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.
CHAPTER XIV
PARANOIA AND THE PARANOID CONDITIONS
A discussion of the part played by paranoia, or the paranoid conditions however characterized, in the psychiatry of the present day, is essentially a review of the final chapter in the history of a psychiatric conception which is several centuries old. The word paranoia, like many other terms still in use, is of Greek origin and was apparently applied by Hippocrates in a very general way to "madness" of any or all forms. It almost certainly had no more definite significance than that, in the works of Plato and Aristotle, nor can it be said to have been used in its modern sense by Celsus or Aretaeus. It seems to have meant something more in the vocabulary of Vogel, an eighteenth century writer. Under the heading of paranoia, according to Jelliffe,[314] Plocquet in 1772 included Paracope or delirium with six subdivisions:—(a) pathetica, (b) phronestica, (c) entomica, (d) encephalica, (e) hyperesthetica, and (f) sympathica. It was not recognized to any great extent by the earlier writers of the French school, but occupied a very prominent place in the development of German psychiatry. Heinroth in 1818 included the paranoias in his disorders of the intellect under the name of verrücktheit, a word that was destined to become one of great importance later, and spoke of an exaltation of the feelings which he called "paranoia ecstasia."