Introduction and Overview of Dementia Praecox

DEMENTIA PRAECOX AND PARAPHRENIA

Professor EMIL KRAEPELIN of Munich

TRANSLATED BY

R. MARY BARCLAY, M.A., M.B.

From the Eighth German Edition of the “Text-Book of Psychiatry,” vol. iii., part ii., section on the Endogenous Dementias

EDITED BY

GEORGE M. ROBERTSON, M.D., F.R.C.P. (Edin.)

Lecturer on Mental Diseases in the University of Edinburgh and Physician to the Royal Asylum, Morningside

Editor’s Preface

Dementia Praecox has excited more interest and speculation than any other form of insanity in our time, with the possible exception of general paralysis of the insane. I therefore value highly the usefulness of the work that Dr Mary Barclay has done in thus bringing before English-speaking physicians a faithful translation of the views of Professor Kraepelin, who is the recognised authority on this subject. In no country has there been less inclination to accept his doctrines without qualification than in this, but so important are they, that every physician of the mind, who would keep himself abreast of modern clinical research, must be familiar with them. The present work therefore supplies a want in giving in an accessible form the complete and latest account of this subject by Professor Kraepelin. In addition, there is no other publication in the English language which deals solely with dementia praecox in all its various aspects.

Professor Kraepelin informs us that he got the starting point which led to dementia praecox being regarded by him as a distinct disease, in the year 1896. He admits “that Clouston also, who spoke of an ‘adolescent insanity,’ had evidently before everything dementia praecox in view, though he did not yet separate it from manic-depressive cases, which likewise often begin about this time.” The identity of Clouston’s “secondary dementia of adolescence” with the chief forms of dementia praecox is quite apparent to anyone reading the remarkable address on dementia which he delivered in 1888 when President of the Medico-Psychological Association. While, however, Sir Thomas Clouston regarded some of his cases of adolescent insanity as being of an unfavourable type which often ended in secondary dementia, Professor Kraepelin would regard these very cases, from their initial symptoms onward, as being examples of a distinct form of disease, namely dementia praecox. This situation therefore recalls in an interesting manner the circumstances connected with the discovery of general paralysis of the insane. Esquirol and his pupils had for seventeen years been observing cases of “insanity complicated with paralysis,” when Bayle, in 1822, boldly asserted that the symptoms of this clinical condition were those of a separate and definite disease. This hypothesis has proved true; is it too soon yet to say the same of the former?

Professor Kraepelin’s task in depicting the characteristic features of dementia praecox has not been an easy one, and even now he has not reached finality in his opinions. He is not satisfied with his delimitation of its boundaries, nor with all the sub-divisions which he has created, though he believes that his main thesis has been substantiated. Neither terminal dementia nor precocity is, however, an essential element of the clinical picture, though his reluctance to discard the former is very evident, and this masterly summary has been as a matter of fact prepared solely from observation of cases which actually became demented.

Now that general paralysis of the insane, after a century of observation and research, has yielded up most of its secrets, by far the most important practical problem facing the psychiatrist and the community, in the domain of mental hygiene, is that of dementia praecox. The patients suffering from this disease form the major part of the inmates of our mental hospitals. The heavy financial burden imposed upon the public for the treatment of the insane, resolves itself therefore very largely into the outlays needed for the lifelong care of the almost hopeless victims of this disorder. Moreover, as the disease does not directly cause death, and as such patients lead protected lives and live long, they tend to accumulate. They thus form the chief reason for the periodical necessity of enlarging our mental hospitals, and of erecting new ones. Could a study of the causes and treatment of this disorder result in its prevention or diminution, its cure or alleviation, a practical benefit to society of the most direct and valuable kind would be conferred. Such an enquiry should have the support of the Ministry of Health as this disease costs the State more than any other. How to avert this dementia continues to be the cardinal problem of psychiatry.

It is hoped that the publication of this translation will stimulate the interest of English-speaking physicians in these peculiar states of mental enfeeblement, promote further clinical observation and research, and lead to greater accuracy of diagnosis and prognosis, with a better understanding of the nature of the disease.

GEORGE M. ROBERTSON.

UNIVERSITY OF EDINBURGH, July 1919.

Translator’s Preface

As the aim of this translation is to bring the views of Professor Kraepelin, of Munich, on dementia praecox before the English-speaking members of the medical profession who may not be intimately acquainted with German, I have made it as literal as seemed consistent with readable English. Professor Kraepelin’s Psychiatry is the leading German text-book on disorders of the mind, and I therefore willingly acceded to the wish of Dr George Robertson to make a complete translation of the section on dementia praecox. This special disease still requires much elucidation, and in its study medical practitioners, educationalists, and criminologists may well work together. It is especially on the educational side that Professor Kraepelin’s observations or investigations appear to be deficient. It should not be difficult in this country to collect the required facts relating to individual cases, and to a certain extent this is being done already. When these facts are classified, much benefit should accrue to education, medical advancement, and the public welfare.

To Dr George Robertson I have to express my thanks for many useful suggestions, and to Dr Walker for the unwearying care with which he has revised the proofs.

R. MARY BARCLAY. Edinburgh, July 1919.

Contents

Introduction—The Endogenous Dementias

I. Dementia Praecox

II. Psychic Symptoms

• Perception
• Attention
• Hallucinations (thoughts heard, thought influence)
• Orientation
• Consciousness
• Memory
• Retention (pseudo-memories)
• Train of thought (loss of mental activity)
• Association
• Stereotypy
• Paralogia, evasion
• Constraint
• Mental efficiency
• Judgment
• Delusions
• Emotional dulness, ataxia of the feelings
• Weakening of volitional impulse
• Automatic obedience (catalepsy, echolalia, echopraxis)
• Impulsive actions
• Catatonic excitement
• Stereotyped attitudes and movements
• Mannerisms
• Parabulia
• Negativism (autism, stupor)
• Personality
• Practical efficiency
• Movements of expression
• Incoherence
• Stereotypy (verbigeration)
• Negativism (mutism, evasion)
• Derailments in word-finding
• Paraphasia
• Neologisms
• Akataphasia
• Syntax
• Derailments in train of thought

III. General Psychic Clinical Picture

• Blunting of emotions
• Intrapsychic ataxia

IV. Bodily Symptoms

• Headaches
• Pupillary disorders
• Tendon reflexes
• Muscular movements
• Seizures
• Grimacing
• Aphasia
• Vasomotor disorders
• Blood-pressure
• Respiration
• Secretion of saliva
• Temperature
• Menses
• Blood-picture
• Metabolism
• Changes in the thyroid
• Sleep
• Nourishment
• Weight

V. Clinical Forms

• Dementia praecox simplex
• Silly dementia praecox, hebephrenia
• Simple depressive dementia praecox, stupor
• Delusional depressive dementia praecox
• Circular dementia praecox
• Agitated dementia praecox
• Periodic dementia praecox
• Catatonia, excitement, stupor (melancholia attonita)
• Paranoid dementia praecox, gravis
• Paranoid dementia praecox, mitis
• Confusional speech dementia praecox, schizophasia

VI. Course, Remissions

VII. Issue

• Recovery, recovery with defect
• Simple weakmindedness
• Hallucinatory weakmindedness
• Paranoid weakmindedness
• Drivelling dementia
• Dull dementia
• Silly dementia
• Manneristic dementia
• Negativistic dementia
• Prognostic indications
• Death, mortality

VIII. Morbid Anatomy

• Cell morbidity
• Changes in glia
• Atrophy of medullary fibres
• Relations of the changes in the cortex to the clinical picture

IX. Frequency, Causes

• Time of life
• Engrafted hebephrenia
• Idiocy
• Dementia praecissima
• Late catatonias
• Dementia tardiva
• Sex
• General conditions of life
• Hereditary predisposition
• Injury to the germ, alcoholism, syphilis
• Personal idiosyncrasy
• External causes—over-exertion, infection, syphilis, head injuries, alcohol, imprisonment, reproduction
• Sexual life
• Auto-intoxication
• Freudian complexes

X. Delimitation

• Paranoid forms
• Catatonia
• Late catatonias
• Periodic forms
• Confusion of speech

XI. Diagnosis

• Catatonic symptoms
• Psychopathic states
• Imbecility and idiocy
• Manic-depressive insanity
• Hysteria
• Psychogenic psychoses
• Dissimulation
• Epilepsy
• Paralysis
• Amentia (confusional or delirious insanity)
• Cerebral syphilis
• Paranoid diseases

XII. How to Combat It

• Treatment of the cause (castration, immunization, excision of the thyroid), prophylaxis
• Treatment of the morbid phenomena, occupation
• Treatment by leucocytosis

XIII. Paraphrenia

• Definition and classification
• Paraphrenia systematica
• Paraphrenia expansiva
• Paraphrenia confabulans
• Paraphrenia phantastica

List of Illustrations

Fig. 1. Calculation Tests

Fig. 2. Bodily Influences

Fig. 3. Group of Schizophrenic Patients

Fig. 4. Waxy Flexibility (a)

Fig. 5. Waxy Flexibility (b)

Fig. 6. Waxy Flexibility (c)

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