CHAPTER XIIIDEMENTIA 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 mechanismsand 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 characteristicfeatures 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 characteristicdestruction 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 aliveor 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, gaverise 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 bycrouching. 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 byHoch[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 himselfpregnant, 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 apreliminary 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 depressiveor 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 delusionsand 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 hundredand 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 importantsmaller 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 prominenceof 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 asfollows:—
TypeNumber of CasesPercentageParanoid357958.34Catatonic4687.63Hebephrenic146323.84Simple62510.19
In Massachusetts in 1917-18-19 there were 2,921 cases, distributed asfollows:—
In a group of nineteen other institutions there were 3,184 cases, asfollows:—
We have thus a total of 12,240 cases, a composite group classified according to types asfollows:—
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 followingtable:—
Age GroupPercentageUnder 15 years.215 to 19 "7.820 " 24 "20.125 " 29 "22.030 " 34 "16.635 " 39 "13.540 " 44 "8.445 " 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.