Under the name hebephrenia, Hecker, inspired by his preceptor, Kahlbaum, described a psychosis which develops by predilection at the age of puberty and which terminates in a peculiar state of mental deterioration.
Later Kraepelin extended the views of Hecker and added to this group catatonia,1 which had previously been considered an independent affection, and paranoid dementia, which included the majority of delusional states then commonly assigned to the vast and ill-defined group of paranoias. This fusion resulted in a new morbid entity: dementia prcecox.
As we shall see later on, dementia praecox cannot be defmed either by the age at which it occurs or by the rapidity with which it develops. Its specific element lies in the sum of the psychic changes, affecting the emotions, the will, and association of ideas. Generally these changes are permanent and constitute the mental deterioration which is the most common outcome of the disease. In some cases these changes may recede either temporarily or even permanently.
Dementia praecox appears in many forms that are difficult to classify. In Germany, fol owing Kraepelin, three principal forms are distinguished: hebephrenia, catatonia, and paranoid dementia. Delusional types of hebephrenia resemble paranoid dementia so closely that it is often impossible to determine to which of these groups a given case should be assigned. It seems more convenient for practical purposes to describe separately the following three forms: simple dementia praecox without delusions; dementia praecox of catatonic form; and dementia praecox of delusional form.
1 Kahlbaum. Die Kaiaionie oder das Spannungsirresein, 1894.
We shall study first the psychic and somatic symptoms that are common to all forms.
All psychic functions are not equally affected. While orientation and memory are often preserved or but little affected, attention, association of ideas, the emotions, and the reactions are always markedly involved.
These very frequently remain intact, although the appearance of the patients would scarcely lead one to think so. Many patients appear to be ignorant of what occurs about them, yet they will give rational and correct replies to questions concerning the date, their surroundings, and even the important events of the day. We shall return to this question in connection with the study of catatonia.
Like lucidity, memory is but slightly affected, at least in the majority of cases for a considerable number of years. Old impressions remain well defined, and the knowledge acquired during youth and childhood is often astonishingly well preserved. An old asylum inmate, a typical case of dementia praecox, who had been in the institution for fifteen years, was still able to name without hesitation and in their proper succession all the French rulers from the time of Clovis.
Actual occurrences impress themselves quite durably upon the memory. Many patients are able to relate events that have taken place since their commitment, and can often even name the physicians and attendants who have followed each other on the service during several years.
1 Masselon. Psychologie des dements precoces. These de Paris, 1902.
However, when the affection is of long standing it is rare for the memory not to have become impaired to some extent. Anterograde amnesia is the first to appear; the power of fixation becomes diminished. Retrograde amnesia appears later and is usually less marked. Little by little old impressions grow fainter and may even become entirely effaced.
This faculty is always weakened. Any labor requiring some degree of concentration becomes impossible.
These are sluggish and often occur without any apparent connection, giving rise to speech which may reach the extreme limits of incoherence. We have given an example of such speech.1 These incoherent phrases are uttered quietly and without the volubility which characterizes flight of ideas of the maniac. On superficial examination this phenomenon may create the impression of a profound state of dementia or mental confusion, which in reality does not exist. The patient whose incoherent speech we have quoted as an example is perfectly oriented and possesses good memory.
The affectivity and the reactions are greatly impaired from the beginning. Indifference constitutes an early and very prominent symptom of dementia precox. The patient takes no interest in anything, expresses no desires, makes no complaints. Often even hunger determines no reaction. If the patient is accidentally forgotten at meal time he evinces no surprise and makes no protest. As in all conditions of dementia, this disorder of affectivity is not a conscious one.
Occasionally, especially at the onset of the illness, this habitual state of indifference is interrupted by explosions of anxiety or of anger, for which there is often no apparent cause.
A priori the emotional indifference of dementia praecox would be expected to lead to a reduction of the voluntary and normal reactions. Observations upon patients show this, indeed, to be the case.
1 See page 51.
On the other hand, the automatic reactions are often exaggerated. They manifest themselves under all the forms described in Part I of this Manual: pathological suggestibility, negativism, impulsiveness (stereotypy of movements and of attitudes, verbigeration, grimaces, unprovoked laughter, etc.).
When, as is most often the case, the disorder of attention, the sluggish formation of associations of ideas, and the impairment of affectivity and of the will, or in other words, when all the symptoms which we have described above have become definitely established, we have mental deterioration.
The degree of deterioration is variable. In some cases it apparently affects the psychic functions to so pronounced a degree that all mental activity seems to have disappeared, and, from this point of view, the patient cannot be distinguished from an idiot or from an advanced general paralytic. Such cases are exceptional, and often enough the dementia is much less complete than it appears to be from a superficial examination, as is shown by the following case:
Theresa C, formerly a school teacher, at present (1905) a patient at the Clermont Asylum, aged thirty-four years. The disease came on at the age of twenty-five. For several years this patient has lived in a state of apparently complete unconsciousness, incapable of carrying out the simplest commands or answering the most elementary questions. The facial expression is silly. The patient spends most of her time sitting in a chair or wandering about the court-yard, talking incoherently, her utterances showing marked stereotypy. The word "mystery" keeps recurring in the manner of a Leitmotiv: "To digest the nature of mystery, Claude of mystery, Matthew of mystery, Joseph of mystery. It is a conflagration, it is a petticoat, it is an oblation, resurrection, when will you wake up like the brutes. Mystery, of mystery, forty-eight of mystery," etc. Totally indifferent to everything, she manifests not the slightest emotion when spoken to about her family, or when offered her release. She is filthy in her habits. And yet, when a pen is put in her hand she will write disconnected words or fragments of sentences without a single orthographical error.
No example could illustrate more clearly the dissociation which characterizes dementia praecox in which total ruin of some faculties is compatible with perfect conservation of knowledge acquired previously.
These are present in all three forms of the disease, though they are perhaps most marked in the catatonic form.
The disorders of motility- consist in hemiplegias and monoplegias that are slight and of short duration; convulsive hysteriform or epileptiform seizures; and fainting spells. The contractures often observed are usually the consequence of negativism.
One must be guarded against attributing the absence of reaction to pricking, which results from negativism, to ansethesia. True disorders of sensibility are, however, far from being exceptional. They are often unilateral, as in hysteria. Other hysteriform symptoms of the same order are also encountered: tender areas, clavus, globus hystericus, etc.
Sometimes diminished or abolished, much more frequently exaggerated.
Their disorders are frequent but variable: inequality, mydriasis, sluggish reaction, the phenomenon of Pilcz, i.e., contraction of the pupils on forcible closure of the eyelids. This phenomenon is analogous to the following one, which was observed at the same time, independently, by Pilcz and by Westphal: "If the patient attempts to shut his eye while his effort is opposed by the examiner who holds the lids apart forcibly with the fingers, a contraction of the pupil takes place while the eyeball is rolled upward and outward." 2
The pupillary disorders often undergo fluctuations corresponding to those of the mental condition. We recall a case of catatonia in which the intensity of the stupor determined, as it were, the degree of mydriasis. As the stupor disappeared the pupils reassumed their normal size.
1 Serieux et Masselon. Les troubles physiques chez les dements precoces. Soc. med psych., June, 1902.
2 Pilcz. Revue ueurologique, 1900, No. 13.
Vasomotor disorders causing oedema, cyanosis of the extremities, and dermatographia are frequent. Sometimes the pulse is slowed.
The temperature may be subnormal (Kraepelin) .l
Indigestion, anorexia, and constipation are often found, especially during the acute period. The development of mental deterioration is occasionally marked by boulimia.
Sometimes there is polyuria, at other times, on the contrary, oliguria. The changes in the composition of the urine are but little known. A diminution of urea and an increase of chlorides have been found.2
We know nothing of the disorders of the secretions excepting that of saliva, which in some cases is greatly increased.
Its changes, though undoubtedly of great importance, are as yet but little known. The weight is reduced in the acute stages, but rises again during the quiet periods. Some precocious dements present a remarkable degree of corpulence.