowhere else. Accessory symptoms of a characteristic type are particularly common.... Dementia praecox in any stage may come to a stop, and many of its symptoms partially or entirely disappear but when it progresses further it leads to dementia and dementia of a definite type." A fundamental symptom, according to Bleuler, is the disturbance of association of ideas. "The normal association of ideas loses its stability; others enter at will and take their place. Thus the ideas lose their relation to each other and thought becomes incoherent." As Hoch[297] says of this disturbance, "Bleuler described it very extensively, and yet somehow it is not so very easy to grasp the nature of this disorder; it is evidently not so very different from Wernicke's sejunction, though free from all localizing anatomical bywork. It is conceived of as a more or less widespread primary interruption of the associative connection of ideas. Actual or latent associations, which, in the normal, determine the train of thought or combinations of such ideas may remain without influence upon it in an apparently aimless fashion, whereas other ideas which have no connection may intrude themselves. Hence the train of thought is scattered, bizarre, illogical, abrupt. This may be so slight that it is difficult to discover, and in his description of mild conditions he says it may not be found, or only after a thorough search; it accounts for much of the scattering of ideas in chronic states, and, as we have said, it is supposed to be the explanatory principle in acute incoherence. On the other hand, similar phenomena may be due to the action of complexes, and have to be explained psychogenically. But the psychogenic explanation does not appear to him sufficient. It is somewhat difficult to see, especially when we consider the extensive symbolization and substitution, the indifference, the negativism, etc., why something beyond these psychogenically explicable disorders is required." An essential feature of Bleuler's[298] concept is "autismus." "The schizophrenics lose their contact with reality, the mild cases inconspicuously here and there, the severe cases, completely".... "When we allow our fancies free reign in mythology, in dreams and in many of the morbid states, thought will not or cannot concern itself with realities; it follows the dictates of instincts and emotions. This disregarding of the inconsistency with reality is characteristic of autistic thinking."

In his excellent review of Bleuler's schizophrenia already referred to, Hoch[299] makes the following comments on this subject:—"A difficult subject is autism. By autism Bleuler means that which we have called the shut in tendency, the more or less complete shutting out of the environment, or at any rate, all that which does not correspond to the wishes. It may be so marked that the patients even shut out all sensory impressions, close their eyes and ears, make their body as small as possible by crouching. Bleuler regards this autism as a secondary phenomenon, and looks upon it as one of the results of his association disorder, whereas the autistic thinking is the day-dreaming, the thinking without reference to reality. This autistic thinking flourishes in schizophrenia—Bleuler thinks that the schizophrenic defect in logic makes the exclusion of a great many external and internal facts possible, and thus gives sway to a tendency which we all have, namely, to live in fancies which suit us, something which we indulge in but do not allow to influence our conduct, but which in the schizophrenic assumes the value of reality." An outline of Bleuler's views would not be complete without his definition of blocking,[300] an important symptom. "Blocking is a sudden emotional inhibition of the psychic processes and in itself not pathological." He found it in normal individuals in nervousness and in hysteria. "Where it is not based on adequate psychological grounds, is generalized or of long duration, its presence warrants the diagnosis of schizophrenia."

A study of the psychogenic factors concerned in dementia praecox led Meyer[301] to the conclusion that the psychological processes of the disease were due to abnormal mental mechanisms developing in individuals unable to adjust themselves to their surroundings. "The general principle is that many individuals cannot afford to count on unlimited elasticity in the habitual use of certain habits of adjustment, that instincts will be undermined by persistent misapplication, and the delicate balance of mental adjustment and of its material substratum must largely depend on a maintenance of sound instinct and reaction type." This theory is supported somewhat by the "shut in personality" found by Hoch[302] in his studies of the history of a large number of cases developing dementia praecox.

Elaborate analyses of the psychological mechanisms involved in dementia praecox have been made by Jung and others. Freud believed hysteria to be the result of a psychic trauma. The unpleasant idea associated with this trauma is repressed into the subconscious because the individual is unable to react to it in a normal way and it is forgotten, but not until it is compensated for by a hysterical symbol or symptom which takes its place. By means of psychoanalysis, the association test and the study of dreams the nature of the psychic trauma can often be determined. Jung[303] adapted these methods of study to a consideration of dementia praecox. His investigations showed that many of the seemingly meaningless manifestations of that disease are symbols or substitutes for buried complexes. In some instances these remain in their original form without transformation. Complexes associated with a feeling of deficiency and injured pride may lead to suspicion and delusions of persecution. Unfulfilled longings may be actualized in a delirium or delusion of grandeur. Symbols and substitutes generally are said to represent complexes which are antagonistic to the ego and are therefore transformed and become unrecognizable. The peculiar symptoms of dementia praecox as a rule are a result of the individual's inability to make compensatory readjustments. In the paranoid forms the patient entirely reconstructs his psychical life. White[304] attempts to explain the meaning of some of these delusional formations in his "Outlines of Psychiatry":—"The relation of the delusion to the complex is often obvious if one is familiar with the more important of the infantile material. A man believes himself pregnant, that a child is in his stomach. This is obviously a regression to the period when as an infant he had not understood that gestation was a particular function of the female. Another patient enucleated his eye (castration symbol); a colored man of about forty years of age invented a perpetual motion machine (compensation for impotence); a man tries to invent the greatest cannon on earth (compensation for small penis complex); a homosexual man of the "sissy" type made wild claims of physical prowess, fighting ability, and incessantly swore and used vulgar language to demonstrate his toughness (over-compensation of homosexuality); a woman complains that her sister's husband follows her through underground passageways and shoots electricity into her genitalia and anus (anal erotism); an oral erotic woman starves herself in order to be tube fed; oral erotic patients often cut their throats while under the erotic pressure; patients frequently say that God talks with them or go to Washington to see the President (father complex); in severe grades of introversion they sit in a dark corner, head on breast, arms folded and legs and thighs flexed (intra-uterine position); a young woman says her real parents are the King and Queen of Norway (Œdipus phantasy); etc. Of course much of the delusional material is not so obviously related to infantile material and must be worked out at length with the individual to determine its meaning. It must not be forgotten that a praecox may have, however, complex reactions exactly like that of hysteria and the psychoneuroses. To that extent such a patient is hysterical or psychoneurotic."

The appearance of the last edition of his textbook showed that Kraepelin has somewhat revised his views on the subject of dementia praecox. He now speaks of a series of morbid pictures "brought together under the designation endogenous dementias for the purpose of a preliminary understanding." This embraces not only dementia praecox but a new entity described as "paraphrenia."[305] This includes forms "which, contrary to the usual manifestations of dementia praecox, are characterized throughout their entire course by the marked prominence of a characteristic intellectual disturbance while an independent impairment of volition and particularly an emotional alteration are lacking or only present in a mild form. For this differentiation it seems to me that no more suitable expression than "paraphrenia" could be employed for the designation of the disease processes experimentally brought together here." He speaks of the following types:—systematica, expansiva, confabulans and phantastica.

The clinical forms of dementia praecox shown in his last edition are as follows:—dementia simplex, hebephrenia, simple depressive or stuporous dementia, depressive delusional dementia, circular, agitated and periodic forms, katatonia, paranoid types (dementia paranoides gravis and mitis, hallucinatory and paranoid feeblemindedness) and confusional speech or schizophasia.

His views as to the delimitation of these different types should be expressed perhaps in his own words: [306]

"Simple progressive deterioration as described by Diem under the designation of 'Dementia Simplex,' consists in an imperceptible and complete impoverishment and breaking down of the entire mental life."

Of hebephrenia or silly dementia he says, "In this disease picture there stands out particularly with the progressive deterioration of the mental life, an incoherence of thought, feeling, and conduct."

"As the third group of dementia praecox I should like to group together, under the designation of simple depressive or stuporous dementia, those cases in which, after an initial depression, with or without the appearance of stupor, a terminal mental deterioration gradually develops."

"Those cases which progress to the marked development of phantastic delusions we group together in the fourth form of dementia praecox—depressive delusional dementia."

"The next large group includes those cases in which severe and protracted excitements develop."

"The first sub group which on account of its course we may designate as the circular form shows the nearest relationship to the disease picture just described in that it also begins with a depression and usually manifests active delusions."

"As a second sub group, the agitated form, we bring together those cases in which the disease begins with an excitement and then immediately or after more or less frequent remissions and relapse passes into the terminal stage."

"In close relation to the cases brought together here we have to consider a small group which either in the initial stages of the disease or throughout its entire duration follows an outspoken periodic course; these amount to less than 2 per cent of all cases."

"The excitements of dementia praecox constitute an important part of the clinical form—Katatonia—which we must now consider. Under this designation Kahlbaum described a disease picture which in turn presents the symptoms of melancholia, mania and stupor, the unfavorable cases being accompanied by confusion and deterioration and is furthermore characterized by the appearance of certain motor seizures and inhibitions—in other words, the catatonic disorders."

"In many respects a dissimilar picture is shown by those cases in which the essential symptoms are delusions and hallucinations; these we characterize as paranoid forms. The justification for including them with dementia praecox I get from the fact that in them sooner or later the delusion formation is invariably associated with a series of disturbances which we find everywhere in the other forms of dementia praecox."

Cases "which do begin with a simple delusion formation but which in the further course exhibit still more clearly the peculiar destruction of the mental life and particularly the emotional and volitional disturbances which characterize dementia praecox may be grouped together under the name 'dementia paranoides gravis'."

"As a fourth form of paranoid dementia praecox, I believe still another group should be added, those which on the one hand show a similar development and the same delusion formation as the paranoid disorders just described but which on the other hand terminate in a characteristic mental enfeeblement." These he would call 'dementia paranoides mitis'."

"A last very characteristic group of cases the discussion of which must be included here, is formed by the patients with confusional speech." These are the Schizophasias of Bleuler.

It must be admitted that in view of Kraepelin's former contributions on this subject this classification must be looked upon as somewhat involved and confusing. It suggests an unnecessary complication of an already difficult subject to no great advantage. These varying conceptions are difficult to understand. Perhaps, as Meyer[307] expresses it, "the symptomatology in its first formulation in 1895, and later, emphasized too many things which prevail also in other conditions, so that altogether too many errors occurred. In four hundred and sixty-eight of Kraepelin's Munich diagnoses even between 1904 and 1906, 28.8 per cent were cases subsequently considered to be manic-depressive (Zendig)—altogether too broad a margin of uncertainty."

In summarizing the whole situation the conclusion reached by Buckley[308] would appear to be thoroughly established:—"Most authorities agree, however, that the term dementia praecox includes the psychoses which appear prior to mental maturity (early in some and much later in others), with a tendency to permanent mental defect in the long run, but which may follow a chronic course, may be divided into attacks, or may improve or stop at any stage, but never with restoration to absolute normal health."

Notwithstanding the elaborate investigations of Alzheimer, Sioli, Klippel, Lhermitte, Moriyasu, Goldstein, Nissl and many others, no definite pathological basis for dementia praecox has ever been established.

For purposes of statistical study in the collection of data relative to this disease entity, as in all other cases, the American Psychiatric Association has endeavored to adhere to fundamental conceptions generally accepted by the profession and has avoided as far as possible adherence to the tenets of any one school. For purposes of uniformity the following suggestions were made in the "statistical manual" as to the classification of psychoses to be reported under the designation of dementia praecox.

"This group cannot be satisfactorily defined at the present time as there are still too many points at issue as to what constitute the essential clinical features of dementia praecox. A large majority of the cases which should go into this group may, however, be recognized without special difficulty, although there is an important smaller group of doubtful, atypical, allied or transitional cases which from the standpoint of symptoms or prognosis occupy an uncertain clinical position.

"Cases formerly classed as allied to dementia praecox should be placed here rather than in the undiagnosed group. The term "schizophrenia" is now used by many writers instead of dementia praecox.

"The following mentioned features are sufficiently well established to be considered most characteristic of the dementia praecox type of reaction:

"A seclusive type of personality or one showing other evidences of abnormality in the development of the instincts and feelings.

"Appearance of defects of interest and discrepancies between thought on the one hand and the behavior-emotional reactions on the other.

"A gradual blunting of the emotions, indifference or silliness with serious defects of judgment and often hypochondriacal complaints, suspicions or ideas of reference.

"Development of peculiar trends, often fantastic ideas, with odd, impulsive or negativistic conduct not accounted for by any acute emotional disturbance or impairment of the sensorium.

"Appearance of autistic thinking and dream-like ideas, peculiar feelings of being forced, of interference with the mind, of physical or mystical influences, but with retention of clearness in other fields (orientation, memory, etc.).

"According to the prominence of certain symptoms in individual cases the following four clinical forms of dementia praecox may be specified, but it should be borne in mind that these are only relative distinctions and that transitions from one clinical form to another are common:

"(a) Paranoid type: Cases characterized by a prominence of delusions, particularly ideas of persecution or grandeur, often connectedly elaborated, and hallucinations in various fields.

"(b) Catatonic type: Cases in which there is a prominence of negativistic reactions or various peculiarities of conduct with phases of stupor or excitement, the latter characterized by impulsive, queer or stereotyped behavior and usually hallucinations.

"(c) Hebephrenic type: Cases showing prominently a tendency to silliness, smiling, laughter, grimacing, mannerisms in speech and action, and numerous peculiar ideas usually absurd, grotesque and changeable in form.

"(d) Simple type: Cases characterized by defects of interest, gradual development of an apathetic state, often with peculiar behavior, but without expression of delusions or hallucinations.

"(e) Other types."

A sufficient number of reports has been received from hospitals using this classification to warrant a preliminary survey of the information available at this time on the subject of dementia praecox. Perhaps it would be well to summarize first such information as is to be obtained from other sources. Diefendorf[309] states that dementia praecox constitutes from fourteen to thirty per cent of all admissions to institutions, fifty-eight per cent of the total number being of the hebephrenic, eighteen per cent, of the catatonic, and twenty-two per cent, of the paranoid variety. Kraepelin[310] (1913) found that dementia praecox constituted ten per cent of all admissions, classified as to types as follows:—Silly dementia, thirteen per cent; simple depressive dementia, ten per cent; delusional depressive dementia, thirteen per cent; circular dementia, nine per cent; agitated dementia, fourteen per cent; periodic dementia, two per cent; and katatonia, 19.5 per cent. He reported a history of hereditary taint in seventy per cent of his cases. Diefendorf found the onset of the disease in sixty per cent of all cases before the twenty-fifth year, Kraepelin, in fifty-seven per cent. Kraepelin[311] states that seizures occurred in twenty-one per cent of his cases of silly dementia and in the other types as follows:—simple depressive dementia, seventeen per cent; delusional depressive dementia, twenty-seven per cent; circular dementia, twenty per cent; agitated dementia, twenty per cent; katatonia, seventeen per cent; paranoid dementia gravis, three per cent and paranoid dementia mitis, five per cent. Unfortunately a survey of the other literature of the day throws little additional light on these subjects.

A study of the statistical reports made by Pollock for the State Hospital Commission shows that during the five years ending on June 30, 1919, dementia praecox constituted 14.42 per cent of the 2,024 voluntary cases admitted to the thirteen New York state hospitals. During a period of eight years ending on June 30, 1919, there were 49,640 first admissions to the New York state hospitals; 12,199, or 24.57 per cent, of these were diagnosed as dementia praecox or conditions allied thereto. The "allied" conditions have not been shown in the New York reports since 1917. In 1918 and 1919 there were 13,588 first admissions, 3,753, or 27.61 per cent, of which were cases of dementia praecox. This would indicate an increase in the incidence of that disease in New York during recent years. The Massachusetts first admissions for 1918 and 1919 show a total of 7,582 cases, 1900, or 25.05 per cent, of which were dementia praecox. It will be noted that the percentage is practically the same as that of New York for the same years. In a group of twenty-one other state hospitals, representing fourteen different states using the Association's classification, 18,336 first admissions have been reported, 3,856, or 21.03 per cent, of which were cases of dementia praecox. This represents a variation from the New York and Massachusetts findings which can be explained on various grounds, largely by the fact that these institutions represent a rural population. We have thus in all 70,987 first admissions to state hospitals, with 16,920 cases of dementia praecox, representing 23.84 per cent of the total number.

A consideration of the different types of this disease as represented by the various state institutions shows somewhat different results. In New York during the years 1916-17-18-19 there were 6,135 cases of dementia praecox shown in the first admissions, classified as follows:—

In Massachusetts in 1917-18-19 there were 2,921 cases, distributed as follows:—

In a group of nineteen other institutions there were 3,184 cases, as follows:—

We have thus a total of 12,240 cases, a composite group classified according to types as follows:—

Although this is probably the largest group of cases of dementia praecox recorded we are, unfortunately, not warranted as yet in attempting any final conclusions. The Massachusetts and New York statistics of late years would, I think, justify the tentative statement, at least, that dementia praecox admissions represent approximately twenty-eight per cent of all cases coming into our hospitals.

When we attempt to analyze the types of the disease as reported, it at once becomes evident that there are very divergent standards of diagnosis. There is a radical difference shown in the consideration of the so-called simple dementia praecox with a general average of 8.33 per cent. In Massachusetts there is a much higher percentage of the catatonic forms, with a predominance in New York of the paranoid variety. The proportion of hebephrenic types in the other nineteen institutions is at wide variance with the reports of Massachusetts and New York. In all probability the percentage shown in the analysis of the total number from forty-six state hospitals is not far from representing conditions existing in American institutions. A careful study of more complete reports extending over a number of years should settle this question to what may be spoken of as almost a mathematical certainty.