Psychic Symptoms and Clinical Manifestations

Hair-pulling Patient

Embroidered Handkerchief

Peculiar Stocking (Catatonia)

Drawings (Metamorphoses)

Senseless Drawing

Queer Drawing

Normal Finger Movement

Simple Finger Movement in Catatonia (a)

Simple Finger Movement in Catatonia (b)

Simple Finger Movement in Catatonia (c)

Simple Finger Movement in Catatonia (d)

Normal Rhythmical Finger Movements

Rhythmical Finger Movements in Catatonia

Temperature Chart at the End of Life of a Catatonic Patient

Body Weight in Catatonic Stupor with Dementia

Body Weight in Catatonic Excitement

Body Weight in Alternation of Stupor and Excitement with Dementia

Fluctuations of Body Weight at the Commencement of Dementia Praecox

Fluctuations of Body Weight in Periodic Excitement

Stuporous Patient Lying on the Edge of the Bed

Finger Contracture in Catatonia

Stuporous Patient

Expression of Face in Catatonic Stupor (a)

Expression of Face in Catatonic Stupor (d)

Nasal Stopper of a Paranoid Patient

Ornamented Paranoid Patient

Hopping Patient

Patient in Distorted Attitude

Patient Continually Holding her Head

Nerve Cells surrounded by Glia Nuclei x 484

Fibrinous Granules in Glia Cells x 484

Illustrations

Fig. 39. Normal Nerve Cells with Glia Nuclei x 484

Fig. 40. Sclerotic Nerve Cells in Dementia Praecox x 484

Fig. 41. Healthy Nerve Cells X 484

Fig. 42. Highly Morbid Nerve Cells filled with Lipoid Products of Disintegration x 484

Fig. 43. Percentage Distribution of 1054 Cases of Dementia Precox at Different Ages

Idiot with Manneristic Movements

Specimens of Writing

1. Incoherence
2. Incoherence with Stereotypy
3. Stereotypy
4. Letter of a Hebephrenic
5. Writing of a Paranoid Patient
6. Writing of the Same Patient Seven Months Later
7. Paraphrenia Phantastica x §

Introduction. The Endogenous Dementias

A series of morbid pictures are here brought together under the term “endogenous dementias” merely for the purpose of preliminary inquiry. Their clinical relations are not yet clear, but they all display two peculiarities, that they are in the first place, so far as can be seen, not occasioned from without but arise from internal causes, and that secondly, at least in the great majority of cases, they lead to a more or less well-marked mental enfeeblement. It appears that this form of mental weakness, in spite of great differences in detail, exhibits many features in common with other forms of dementia, such as are known to us as the result of paralysis, senility or epilepsy. For this reason I have hitherto described under the one name, dementia praecox, the morbid pictures under consideration. Bleuler also has taken them together in his “group of the schizophrenias,” without trying to make a further division of this group. I consider it an open question whether the same morbid process is not after all the cause of all the different forms, though differing in the point of attack and taking a varying course. It appears to me expedient at the present stage to separate out a number of these clinical pictures from the domain of dementia praecox, which in any case is very extensive. Nevertheless it is dementia praecox which we must take as the first division of the endogenous dementias to be reviewed.

These clinical pictures referred to differ considerably in one direction or another from the current conceptions of dementia praecox. It would perhaps have been possible to carry this separation still further, and, for instance, allow a separate place also to the forms which have a periodic course, or which lead to confusion of speech. Meanwhile this has not been done, and therefore, to begin with, only those forms have been singled out and placed together subsequently which are distinguished in their whole course by very definite manifestations of peculiar disturbances of intellect while lacking enfeeblement of volition and especially of feeling, or at least such symptoms are only feebly indicated. It seems to me that the term “paraphrenia,” which is now no longer in common use, is in the meantime suitable as the name of the morbid forms thus delimited which are here by way of experiment brought together.

Chapter I. Dementia Praecox

Dementia praecox consists of a series of states, the common characteristic of which is a peculiar destruction of the internal connections of the psychic personality. The effects of this injury predominantly affect the emotional and volitional spheres of mental life. To begin with, the assertion that this is a distinct disease has met with repeated and decided opposition, which has found its strongest expression in the writings of Marandon de Montyel and of Serbsky. But even though in many details there are profound differences of opinion, still the conviction seems to be more and more gaining ground that dementia praecox on the whole represents a well characterised form of disease, and that we are justified in regarding the majority at least of the clinical pictures which are brought together here as the expression of a single morbid process, though outwardly they often diverge very far from one another.

The objections have been directed even more against the name than against the clinical conception. I got the starting point of the line of thought which in 1896 led to dementia praecox being regarded as a distinct disease, on the one hand from the overpowering impression of the states of dementia quite similar to each other which developed from the most varied initial clinical symptoms, on the other hand from the experience connected with the observations of Hecker that these peculiar dementias seemed to stand in near relation to the period of youth. As there was no clinical recognition of it, the first thing to be done for the preliminary marking off of the newly circumscribed territory, was to choose a name which would express both these points of view. The name “dementia praecox,” which had already been used by Morel and later by Pick (1891), seemed to me to answer this purpose sufficiently, till a profounder understanding would provide an appropriate name.

It has since been found that the assumptions upon which the name chosen rested are at least doubtful. As will have to be explained more in detail later, the possibility cannot in the present state of our knowledge be disputed, that a certain number of cases of dementia praecox attain to complete and permanent recovery, and also the relations to the period of youth do not appear to be without exception. I certainly consider that the facts are not by any means sufficiently cleared up yet in either direction. If therefore the name which is in dispute, even though it has been already fairly generally adopted, is to be replaced by another, it is to be hoped that it will not soon share the fate of so many names of the kind, and of dementia praecox itself in giving a view of the nature of the disease which will turn out to be doubtful or wrong.

From this point of view, as Wolff showed, a name that as far as possible said nothing would be preferable, as dysphrenia. The name proposed by Evensen “amblynoia,” “amblythymia,” further the “demenza primitiva” of the Italians, or the one preferred by Rieger, which meanwhile has certainly been already used in a narrower sense, “dementia simplex,” might also be taken into consideration. Bernstein speaks of a “paratonia progressiva,” a name that would suit only a part of the observed cases. Other investigators accentuate the peculiar disturbance of the inner psychic association in our patients and call the disease “dementia dissociativa,” “dissecans,” “sejunctiva” or with Bleuler “schizophrenia.” It remains to be seen how far one or other of these names will be adopted.

Chapter II. Psychic Symptoms

The complexity of the conditions which we observe in the domain of dementia praecox is very great, so that their inner connection is at first recognizable only by their occurring one after the other in the course of the same disease. In any case certain fundamental disturbances, even though they cannot for the most part be regarded as characteristic, yet return frequently in the same form, but in the most diverse combinations. We shall therefore try to give a survey of the general behaviour of the psychic and physical activities before we describe the individual clinical manifestations of the disease.

Perception of external impressions in dementia praecox is not usually lessened to any great extent as far as a superficial examination goes. The patients perceive in general what goes on around them often much better than one would expect from their behaviour. One is sometimes surprised that patients to all appearance wholly dull, have perceived correctly all possible details in their surroundings, know the names of their fellow patients, and notice changes in the dress of the physician. By more accurate observations, however, such as were carried out by Busch and by Gregor, it becomes evident that the extent and especially the trustworthiness of perception are decidedly decreased. This is chiefly so in the acute phases of the malady, and then again in the last periods of its course. It was specially striking in the experiments of Busch to find that the patients usually made, along with a few correct statements, a great many wholly false ones. For instance, in the perception of letters they uttered repeatedly the same arbitrary series or sometimes parts of the alphabet. It was evident that they could not make the effort to retain and to reproduce what they really saw; instead of this they named at random whatever happened to occur to them.

Attention

This behaviour is without doubt nearly related to the disorder of attention which we very frequently find conspicuously developed in our patients. It is quite common for them to lose both inclination and ability on their own initiative to keep their attention fixed for any length of time. It is often difficult enough to make them attend at all. The patients do not look up when spoken to, and betray neither by look nor by demeanour in any way that they are sensitive to external impressions. Although this is so, they have perhaps perceived all the details, but have not experienced any real internal appreciation of their significance. Sometimes in cases of profound stupor or in many other insane states it is no longer possible, even by the strongest stimulus, to force the patients to show any interest.

But the patients do not take any notice of what they may perceive quite well, nor do they try to understand it; they do not follow what happens in their surroundings even though it may happen to be of great importance for them. They do not pay attention to what is said to them, they do not trouble themselves about the meaning of what they read. On this depends what was observed by Ossipow in some of the patients, “photographic” reading, the thoughtless repetition of what is printed with all the signs of punctuation. Further there is seen the tendency of groups of patients, when they transcribe to copy carefully all mistakes, corrections, interpolations, and marginal notes. In psychological experiments the patients cannot stick to the appointed exercise; they feel no need to collect their thoughts in the appointed manner, or to reach a satisfactory solution. Perhaps the experience related by Dodge and Diefendorff, that patients do not usually follow a moving pendulum continuously, as normal persons do, but intermittently and hesitatingly, may be explained by a similar disorder of attention.

With this loss of capacity to follow a lead is connected a certain unsteadiness of attention; the patients digress, do not stick to the point, let their thoughts wander without voluntary control in the most varied directions. On the other hand the attention is often rigidly fixed for a long time, so that the patients stare at the same point, or the same object, continue the same line of thought, or do not let themselves be interrupted in some definite piece of work. Further it happens that they deliberately turn away their attention from those things to which it is desired to attract it, turn their backs when spoken to, and turn away their eyes if anything is shown to them. But in the end there is occasionally noticed a kind of irresistible attraction of the attention to casual external impressions. The patients involuntarily introduce into their speech words that they have heard, react to each movement of their neighbours, or imitate them. Leupoldt describes patients who instinctively had to touch or count objects as they came within their field of vision. On the disappearance of stuporous conditions a distinct inquisitiveness sometimes appears in the patients: they surreptitiously watch what happens in the room, follow the physician at a distance, look in at all open doors, but turn away if any one calls them. We shall later see that all these disorders of that inner activity of volition, which we call attention, represent only partial manifestations of general morbid changes in the processes of volition.

Hallucinations

Sensation is very often profoundly disordered in our patients as is evident by the occurrence of hallucinations. They are almost never wanting in the acute and subacute forms of the disease. Often enough they accompany the whole course of the disease; but more frequently they gradually disappear, to reappear more distinctly from time to time in the last stages. By far the most frequent are hallucinations of hearing. At the beginning these are usually simple noises, rustling, buzzing, ringing in the ears, tolling of bells (“death-knell”), knocking, moving of tables, cracking of whips, trumpets, yodel, singing, weeping of children, whistling, blowing, chirping, “shooting and death-rattle”; the bed echoes with shots; the “Wild Hunt” makes an uproar; Satan roars under the bed.

And then there develops gradually or suddenly the symptom peculiarly characteristic of dementia praecox, namely, the hearing of voices. Sometimes it is only