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.