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:—
_Type_ _Number of Cases_ _Percentage_
Paranoid 3579 58.34
Catatonic 468 7.63
Hebephrenic 1463 23.84
Simple 625 10.19
In Massachusetts in 1917-18-19 there were 2,921 cases, distributed as
follows:—
Paranoid 1248 42.72
Catatonic 678 23.21
Hebephrenic 828 28.34
Simple 165 5.64
In a group of nineteen other institutions there were 3,184 cases, as
follows:—
Paranoid 800 25.12
Catatonic 438 10.61
Hebephrenic 1666 52.32
Simple 230 7.22
We have thus a total of 12,240 cases, a composite group classified
according to types as follows:—
Paranoid 5627 45.97
Catatonic 1584 12.12
Hebephrenic 3957 32.32
Simple 1020 8.33
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.
Pollock and Nolan[312] have made a study of 9,124 admissions of
dementia praecox to the New York hospitals during a period of six and
three-quarters years. Of these cases 52.2 per cent were men and 47.8
per cent, women. The distribution shown by age groups is interesting
and significant, as is shown by the following table:—
_Age Group_ _Percentage_
Under 15 years .2
15 to 19 " 7.8
20 " 24 " 20.1
25 " 29 " 22.0
30 " 34 " 16.6
35 " 39 " 13.5
40 " 44 " 8.4
45 " 49 " 5.3
This would not appear to suggest an adolescent origin for this disease
to the extent advocated in our textbooks. The highest rate shown by
males was in the age group from twenty-five to twenty-nine years and in
the female cases, from thirty-five to thirty-nine years. Forty-nine per
cent were thirty years or over at the time of admission, forty-three
per cent were between twenty and thirty years of age and thirty per
cent, between thirty and forty. Nineteen per cent were forty years or
over at the time of admission. Pollock's[313] investigation, the most
exhaustive statistical study yet made of dementia praecox, shows that
fifty per cent of the cases have a family history of insanity, nervous
diseases, alcoholism or neuropathic or psychopathic traits, with a
full fifty per cent showing no evidence of unfavorable heredity. This
again is at variance with opinions usually expressed on this subject.
Forty-six per cent were of normal mental makeup and seventy-eight per
cent intellectually normal before the onset of the psychosis. Alcohol
was an assigned etiological factor in four per cent of these cases and
there was a history of intemperance in eight per cent of the others.
The incidence of dementia praecox is more than three times as great in
cities as it is in the rural districts. The average length of hospital
residence was sixteen years. The foreign born dementia praecox first
admissions were found to be principally from Austria, Germany, Hungary,
Ireland, Italy and Russia. Fifty-one and four-tenths per cent of the
cases were natives of this country and 48.3 per cent, of foreign birth.
It is interesting to note that in 1919, 39.9 per cent of the first
admissions to the New York institutions for the criminal insane were
cases of dementia praecox. The rate of admission was 37.1 per cent in
1918, 20.5 per cent in 1917, 30.8 per cent in 1916 and 32.8 per cent in
1915. Of the 37,607 patients in the New York state hospitals on June
30, 1919, 22,036, or 58.8 per cent, were cases of dementia praecox. One
hundred and thirty-eight were discharged as recovered during a period
of three years. This number represented 5.2 per cent of the cases of
dementia praecox discharged during that time, 2.01 per cent of those
admitted, 1.1 per cent of all discharges, and .6 per cent of all first
admissions. A review of the cause of death in 2,988 cases shows that
the rate for tuberculosis was thirty-three per cent during four years
when there was no influenza epidemic. This constituted over fifty-nine
per cent of all of the deaths due to tuberculosis during that period of
time.
Dementia praecox with the highest admission rate of any of the
psychoses, its exceedingly unfavorable recovery rate, its extreme
susceptibility to tuberculosis, and representing as it does over
one-half of the population of our hospitals, must unquestionably be
looked upon as the most important form of mental disease with which
we have to deal today. The number of cases of dementia praecox in the
Massachusetts and New York hospitals justifies the statement that there
are approximately 120,000 persons suffering from this disease in the
institutions of the United States, their maintenance alone costing the
country twenty-five million dollars annually. Their permanent removal
would make it possible to close at least sixty institutions larger than
any state hospital in Massachusetts.