Frequent contributions have been made from time to time to the literature of psychiatry on the subject of dementia praecox. Voluminous articles have been written on its pathology, psychological mechanisms, etiology, etc. Many of the theories advanced are not in harmony with what little definite information we possess. Many of the theses on this subject have been based on the study of a surprisingly small number of cases. The statement has been made[125] that attacks either of a syncopal or epileptic nature are among the most important physical symptoms of dementia praecox, and "occur in about eighteen per cent of the cases." In his eighth edition Kraepelin speaks of convulsive attacks of various sorts in sixteen per cent of all cases of dementia praecox, and says that they also occur in a few cases of manic-depressive insanity. These findings are certainly not consistent with those of other observers. In a review of eight hundred cases, five hundred of dementia praecox, one hundred and eighty of manic-depressive insanity and sixty in each of the "allied to" groups, Simon[126] found convulsions in less than one per cent of the total number of cases in which epilepsy or organic conditions could be definitely excluded. In a study of 367 cases of dementia praecox Ullman[127] found convulsive manifestations in 2.7 per cent of the total. He also reported seizures in 1.4 per cent of 340 cases of manic-depressive insanity. Kraepelin formerly held that recovery was to be expected in about eight per cent of the cases of hebephrenic dementia praecox and thirteen per cent of the cases of katatonia (seventh edition). Notwithstanding this, he says in his eighth edition in one place:[128] "Further investigations of a series of observations carried on extensively and carefully for decades must show how far the view, which is gaining in probability for myself, is correct, that permanent and complete recoveries of dementia praecox, though they may perhaps occur, still in any event belong to the rarities." As Kraepelin himself suggests, the widely varying views on this subject are due to different conceptions as to what constitutes dementia praecox and what is to be considered a cure. Certainly we are in need of further information. On June 30, 1918, there were 37,352 patients in the state hospitals of New York.[129] Twenty-one thousand nine hundred and two cases were diagnosed as dementia praecox. Fifty-four of these were discharged as recovered during the year. This represents 3.2 per cent of the 1,687 cases discharged as recovered, 2.8 per cent of the 1,883 cases of dementia praecox admitted during that period (first admissions) and .2 per cent of the 21,902 cases of dementia praecox in the hospitals. The reports of the State Psychopathic Hospital at the University of Michigan show 1.19 per cent of recoveries in the cases of dementia praecox discharged during a period of eleven years. Reference is made to these discrepancies not in any spirit of criticism but for the purpose of pointing out the necessity of utilizing such facts as may be available.
There is nothing new about this suggestion. It was strenuously advocated by Louis, the founder of one of the greatest French schools of medicine many years ago. This was referred to by his pupil and admirer, Oliver Wendell Holmes, in his farewell address to the Harvard Medical School in 1882 in the following words: "The 'numerical system,' of which Louis was the greatest advocate, if not the absolute originator, was an attempt to substitute series of carefully recorded facts, rigidly counted and closely compared, for those never-ending records of vague, unverifiable conclusions with which the classics of the healing art were overloaded. The history of practical medicine had been like the story of Danaides. 'Experience' had been, from time immemorial, pouring its flowing treasures into buckets full of holes."
A determined effort has been made by the American Psychiatric Association to correlate the activities of the various state hospitals for mental diseases and utilize the great wealth of clinical material within the walls of these institutions for such studies as may promote the advancement of psychiatry. With this end in view a committee was appointed at the annual meeting at Niagara Falls in 1913 to formulate a plan for the compilation of statistical data relating to mental diseases. The conclusions reached by this committee are illustrated by the following quotation from their report in 1917: "That the statistical data annually compiled by the various institutions for the insane throughout the country should be uniform in plan and scope is no longer open to question. The lack of such uniformity makes it absolutely impossible at the present time to collect comparative statistics concerning mental diseases in different states and countries, and extremely difficult to secure comparative data relative to movement of patients, administration and cost of maintenance and additions. The importance and need of some system whereby uniformity in reports would be secured have been repeatedly emphasized by officers and members of this Association, by statisticians of the United States Census Bureau, by editors of psychiatric journals, and by administrative officials in various states. We should know accurately the forms of mental disease occurring in all parts of the country; we should know the movement of patients in every hospital for the insane; we should know the cost of maintenance of patients and the amounts spent for additions and improvements in every state hospital; we should be able to compile annually complete data concerning these and other matters, and compute rates and draw comparisons therefrom. Such data would serve as the basis for constructive work in raising the standard of care of the insane, as a guide for preventive effort, and as an aid to the progress of psychiatry."
A permanent committee on statistics has been maintained by the Association since 1913. The following statistical tables were officially adopted some years ago and are now in general use: 1. General information; 2. Financial statement; 3. Movement of patients; 4. Nativity and parentage of first admissions; 5. Citizenship of first admissions; 6. Psychoses of first admissions, types as well as principal psychoses to be designated; 7. Race of first admissions classified with reference to principal psychoses; 8. Age of first admissions classified with reference to principal psychoses; 9. Degree of education of first admissions classified with reference to principal psychoses; 10. Environment of first admissions classified with reference to principal psychoses; 11. Economic condition of first admissions classified with reference to principal psychoses; 12. Use of alcohol by first admissions classified with reference to principal psychoses; 13. Marital condition of first admissions classified with reference to principal psychoses; 14. Psychoses of readmissions, types as well as principal psychoses to be designated; 15. Discharges of patients classified with reference to principal psychoses and condition on discharge; 16. Causes of death of patients classified with reference to principal psychoses; 17. Age of patients at time of death classified with reference to principal psychoses; 18. Duration of hospital life of patients dying in hospital, classified with reference to principal psychoses.
An elaborate statistical manual fully explaining the use of these tables has been furnished to the psychiatric hospitals of the country by the Association. Since this work has been undertaken the full cooperation of the institutions of the following states has been assured: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin and Wyoming, and the District of Columbia. Practically every state hospital in the United States is now officially represented in this important movement. The success of this undertaking has been largely due to the active cooperation of the National Committee for Mental Hygiene through its Bureau of Statistics. It should receive the enthusiastic support of all who are interested in the future progress of modern psychiatry.
CHAPTER XIV
THE CLASSIFICATION OF MENTAL DISEASES
When the American Psychiatric Association first approached the problem of formulating a definite scheme for the collection of statistical data relating to mental diseases it was immediately confronted with the necessity of adopting an official classification of psychoses purely for purposes of uniformity. This undertaking, which suggested no difficulties at the outset, led to all kinds of unexpected complications and embarrassments. Classifications of "insanity" are almost as old as the terms mania and melancholia and have been given a grossly exaggerated importance by the space which for so many years has been devoted to a consideration of this subject in textbooks. This, if nothing else, appears to have been demonstrated quite clearly by the discussions of the last few years.
A review of the literature of psychiatry shows that attempts to classify the psychoses date back almost to the beginning of medical history. Hippocrates is said to have recognized three forms of mental disorders—mania, melancholia and dementia, although there is some question as to his having used those terms in accordance with their present significance. Celsus[130] also described three forms of insanity. The first, which was accompanied by febrile symptoms, he termed phrenitis. The second was characterized by sadness and caused by black bile. The third was accompanied in some cases by false images, while in others the whole mind or judgment was impaired. The Roman law divided the dementes or mad into two classes, the excited or violent (furiosi) and those deficient in intellect (menti capti). Aretaeus[131] discussed mania, melancholia and dementia, apparently regarding them as all manifestations of some one disease process. Melancholia, he said, "does not affect all the faculties of the mind; the patients are sad and dismayed; they are without fever." He described it as only an initial stage of mania. Caelius Aurelianus[132] did not regard melancholia as a form of insanity, "from which disease it differs in that the stomach chiefly suffers, while in Madness it is the head." Galen in his writings referred to amentia or dementia, imbecility, mania and melancholia.