In 1838 Esquirol and Morel discussed whether the weak- mindedness that sometimes supervenes in youth was acquired or constitutional; this condition Pinel had noticed in 1809. Schneider, in his voluminous discussion of the neuralgias of puberty in 1842, declared that the involutions which belong to old age might occur earlier, but in a long article of Hecker's ^ in 1 87 1, on the basis of fourteen cases in his own asylum at Gorlitz, we have the first description of a mental disease pecul- iar to adolescence, for which he proposed the name hebe- phrenia, or the insanity of puberty. He assumed that in a disease so mild, relatively few cases needed asylum treatment, and those few are seen there only in the later stages. As the symptoms are so protean, it was not strange that its features were not very exactly defined or that its existence as a morbid entity especially in other lands was regarded as one of the most questionable products of the German school of clinicians. Hecker conceived it as a psychic crippling that tended strongly to eventuate in some degree of imbecility, but in other respects he found it hard to distinguish between what was general in its nosology and what was due to individual difference of char- acter. Moreover, the symptoms are not stationary, but all rapidly progressive toward either recovery, or, more commonly, to psychic decay. He sought to connect its abnormal manifes- tations with the ordinary phenomena of the Flegel or Lummel- jahre of boys and the BacMsch age of girls with its fanaticism, romanticizing, overtension, and superlativeness. At first there was crass rawness, angularity of thought and movement and a dissociation that threatened the integrity of the ego, and later, at the age of eighteen or nineteen, came a tendency to collect and concentrate. The strife of opposite moods leads to dys- thymia or else to a passion for simulation, which is the easiest form of the coexistence of two different states.
In another epoch-making work, which has ever since and especially in the last few years been much discussed by German clinicians, Kahlbaiim ^ described a symptom group which he * Klin, Abhand. Ueber psych. — Krankh. Heft I. Berlin, 1874.
268 THE PSYCHOLOGY OF ADOLESCENCE named catatonia, or the insanity of tension, and illustrated its various phases by twenty-six cases. He distinguished it from atonic melancholy, some phases of which resemble it, in that the depressive is prone to be followed by an excited stage, and there is danger of terminal psychic impairment. Sometimes thought stagnates, or there is a rapid flux of ideas, incessant repetitions, use of diminutives, patheticism, a strained intellectual effort, religious exaltation, etc. He thought it related to the preach- ing mania found among the convulsionaires described by Cul- meil,Leubuscher,and Jessen,and found it most common among the children of teachers, and often associated with sexual abnor- malities; he also thought that it was most frequent from the dawn of puberty to early middle life, and that heredity was a less dominant influence in its causation than in most other forms of psycho-neural disease. The characteristic features of pro- nounced cases are an immobility that resists efforts to produce passive movements and the state of waxy flexibility character- istic of catalepsy. In this state, repetition of movements, or in the acute form, of words often occurs, and monotony or motor inhibition is very typical.
For years, while alienists often referred to the subject, little additions were made to the knowledge of these psychoses. In 1880 Fick ^ urged that hebephrenia is a disease of degener- ation and that all affected by it are more or less idiotic. It may be latent during infancy and crop out only when more activity is demanded. The process of renewal of the ego that then takes place is the first serious strain to which the psycho- physical organism is subjected. It differs from other mental diseases, all of which may occur at this age, in being an arrest of development caused by a degenerative basis, and we may conclude that wherever there is hereditary mental defect, hebe- phrenia is the most common of all psychic diseases. Save in the absence of characteristic cramp it differs little from cata- tonia and verbigeration. Favorite special phrases, obstinate silence, peculiar attitude, refusal of food are common to both; but the latter is often curable, the former is almost hope- less.
' Beitrage ztir Kentniss des Jugendirrcseins. AUg. Zeits. f. Psychiatric, 1880, DISEASES OF BODY AND MIND 269 During the tumult of the first stages of puberty, which often threatens decomposition of the personaHty, and before the new orientation, the psycho-physic organism is pecuharly sensitive. The critical faculties are often hardly able to supply reductives of extravagant impulses or of visions, etc. Ideas flow rapidly but are very superficial, and so great is the vulnerability, that outside influences which would be ordinarily healthful, may break up the slow progress toward reorganization and leave their mark in exaggerated religiosity, or paranoeic symptoms and perversions of many kinds. Especially in natures of mor- bid heredity, the soul seems to lapse to a lower plane and ordi- nary prudence and judgment are superseded. Clouston said that if fifty such individuals were on a savage island, they would not sow or reap and would die of hunger.
Seppelli ^ found that out of 6,000 insane only 400 cases, or less than seven per cent, became so between twelve and twenty- two years of age. For these he laid great stress upon heredity, particularly from the mother, and also upon precocious mental work and emotional strain. He also found that melancholia was rarer than mania, but that such cases frequently took on a circular and periodic character, and easily passed to stupor or even dementia. There were frequent signs of degeneration, perversions of the ethical sentiments, some cases of hysterical and moral insanity, but none of Kahlbaum's hebephrenia.
Hammond ^ thought puberty a more efficient cause of in- sanity in girls than in boys. While the latter have no sudden physical sign like menstruation to mark the advent of puberty, he judged that delayed spontaneous emissions in rare cases may be like a delayed first period in girls, a cause of mental alienation. He opined " reasoning mania " to be most com- mon in boys of this age. The subject is ready with specious excuses for bad conduct. He runs away, is spied on, thinks every woman is in love with him. Emminghaus ^ held that hereditary forms of insanity most frequently develop between beginning puberty and the twentieth year; he said that girls * Delia psicosi della puberta. Atti del V. Congresso della Soc. Fren. 1886, p 270 THE PSYCHOLOGY OF ADOLESCENCE inherit it most often, and that while they are most commonly affected by the insanity of the mother, they are more intensely influenced by it in the father than are boys. In girls he thinks melancholy more common and that it easily develops under proper conditions into acute nostalgia, and religious and moral perversity. Maudsley ^ described as a common trait of this period the craving of something objective to attach to, which inclines the mind to idealize uftfit persons, or even to create imaginary ones. Girls are most prone to it because the affective overtops the intellectual life. Sex organs are larger and more dominant, and woman's range of activity is more limited, society insists on more conventionalities and restrictions, and their periodicity constantly obtrudes this part of their natures. Pertness, self-conceit, and caprice are largely automatic, so that they are only "involuntary wilful." Dr. Campbell Clark^ agrees with Trousseau that chlorosis is a nervous disease, originating at puberty, that anemia and menstrual irregular- ities are sequential to it, and that it colors nearly all the in- sanities of early womanhood, and distinctly diminishes sexual feeling. Regis and Berkhan thought pubertal insanity more often depressive than maniacal, and Levinstein thinks puberty a frequent cause of melancholy in females, and that at this period and in senescence the latter sex predominates, while in advanced age both are equally liable. Blanford and Clouston held mania far more common at puberty than melancholy.
Out of 1,800 insane, Clouston^ found 230 between four- teen and twenty-five years of age; 49 between eighteen and twenty; 157 between twenty-one and twenty-five years of age. Fink* reported that of 1,892 inmates of the Wurzburg Hos- pital 228 were under twenty-nine, 12.5 per cent males and 11.5 per cent females. Cullerre ^ found in France that 4.7 per cent of all were between fourteen and twenty, and 8.8 per cent be- tween twenty and twenty-five. Hagen's ^ figures on the age of the first attack of insanity were as follows: * Pathology of Mind, p. 449.
'Journal of Mental Science, 1888, p. 385.
■Alienist and Neurologist, 1892. Quoted from Wille, pp. 403-40$.
* Beitr'age zur Kentniss des Jugendirreseins, Bd. 2.
* Traits pratique, Paris, 1890. • Psychiat Untersuchungen, 1876.
DISEASES OF BODY AND MIND Inmates.
16 Males.
IX Females.
Total, 27.
25 7 32 79 90 "5 64 All of these tables show a marked increase during puberty. The danger is always more grave if the accented physical symp- toms are severe, as bodily weakness, palpitation, headache, chorea, irregular menstruation. Females are on the whole more disposed than men because the changes are greater and because nutritive complications like anemia and chorea are more common. The great effect of heredity is shown by Hagen, who estimates that of cases inheriting mental abnor- malities forty-two per cent of all first occur between sixteen and twenty. Savage holds that while psychoses are readily transmitted, if those who inherit them reach puberty safely they are more likely to recover than those attacked for the first time at this age without heredity. Too strict or too negligent education before the age of personal responsibility, overwork with the brain, which tends to overlabile equilibrium, are as bad for the cultivated as abnormalities of nutrition are for the lower classes, and are also prominent causes. The state of overirritability of brain often produced by high pressure can weaken all bodily functions and arrest growth. Matusch^ holds that grave symptoms at puberty portend serious and per- haps similar complications at senescence. Regis thinks that puberty is less dangerous in girls, because when once regularly established menstruation has a curative effect that makes dis- tinctly for sanity. Circular and periodic psychoses usually be- gin in these years, and Wille thinks seventy per cent and Clouston, sixty-six per cent recover. Brosius urges that these pubertal abnormalities may mark a fortunate episode during which earlier hindrances to psychic development may be obviated. Changes may be advantageous and permanent. Many of these psychoses are very fugitive and the recupera- tive power is greater than in later life.
THE PSYCHOLOGY OF ADOLESCENCE A good estimate of age liability was lately compiled on a basis of 1 16 men and 107 women as follows: ^ 31 28 27 95 26 25 n 28 20 19 18 ^^ 10 10 7 6 -J 6 ■^ 4 4 L_ ^~ 2 t—i 1 n n □ □ 0 Men Women Schule,^ on the other hand, not only doubts the existence of this disease, but still more that of a katatonic motility neurosis and would preserve the adjective form of the word as a col- lective or heuristic term for many kinds of symptoms of motor stimulus and inhibition. It also lacks a psychic character of its own such as, e. g., epilepsy, hysteria, etc., have, from which other troubles can be clearly distinguished.
Marro ^ tabulated the age of the first appearance of in- V sanity in 1,649 niales and 1,257 females in the asylum at Turin during the decennium i886-'95, and presents his results in the table on p. 273, in which, however, he included idiots and cre- tins, and all forms of arrested or perverted development. The age of most rapid increase is from about sixteen to twenty, and at twenty-five the age of greatest liability is already passed.
Some special forms of insanity are particularly prominent at this age. The epileptic neurosis tends to discharges of ex- plosive or fulminating violence, which by undue forcing of * Gustav Aschaffenburg: Die Katatoniefrage. Allg. Zeits. f. Psychiatric, 1897, ' Zur Katatonie-Frage. Ibid, pp. 512-552. See also Nolan, who accepts Aschaffenburg. Jour, of Mental Science, Oct., 1892, p. 531.
DISEASES OF BODY AND MIND nascent nerve tracts do great damage to unstable nerve sys- tems. In its grave forms it is a kind of universal spasm and much depends on the momentum of the discharge, whether it originates in the higher areas and begins with loss of conscious- ness, or whether it begins in more basal and reflex centers and spreads upward to these later. There are, therefore, as many- epilepsies as there are seats of the difficulty, and in its milder forms it shades down to a yawn, hiccough, sneeze, momentary shudder, a faint lapse of consciousness seen in petit nial, etc. In the preparoxysmal stage there are various symptoms — gloom, , Males ■ Females >« //Age / "^ Under 10 restlessness, dread, confusion, delusion, and just before the fit comes various aurae or warnings, the nature of which is of great significance. There may be flashes of light, subjective sensa- tions of touch, taste, smell, or hearing, or of organic life. After the convulsion there is a stage of exhaustion and confusion, and hysterical symptoms are often complicated throughout. In the epileptic state instincts, impulses, or automatic acts, often compHcated, may appear without full consciousness in sub- sequent memory, and this makes the medico-legal relationships of the disease difficult. Scientifically, epilepsy is one of the most interesting and instructive of diseases, still more so as it is easy to feign. ^ Of fifty-eight cases of epilepsy observed by Sieveking,^ forty were first developed before the age of twenty-one, and he * For a good characterization of this state, see Bevan Lewis's Text-Book of Mental Diseases, p. 221.
* On Epilepsy, etc. London, 1858, p. 91.
19 THE PSYCHOLOGY OF ADOLESCENCE says that it appears that " the greatest procHvity to epilepsy is to be found in the period of puberty, a fact upon which there is scarcely any difference of opinion among writers," although the age of greatest mortality from this cause comes a little later. Reynolds,^ from his own and other cases, concluded that " the period of first arriving at puberty is in regard to age the most powerful predisposing condition to epilepsy "; that the proclivity of females before ten was slightly greater than males; that from ten to twenty there was little difference; that after twenty-one nearly four times as many males as females were attacked; and that although no age is exempt, the probability of becoming epileptic is less each decennial after twenty. J. Langdon-Down ^ quotes approvingly West's con- clusion, that " it is usually with development of the sexual sys- tem that hysteria shows itself," and Trowbridge^ thinks it often closely associated with chorea.
Of 1,288 cases collected by nine French authorities, 486 begin between the tenth and twentieth years. Gowers's 1,450 cases were distributed as follows:* (21 cases later.)
Between ten and twenty nearly one-half of the total num- ber of cases or 46 per cent occurred. More specifically these cases when tabulated for each year show that those appearing the first year are 5^ per cent of the whole, that the number falls at three, and reaches a minimum at five. " From this there is a considerable rise at seven, the commencement of the second dentition, then a fall at eight, and from this a maximum is reached at fifteen and sixteen, at each of which 84 cases or 5} per cent of the total number occur. From this period we have a rapid fall to twenty-one, when only 22 per cent of the whole occurred," and from here on there is a general decline. The maximum number for males is at thirteen, and for females at sixteen. In the second decade the females are 18 per cent and * Epilepsy: its Symptoms, Treatment, etc. London, 1861, p. 12() et seq. 'On some of the Mental Affections of Childhood and Youth. London, 1887.
* Relations between Chorea and Epilepsy, Alienist and Neurologist, Jan., 1892, DISEASES OF BODY AND MIND 275 in the third 12 per cent in excess of the males. The maximum of hereditary cases occurred one year earher than that for non- hereditary cases. The percentage of hereditary cases distinctly declines with age. The hysteroid or coordinated form of the convulsions is greater at every age for females. With them this form reaches its maximum in the second decade and after adolescence it is about twice as frequent. Cases traceable to exciting causes are most frequent in males after ten, and of these causes fright, excitement, and anxiety are most common and mostly occur early in life, while the prospect of cure is some- what better in cases that commence under ten than in those that commence between ten and twenty. Those beginning under twenty are considerably less curable than those beginning later.^ Donath ^ seeks to establish an epileptic impulse to wander off, posiomania, and some of his most interesting cases were adolescents. A fourteen-year-old boy started off, in an epi- leptic state, seven times in three years to make long journeys, while a less impulsive girl of nineteen took money and made other preparations for such trips. Hypnosis recalled the normal consciousness. Denomme ^ has given the literature of such cases.
Bruns holds that while in young children hysteria is about as frequent among boys as girls, that " the nearer puberty ap- proaches the more girls preponderate." * The childish form of hysteria is most common between seven and fourteen. That it is not a disease of overculture, he thinks proved because the most severe cases are found in country children. This has especially been the case in the epileptoid and also in the conta- gious forms. In its causation, most writers, and especially those of the Charcot school, have perhaps assigned too pre- dominant a role to heredity both for its direct and homolo- gous forms. However, as Clouston thinks, much depends on ' Der epileptische Wandertrieb. Arch. f. Psychiatric, 1899.
' Des impulsions morbides k la deambulation au point de vue m^dico-l^gal.
* Die Hysteria im Kindesalter. Samml. zwangloser Abh. der Nerven und Geis« teskrankheiten. 1897, vol., p. 26.
THE PSYCHOLOGY OF ADOLESCENCE whether we "go on Charcot's Hnes and look out for local anesthesias and irregular motor symptoms chiefly, or take in perverted conduct and character or diminished control," ab- normal feelings, etc. At or soon after puberty its character becomes more distinguishable for chorea, its provocations change in both kind and degree, and hypnotism is less helpful.
The literature and history on early symptoms of hysteria is well digested up to 1880 by Smidt ^ and Emminghaus ^ emphasizes its slight and transient forms and its relations to epilepsy and catalepsy, chorea, etc. Moreau,^ on the other hand, ascribes little influence to first menstruation, while Klein out of fifty-eight hysterical children, found all between ten and fifteen.
The age distribution of first attacks of hysteria by the two best French authorities is as follows: Landouzy.
Briquet.
Under 10 4 66 48 98 80 71 40 24 38 9 15 9 In a recent study of the dreams of hysterics and epileptics, De Santis found that those of the former were most frequently of pain, next of fear, and were less often erotic Dreams of large animals predominate, while in alcoholism those of tiny ani- mals or microzooscopic dreams were most frequent. With his epileptics, who are mostly men, the dreams are usually brief and simple as opposed to the complex and romantic character of those of the hysterical patients. At bottom both are regarded as determined by sex, which often rises to great prominence in dream life at puberty.
Janet finds a peculiar cerebral exhaustion frequent at puberty, which he describes as " a special moral weakness con- sisting in the lack of power on the part of the feeble subject to gather and condense his psychological phenomena and assimi- ' Die Psychischen Storungen des Kindesalters. 1887, p. 276 et seq.
DISEASES OF BODY AND MIND 277 late them to his personality." He summarizes his views as fol- lows: " There is, above all, an age which in this respect is par- ticularly critical — the age of puberty. We speak here not of physical puberty, which has, however, a great influence, but of a state which comes a little later and which might justly be called moral puberty. It is an age slightly variable according to countries and surroundings, when all the greatest problems of life present themselves simultaneously; the choice of a career and the anxiety about making a living; all the problems of love, and for some the religious problems. These are preoc- cupations which invade the mind of young people and com- pletely absorb their feeble power of thought. These thousand influences manifest a psychological insufficiency which remains latent during the less difficult periods. In a mind predisposed by hereditary influences, this psychological insufficiency de- velops, takes a special form, and presently manifests itself by an ensemble of symptoms which we call hysteria." ^ Although the primitive meaning of the word hysteria has much changed, he would preserve the word, because " it has so great and so beautiful a history." He conceives it as mental diseases of brain fag characterized by reduced nutrition and various moral symptoms, especially weakened synthesis, a contracted field of consciousness, and a tendency to complete and permanent divi- sion of personality. This weakened synthesis favors the devel- opment of parasitic ideas which manifest themselves in many forms, sometimes apparently only physical.
Janet finds that obsessions and psychasthenias manifest themselves most frequently between sixteen and twenty, al- though his predecessors in these statistics found that the years from eleven to fifteen were most liable. All authors admit the enormous influence of puberty upon all troubles of this class. Du Saulle held that those who were hereditarily predisposed could not go through puberty without grave dangers. Falret held that very frequently something like a bifurcation then took place, some suffering arrest and tending toward debility, and another class toward reasoning manias and phobias. Baillarger declared that doubting mania almost always made its debut at the epoch of puberty. Janet adds that the development of the monthly periods with the female is often marked by phobias *The Mental State of Hystericals, by Pierre Janet. N. Y., 1901, p. 526.
2yS THE PSYCHOLOGY OF ADOLESCENCE and obsessions.^ Many young people at this age lose courage, live as if a veil were spread over their entire personality, grow indifferent, apathetic, easily fatigued, and agitated. Some of Janet's cases show very clearly the dangers either of precocity or . of unwonted delay of puberty. In the former case there is sometimes terror at the new physical developments peculiar to this age, attempts to obliterate every trace of them and aversion to every thought of marriage, while in cases of abnormal retar- dation, agitation and anxiety predominate.
Sexual psychoses are plainly coming to play a greatly in- creased role in the psychology of the present and the future. They imply unique coordination between the cerebrospinal and the sympathetic system, and involve both in all their interre- lations as do no other phenomena, are especially prominent in the sexual epochs of adolescence, marriage, menopause, etc., and are rejustifying the lately suspected appropriateness of the etymology of the term hysteria. The work of Gattel, Mobius, Breuer, Freud, Scott, Ellis, Moll, Geddes, and many others show the wide irradiation of this function into normal and abnormal psychic life. Although we can not agree with Mobius that all hysteria is of ideational origin, much of it doubtless is, and much depends upon the balance between overexcitation and repression of sexual functions. Far more than has hitherto been suspected depends upon the maintenance of normal tension in this sphere, and nothing is so vicarious, protean, and poly- morphic in its expressions. Psychic lesions here readily be- come physical lesions, and vice versa. Mental pain becomes acute and local neuralgia, moral disgust becomes nausea, anx- iety becomes contraction or cramp if shunted downward, and so 1/ through a long list of psycho-physic kinetic equivalents which with all their wealth of symbolism is yet to be fully worked out. Such metamorphoses constitute the mystery of the domestic de- mon of hysteria, and account for many adolescent symptoms. j Strong and sudden impressions amounting to psychic lesions 1 or traumata, especially in women, particularly in this instable 1 period, and above all in the sex sphere, are thus liable to I entail long, very complex, and obscure results. Prompt, normal, ^ Les Obsessions et la Psychasthenic, par P, Janet. Vol. i, p. 613. See also Vol. 2, by F. Raymond and P. Janet, Paris, 1903, pp. ^^, 253, 370, 470.
DISEASES OF BODY AND MIND 279 and adequate reactions to such experiences there is now great reason to beHeve are often necessary to prevent such morbid transformation. Excessive stimuH must be reacted on and their effects must stream out in some normal channel, or else they will become seated and act as a foreign body with long persistence and transference, and gradually, when perhaps lapsed almost beyond the reach of recall, accrete into a sub- conscious, nascent, alien kind of personality, subcharged it may be with emotional and motor intensity. At this stage they may break out in many kinds of anomalous discharges of accumulated morbidities of a hysteroid or epileptoid nat- ure, while the ideational factors are more or less hMden from ^consciousness and beyond volitional control, ^Excessive re- pression may arouse a " Gegenzville " when control is fatigued, so that the patient does impulsively or imperatively the exact opposite of what is willed.