This condition refers to mental disorders arising usually during the
period of puberty or adolescence, therefore, between the ages of
fourteen and twenty-five for the most part, although apparently similar
cases may arise in later years. The term dementia refers to mental
deterioration and enfeeblement, while “praecox” signifies adolescence,
though some writers infer that the term praecox may be used to indicate
the early or precocious development of the mental enfeeblement. Certain
it is that in most cases deterioration, with its resulting symptoms of
mental enfeeblement giving rise to the term dementia, usually occurs
in time, though by no means always early. It is a chronic progressive
disease which may terminate in a complete loss of mentality; in other
cases it may become arrested in any stage and remain so permanently;
in still others it may recover, though this is rare. By reason of the
variability of the symptoms, three groups are generally recognized,
first suggested by Kraepelin. Each is differentiated by more or
less characteristic symptoms and referred to under the head of the
Hebephrenic, Catatonic and Paranoid types, although all have certain
symptoms in common and there are mixed types.
=Etiology.=—According to the authorities some form of hereditary
factor can be found in some fifty per cent or more of all cases; this
is supposed to create a predisposition, a natural weakness of the
nervous system, which renders it unable to bear the ordinary storm and
stress of life, so that the mechanism becomes according to the French
expression, “wrecked upon the rock of puberty or adolescence;” in other
words, a premature giving way of the nervous system, being inherently
unable to stand the strain of life. Another suggestion is that it
represents the outcome of abnormal types or reactions of the individual
to the environment, with a failure of proper adjustment to surroundings
and the formation consequently of mental problems which to the patient
are incapable of solution. This may be called the psychological theory.
The most commonly accepted idea, however, is the physical causation.
According to this the disease results from auto-intoxication, the
intoxicant arising from the disturbances of the glands with internal
secretions, more particularly the sexual glands. This endocrine theory
is supposed to be supported by the fact of the appearance of this
disease most commonly at the time of puberty and shortly thereafter.
The osteopathic conception fits in very well with this latter view,
inasmuch as the spinal lesions are quite capable of explaining not
only a disturbance of innervation to the glands with the resultant
interference in their normal secretion, but also could produce disorder
of the circulation and nutrition to the brain.
=Symptomatology.=—Although each variety of Dementia Praecox has special
symptoms characteristic of the type there are certain symptoms common
to all forms, and these will be first considered. All the functions
of the mind in the course of time tend to become disturbed and to
be weakened, but in the earlier stages we find marked differences
as regards the disturbance of different functions, thus memory and
orientation in most cases seem good; on the contrary, attention and
association of ideas somewhat poor. Emotional life is almost always
markedly affected, even in the beginning. Very commonly at first there
is depression to be followed later by expansive feelings and then by
apathy in general. The will power is altered early and the conduct
is apt to be peculiar. The judgment becomes impaired. All of these
symptoms mentioned are deviations from the normal in the patient
and therefore presuppose that the patient was formerly normal. This
should sharply differentiate the praecox group from cases of defective
development (imbecility or idiocy). In this latter group there is an
arrest of development of the mind, whereas in praecox there is a loss
in a developed intellect. We see a young patient, for example, who
has lost interest in things about him, neglects his work at school or
at home, remains alone for long periods of time and seems unwilling
to mingle with other people. He gives the impression of one depressed
and worried about something he is trying to solve, perhaps he mutters
to himself or gives way to unprovoked laughter, he may refuse to eat,
or to talk unless questioned and may even then not answer. When he
does talk it will be discovered that he knows perfectly well where he
is, and knows people around him and understands everything that is
going on; his memory will be found good, he can usually recall past
incidents and tell what he has been doing recently. As the condition
progresses, however, while the patient may still for a long time retain
fair orientation and memory for past events, his accumulation of recent
ideas will be found poor, so that he will recall them with difficulty.
We notice that it is difficult to get the patient’s attention and
concentration seems to be impossible, he may answer a direct question,
but immediately seems to be occupied with other thoughts and it takes
some little effort to gain his attention again. If he continues to
talk it is plain that the association of ideas is poor, giving rise to
disconnected phrases which usually come forth sluggishly and without
show of emotion. Dissociation of ideas occurs; that is, different
ideas expressed may practically contradict themselves. For example,
the patient may say he is a king and yet when asked to sweep the floor
will do it perhaps without hesitation, not considering that is hardly
the kind of work a king would do. The dissociation is also marked in
the contradiction found between the content of the thought and its
associated emotional idea, for example, the patient may speak of a
near relative as dying recently, yet with no show of emotion, even
with a meaningless laugh. This dissociation may ultimately result in
complete incoherence, in which no sense can be found whatsoever in his
speech. Emotional indifference is noticeable early and sluggishness
of reactions to stimuli, even failure of such reactions; the patient
will neglect himself, stay away from meals, express no desires and make
no complaints. In the earlier stages, however, the patient who may
have been for some little time apathetic, suddenly without apparent
cause becomes angry, noisy, and possibly violent and destructive,
again gradually relapsing into his quiet, apathetic state. The thought
content is commonly associated with delusions, that is obviously false
ideas, but which the patient is unable to perceive are false. Delusions
of persecution are most common, the patient feeling in a dim way that
everything is not right; and in attempting to explain to himself the
reason, often attributes causes to people or forces outside of himself,
and on account of the feeling of bodily discomfort, also by reason
of the depression, he explains the external forces as unfriendly to
himself. Hallucinations may be present and furnish the material around
which the delusions form; on the other hand hallucinations may result
from the delusions. By hallucination is meant a false sense perception,
as the patient may state he sees someone before him who is not there,
or that he hears voices from individuals who are not around him; he may
also complain of receiving electrical shocks, or wireless messages,
which he usually states come from his persecutors. Symptoms of this
nature form a good example of the so-called split personality, or
“schizophrenia,” wherein certain idea complexes are split off from
the main personality and address themselves to the main portion, the
patient attributing these noises (voices), sensations (visceral and
tactile), tastes and smells to an objective rather than a subjective
source and subsequently forming delusions. However, unless we are
dealing with the paranoid form the delusions are fragmentary, transient
and absurd.
=Hebephrenia.=—This is a progressing mental enfeeblement, terminating
usually in deterioration, and without showing marked peculiarities
in thought or action aside from the progressing deficiency. The
patient appears in general inactive, lacking in energy and ambition,
indifferent, depressed, incapable of much concentration and hence
the efficiency becomes progressively impaired until he is unable
to accomplish anything. From time to time there may be periods of
confusion, depression, passivity, at other times periods of excitement.
=Catatonia.=—In this form the general symptoms are similar to those
of the simple type above described with the addition of the special
symptoms referred to as catatonic excitement and catatonic stupor. The
excitement period is manifested by an unrest and monotonous activity,
stereotyped actions and speech, the patient constantly repeating
some act, such as moving the hand, foot or head over and over again
in the same way, or repeating the same word or phrase indefinitely.
This occurs apparently involuntarily, the actions being automatic in
character. The patient who has been in a semistuporous state may pick
up a glass or chair and without show of emotion break it against the
wall. In catatonic stupor the patient may show in the lighter degrees
a simple loss of interest and feeling with sluggish reaction to
stimuli, or a profound inactivity and stupor in which state he cannot
apparently be reached by any stimuli; nevertheless, he apparently
retains consciousness. In this type we observe the interesting symptom
of negativism in which the patient always does the opposite of what
he is requested, or refuses outright to obey any command. There may
be a refusal of food so that the patient has to be fed by a tube,
mutism may be present, the patient may go for weeks or months without
saying a word; stereotype of attitude results in cataleptic poses and
rigidity, in which the patient may maintain any particular pose for
a prolonged period of time, and if placed in some other attitude may
similarly retain the new attitude for a long time. This constitutes
the so-called wax like rigidity, the patient reminding one of a wax
figure. Pathologic suggestibility occurs in which the patient imitates
movements, or repeats words and phrases that are spoken or performed
before him.
=Paranoiac Form.=—In this type delusions predominate and are
characterized by variability, inconsistency, illogicality and
transitoriness on the one hand, with many gradations to the opposite
extreme where they become more or less fixed, and often dovetail into
each other forming apparently a systematic whole. They tend to be
usually of a persecutory and hypochondriacal character and in later
stages when the mind is distinctly weakened are often of a grandiose
type. Sometimes the patients have some kind of explanations for them
and at other times none whatsoever, and they are often curiously
dissociated from the emotional accompaniment. The patient may state
there is poison in his food, in an indifferent tone of voice or even
with a laugh; he may claim that his teeth are all set in wrong and
offer no explanations to these obviously false ideas. The patient
commonly thinks that somebody “has it in for him,” someone will do
him mischief, will kill him, that people are talking about him and
criticizing him, everything that he hears or reads he thinks has some
bearing on himself, so-called “delusions of reference.” Hallucinations
may be present, the patient hearing voices, or receiving impressions
or ideas which he claims come from without. These external impressions
he misinterprets as voices or forces which are accusing, threatening
and slandering him. Later on, the patient tends to change from the
depressed persecutory stage to an expansive one, when he claims he is
some celebrated person, king or president, or pope. The impairment of
the judgment is clearly demonstrated in these cases since the patient
who may claim to be the king of England may beg the attendant to change
his place at the table or for a postage stamp.
=Pathologic Anatomy.=—This is obscure. Since a certain proportion
of cases recover, there can evidently be no degenerative changes at
the outset, though some cases deteriorate fairly early, others only
after several years. In some chronic cases there have been observed
degenerative changes in the cortical cells.
=Diagnosis.=—First, the common age of onset during puberty and
adolescence, fourteen to twenty-four in the vast majority of cases,
this being the only common mental disease occurring during this age
period. Second, the progressive character terminating in mental
enfeeblement or deterioration, that is “dementia” proper. Third, the
evidence of defect or deficiency symptoms indicating that the patient’s
mind has altered in the sense of deterioration from its former normal
condition, whereas, in imbeciles or idiots the mind has failed to
develop in the first place. Fourth, in the earlier stages particularly
the marked dissociation of the brain powers, some being well maintained
as memory and orientation (that is knowledge of time and space), others
being weakened, such as judgment, power of attention and the like.
Fifth, the early appearance of the emotional defect, a remarkable
indifference and apathy of the patient to people and surroundings,
the patient being unsocial and taking no interest in anything. Sixth,
all the peculiar motor reactions, which are mentioned above under
the catatonic head, and which very rarely occur in any other mental
disorder. Seventh, the delusional content nearly always refers to the
patient’s exterior, forces outside of him, people or things which are
exerting an unfavorable influence upon him, delusions of persecution
and reference. The patient practically never accuses himself, as is the
rule in cases of true melancholia, never blames himself, but always the
other party or the other force outside of him. Eighth, the delusions of
grandeur are usually indicative of a stage of deterioration.
=Prognosis.=—Some authorities are inclined to doubt if any case ever
completely recovers, claiming that in apparent recovery it may have
been a question of mistaken diagnosis, or that the recovery is more
apparent than real, that the patient is not truly well, or will have a
relapse, so that a permanent cure will be impossible. Other authorities
admit the possibility of recovery though in a very small minority
of cases. The statistics of the Still-Hildreth Sanatorium, covering
more than two-hundred fifty cases show total recoveries of at least
one-third. This includes all types and all stages of progress, many
being advanced on entrance. Of the less advanced cases and those of
not more than two or three years’ standing there have been some fifty
per cent recovery. Many cases make improvement or become stationary
in greatly improved condition, but are not included in the thirty per
cent. Of the three types, the catatonic offers the best prognosis, the
hebeprhenic the poorest, while the paranoiac occupies an intermediate
position.
=Treatment.=—Of the etiologic factors above mentioned, that of
auto-intoxication, resulting possibly from endocrine disturbances
or other sources, is most generally accepted in the medical world
and agrees excellently with the osteopathic point of view. Spinal
lesions are regularly found more particularly in the dorsal region,
which are quite capable of disturbing the innervation to the glands;
therefore, their nutrition and activity. A correction of these before
the disturbance has continued too long, and hence before deterioration
has set in, should theoretically normalize the glandular condition and
therefore prevent deterioration and enable the patient to recover.
Such is the probable explanation of the results, and in many cases the
recoveries were obtained in patients previously considered hopeless.