scene or sacrilegious character, of being laughed at, of blushing, etc. Although neurasthenia falls chiefly in a somewhat later stage of life, not only do its symptoms very commonly begin to appear at puberty, but Binswanger,* who has up to date ' G. M. Beard. Neurasthenia. New York, 1888.
* Neurasthenia. Shattuck Lecture. Boston, 1891; and The Mental Symptoms of Fatigue. N. Y. State Med. Ass'n, 1893.
DISEASES OF BODY AND MIND 291 given the fullest exposition of it, describes a special pubertal form, which although not very frequent is more prone to de- generation. He says that neurasthenic symptoms occurring at puberty are often strongly suggestive of mental instability and imperatively call for such care as may prevent the development of actual insanity. He draws special attention to the parallel- ism between fatigue and the symptoms of neurasthenia, and thinks that the latter is overfatigue due to congenital weakness of nerves, and is peculiarly liable to become a settled diathesis during the period of sex evolution. Saville ^ thinks that al- though any age could be affected, " young male adults were slightly predisposed."
Dr. Scholz 2 characterized " pubertal weak-mindedness " as real retrogression rather than as arrested development. The latter he designated as imbecility. The former develops often rather suddenly, and without acute symptoms, in individuals of previously fairly good health. It may be attended by much psychic irritability of expansive form resembling hebephrenia, or it may have a more depressive and paranoeic character. It can proceed to any stage of mental decay and may occur without hereditary predisposition. What cerebral changes accompany it is unknown, but puberty is the causal occasion or basis to which this psychosis owes many of its peculiar symptoms.
Again, that the insanity of doubt, which Legrand du Saulle,^ Kovalevski,* Cowles,^ and many since have studied under various names, with its Grubelsucht, hyperscrupulosity, impera- tive and oft-repeated repetition of the commonest acts, miso- phobia, oiko-, claustro-, agara-, acu-, sito-, and all the score of instinctive phobias, etc., is characteristic of the later stages of adolescence there can be no question, although age statis- tics have been strangely neglected by the authorities. Bail- larger,^ however, collected twenty interesting cases of one form ' Ueber Pubertalsschwachsinn. Allgemeine Zeits. f. Psy. u. Psy. Grcrichtl.
* La Folie du Doute. Paris, 1875.
* Insistent and Fixed Ideas. Am. Jour, of Psy., Feb. 1888, vol. I, pp.
* Folio du doute. Arch. Clin, des Mai. Mentales. Paris, i88i.
292 THE PSYCHOLOGY OF ADOLESCENCE of a malady thus connected which is prone to make its debut at puberty. We can not here consider all disorders. It is probably not too much to say that very nearly if not quite every psychosis or neurosis of defect or excess, if not manifest before puberty, will appear or at least begin its incubation at this time; these beginnings the statistics of insanity always place too late because the early stages are not seen by physicians and appear at institutions still later during the ephebic period. If they do not, it can be said that the tension of this period is safely and healthfully passed and maturity well achieved; that then there follows a stage of relative immunity during which much can with impunity be both done and endured, and which only exceptional strain, shock, organic lesion, or other external non-infectious cause or else early senescent decline, can destroy.
At variance with the older view,^ there is now some indi- cation that general paralysis of the insane has a distinct tend- ency to begin between the ages of thirteen and sixteen, al- though its curve rises higher at a later age. Since the valuable monograph of Alzheimer,^ who collected forty-one well-de- scribed cases, Liihrmann, Infeld, Hoch, and Stewart ^ have col- lected many more. Most of these, of course, but not all, are asylum cases. They were not idiots or infantilists, but had de- veloped intelligence, and retrogressed toward dementia as the disease progressed. From fifteen to sixteen is the most com- mon age of onset. This dreaded disease makes puberty a critical period, especially if there is any syphilitic or luetic taint. The sexes seem, so far as an opinion can be based on the above limited number of cases, to be about equally liable — a fact which differentiates the adolescent form of this disease in a very marked manner from the vast preponderance of cases among males in adult life. Although some ninety per cent of all are syphilitic, this taint is nearly always inherited and not acquired. The psychic symptoms are progressive dulness, apathy, and perhaps stuporose states in children who have been normal or • Alzheimer: Die Friihform der Allg. Prog. Paralysis. Allg. Zeits. f. Psych., • See especially P. Stewart: General Paralysis of the Insane during Adoles« cence. Brains. Spring Number, 1898, p. 39 gf seq.
DISEASES OF BODY AND MIND 293 even supernormal in intelligence. In adolescents the grandiose ideas so characteristic of this disease in adults are absent, and delusion and hallucination if they exist at all are mild and " never of the extravagant type met with in adults." Growth and especially sexual devlopment is arrested, and there are con- gestive attacks and perhaps the fibrillary tremors of tongue, face, and fingers, with slovenly, slurring articulation, weakness of limbs, an ataxic or sometimes a spastic gait. The post- mortem brain changes do not differ from those found in adults. Maudsley's conception of adolescent insanity ^ rests on the general conception that reason is an apparatus of restraint, superposed upon intense and brutal impulses, and that in char- acteristic outbreaks this curb is broken, and all the bonds be- tween the many wild factors of our nature which constitute the ego are also ruptured, so that all that later ages of civilization and even higher barbarism have superposed is gone and de- humanization ensues. All the high social reflexes being lost, diffidence and reserve give place to pertness, self-will, turbu- lence, aimless iteration, etc. This is illustrated by tickling and by the sex act, both of which begin in volition and go on to convulsion and orgasm, as they pass from cerebral down to spinal control. The progress from capricious acts to catalepsy is analogous. The " jumpers," who when suddenly told to jump or seize a hot iron or a friend's throat, or do any other absurd or even criminal act, obey convulsively and on the instant: frights that result in fascination and perhaps imitation of the cause, especially if it is with animals, illustrate the same bou- lepsy. Again, from each act of the body impressions are pour- ing in upon the brain, and the muscle sense should give tone to the will; but among the insane its disorder is connected with the sense of motor impotence. The abdominal organs normally contribute an euphoria of a peculiar intensity, and no one with abdominal disease can be cheerful, while those with thoracic complaints commonly are so. The sex organs, too, contribute their own contingent to the brain and to the sum of somatic feelings; and the latter respond to every change of the former.
The tumultuous changes which occur in pubescent insanity are conditioned by changes either of unusual amount or rapidity in * See Pathology of Mind, pp. 145 and 387.
294 THE PSYCHOLOGY OF ADOLESCENCE these functions, and if the brain is weak it can not bear the strain thus imposed.
In the transition from the grub to the butterfly state, the female is most liable to become psychologically upset, because her reproductive organs and functions are not only larger, but the changes are more rapid. In her, Maudsley thinks love and religion are most often blended. In trances, stupors, or contor- tions, girl lunatics are most prone to symptoms of erotomania, or even nymphomania. There is almost sure to be alternation from depression to excitement, and vice versa, in adolescent in- sanity. Frequent and repeated oscillations, especially the oc- currence of lucid intervals, is a bad sign. Menstruation pre- disposes women to this cyclic upsetting of equilibrium. If in- stead of slowly lapsing to dementia, the patient recovers, she is unconcerned about previous attack, and " the two selves, the sane and insane, pursue their respective courses apart." In depression there are the usual fears of being suspected of ill- doing, of being followed, watched, poisoned, wrongly dieted, slandered, and of being guilty of things never done. Although the symptoms seem superficial and histrionic, they are as real as the limited strength of mind and brain can make them, and the suicidal impulses may be carried out. Feelings that are not directed normally to love, marriage, and motherhood are always liable to devastation, and timely and happy wedlock may improve such cases. All adolescent insanities imperatively require change of surroundings, and too much sympathy is often the very food they feed and grow strong on. Here, too, belong the religious fasters, ecstatics, feigners of strange dis- eases and interesting symptoms, the diabolically clever liars and false accusers, mischievous tricksters, and moral imbeciles of divers types.
Wille,^ whose one hundred and thirty-five cases seem to bear out his view, holds that there is no specific pubertal insanity, but that puberty gives a peculiar character to other psychoses, all of which may occur at this period, yet, as we should expect, with a special prevalence of atypic and mixed forms. Instead, there- fore, of regarding set symptoms and laying stress on the mode of termination, he well urges that psychiatry should take ac- count not only of causes, but of characteristic changes in the * Die Psychosen der Pubertatsalters. Leipzig, 1898, p. 218.
DISEASES OF BODY AND MIND ^95 course of diseases, and that this should be true not only of those which occur at puberty or the age of sexual evolution, which he places between fourteen and twenty-three, but at the age of in- volution or senescence. He classifies his cases (during the preceding fifteen years at the asylum of Basle) as follows: Simple psycho- neuroses.
Cases.
Melancholy 21 Mania, 29 Acute dementia 9 Acute hallucinations ) Females.
Males.
15 6 18 II 8 I 7 3 2 2 3 6 8 29 3 6 I 3 Insanity Confusion lo ^Paranoea 4 r Primary chorea, dementia 9 Organic | Combined neuro and toxic psychoses...37 psychoses, "j Heredity 9 Common hebephrenic traits, Wille thinks, are present and color all these diseases, which become typical somewhat ac- cording to the degree of development toward adult life at which they occur. Superficiality, stupid jests, and jollity in the midst of lamentation and world pain, the most bizarre turns of thought, theatrical reference to a spectator, fanaticism, the sharpest contrasts and conflicts of owlish wisdom and fatuity, selfishness and altruism, idle distraction and great concen- trative energy, savagery and tenderness, hypersensitiveness and obtuseness, growth and development concentrated upon any organ and function, so that there is hypertrophy here and atrophy there, sex organs and instincts enormously and pre- maturely developed or arrested, exotic virtue and brutal crime, exaggerated selfishness and no less extreme generosity and self- abnegation, resistance to authority and exceptional plasticity, fantastic views of life, abhorrence of work or, above all, of regularity in occupation, lunacy with misleading lucid inter- vals, impulsiveness, scrupulosity and reflection on trifles which may be paranoeic — all these occur in different cases and a sur- prising number may follow each other in one individual. Krafft-Ebing, who held that great need of activity and selfconfidence were often combined with chorea and catalepsy, that exaltation and a sense of greatness alternated with a deep sense of demerit and unworthiness; Regis, who thought that pubes- 296 THE PSYCHOLOGY OF ADOLESCENCE cent insanity was more often moral, showing itself in morbid acts and impulses rather than in the intellectual sphere; Savage, who compared the abnormalities of this age with those of early childhood, although holding the former to be more pronounced, and thought dysmenorrhea never so liable to produce intellectual weakness; Blanford, who deemed that violence was more char- acteristic than illusions, and that irregular and uncontrolled and perhaps choreic movements were rarely absent; Trow- bridge, who emphasized the distinction between simple psychic neuroses of short duration and true psychoses, and thought the latter only incurable — all these and other conclusions may be legitimate inferences from different groups of cases, but can not yet be final.
Marro ^ does not accept a distinct pubertal form of insanity. He found that at this period the exigencies of growth had greatly reduced both the albumin and the salts of the blood, and conceives that at this their nascent period sex organs and nerve centers come into the closet rapport; that the mind is being rapidly developed; that sense is evolving into affection; that the nervous hyperesthesia is peculiarly exposed to in- fluences from the gradually im folding sex functions, and that very slight causes may upset sanity. In his twenty-eight fully described cases, fatigue, a glass sliver in the toe, constipation, toothache, and failure to pass examinations, a mild flogging, etc., caused symptoms of the utmost variety, nearly always transitory although often acute, that threatened the ultimate in- tegrity of the whole psychic organism. These " phenomena of first reflexion " are often forms of epilepsy, and indeed the period of fifteen to sixteen has few others. The intelligence, al- ways more or less radically changed, is easily and permanently injured by too intense and extreme perturbations of feeling or of conscience, but much of this is needed to deploy and stretch out the soul to its full dimensions. In the erratic acts of these cases, scratching, biting, screaming, chanting, butting, running aimlessly about, stripping off clothing, eroticism, spasmodic hilarity, pugnacity, exhibitionism, passionate vagrantism and vagabondage, solitude and soliloquy, self-torture, praying, shouting, obscene and profane words, taciturnity, anorexia and polyphagia, filthy acts, etc., we seem to see the vigor and variety 1 La Puberta, p. loi et seq.
DISEASES OF BODY AND MIND 297 of the elements that compose our nature and which are normally broken and harnessed to service of common sense, escaped from control, and suggesting in an unmistakable way the subhuman origin of the crude material of human nature. Many of these are given us in great abundance at adolescence, and the problem of moral and religious education is whether we can thoroughly civilize these barbaric and bestial proclivities and bring them into the harmony and unity of completed character.
Marro ^ describes the morbid congenital instability at this age as follows: " When we consider young people with heredi- tary taints, the picture may represent considerable variety. At one time they are torpid, obtuse, taciturn, without expansion, little given to society, indifferent to affection, but petulant, irri- tated, the reaction has no measure, they cease from their state of torpor to give way to outbursts of an unbounded violence, entirely disproportioned to the injury received. At other times they are unquiet, turbulent, without physical and moral firm- ness, always in motion without determined aim, incapable of attention and reflection, dominated by instantaneous impulses which they do not know how to resist, incapable of persevering in any occupation; impelled by whims which follow each other without any plausible motive to explain the first sympathy and the following aversion; they are always inclined to lamenta- tion, tormented by a sense of ill-feeling which spoils their pleas- ures and magnifies the difficulties which they are about to face. The instinctive impulses and moral impressions find in them little or no power of resistance, and, according to the particular conditions of life and special circumstances, they become so many candidates for prison or the insane asylum."
In Marro's middle period of adolescence, from sixteen to twenty, the psychic changes predominate. There is great and frequent alternation of mood from grave to gay, extreme exag- geration, little power of resistance. In abnormal cases this is the age of gastric catarrh, sudden alterations of body tempera- ture, nutritive disturbances particularly favored by mastur- bation, epigastric sensations of weight, hardness, heat, etc., chloroses, sitophobia, abnormal urinal deposits, and perhaps in- flammation in parts not predisposed to it, auditory and visual 29^ THE PSYCHOLOGY OF ADOLESCENCE hallucination, erotic and religious delusion, and a general lack of horizon for consciousness.
Marro examined 1,643 males and 1,257 females in the luna- tic asylum of Turin. Of those between the ages of twelve and fourteen he found only a few cases of psychoneuroses, and still fewer epileptics. Between fourteen and seventeen was the age of most epilepsies, which abound also during the next few years. From twenty to twenty-three for males and from twenty to twenty-two for females was the age of most psy- choses, and by twenty-five these had nearly ceased. Boys were more prone to melancholia and girls to mania, the latter ac- quiring less power to check reflexes. The moral perversions of boys are prone to take the form of cruelty and crime, while girls are more liable to shameless and erotic perversity, and egoism and self-satisfaction is common to both sexes. He found direct morbid heredity in one hundred and forty-five cases between eleven and twenty-five, ancestral heredity in fifty- four cases, and that paternal was to maternal heredity as eight to five. The effects of old age in the father was found in forty-one per cent and in the mother in twenty per cent of the adolescent cases. Heredity made itself felt more at this period than later, especially from the father, and more so the earlier it appeared. Of psychic causes he found fear and other affections and thwartings of the instincts of self- preservation, which were relatively more prominent before puberty, to give place to insults and other injuries of self-re- spect, religious feelings, love, etc. Failure in examination sometimes reacted into almost maniacal exaltation and de- fiance, and the alienation seemed to be a natural evolution aided by no external cause.
He ^ describes interesting typical cases; one of a bright student of sixteen, whose character seemed to change till he be- came visionary and fantastic, who wrote to the king and queen claiming to be their son, but was at once sequestered, severely lectured, and recovered. Another began with an extravagant dream of pistons working disharmoniously within him, which was continued for four years, with illusions of dual personality. He had an exaggerated sense of mental and physical ineffi- ciency, passed just before intended marriage to aversion to his ^ La Puberta, p. 164 et seq.
DISEASES OF BODY AND MIND 299 bride, alternating from passion to repugnance. Another slowly became a stutterer and feared that every act of his might have fatal consequences. A girl had delirium of sin, tried to give herself to God so passionately that no other could be thought of, and so intense was this eroticism, where religion took the place of sex, that gastric and respiratory symptoms often supervened during a long period of abnormal pubertal evolution. Another girl developed causeless hatred for her mother, grew gushy, sentimental, and familiar to partial strangers, was excitable, dirty, flushed and pale by turns, and became too religious. An- other gave himself up to extreme self-abuse on the view that he must thus rid his system of a poison, and often before others as a sign of contempt for them, etc.
Most of the psychoses of this period appear as symptoms of exhaustion, so that prolonged repose in bed may do great good. Moral and physical development go hand in hand at this age as at no other, and it is very rare to find anomalies of one without those of the other. Marro lays chief stress upon disciplinability and sociability, and to these adds the power of continuous work and the power to pursue a predetermined line of conduct. These for defectives and criminals should be chiefly cultivated. The perfection of the organism and the solidity of moral quali- ties can not be divorced. If there is rapid growth in mind, while the secondary sexual qualities do not develop in propor- tion, the critical period is not yet passed and there is danger. Prevision for self and for others is cultivated by economy. He commends Dr. Wine's system of marks to teach those exposed to these dangers proper care of their own natures and interests, to say nothing of those of others.
Dr. Pickett ^ has tabulated cases of one hundred and sixty- seven young men, obtaining personal histories wherever this was possible. He concludes that from the standpoint of prog- nosis the puberty modifications of insanity are first a tendency to dementia as if the potentiality of mental life were exhausted. Only one- fourth of Pickett's cases left the hospital restored, and even they remained more or less psychic cripples. His para- noeics were a little older than the others, or as Bevan Lewis said, "the delusional cases are older than merely maniacal ones."
^ A Study of the Insanities of Adolescence. Jour, of Nervous and Mental Dis- THE PSYCHOLOGY OF ADOLESCENCE This suggests that age braces the hysterical temperament and increases the assertiveness of the individual, " so that one who at sixteen sinks into catalepsy under a burden of imagined troubles would, if he had escaped until he reached the age of thirty, have risen above his persecutions in the form of egoistic delusions, solely on account of the change in temperament wrought by mature age." He believes that hebephrenia to- day " includes those cases of dementia prse- cox which are not dis- tinctly paranoeic, and not katatonic; it is a group of the unclassi- fied members of de- mentia prsecox." ** To omit all reference to the peculiar types of adolescence seems like rejecting our birth- right— an heritage of the labors of master workmen in the field of psychiatry.
His age table is as shown in the adjoin- ing diagram.
According to Se- rieux,^ who traces its history to Morel, the various forms of pre- cocious dementia are followed after variable time by a special state of psychic en- feeblement. The delirious ideas are slowly attenuated and per- haps entirely lost, so that at its termination the patient has very little in body and mind that is not stereotyped. He distin- guishes four distinct forms: simple, delirious, katatonic and paranoeic — and three periods, that of its debut, characterized uZ 11 B B' S bb i ■ Si 1 ~B~BI 1 ■■Ji" 1 ZBBBil 1 IBBBBB 1 ^BBI IB 1 aaaai n 1 ^aaai n 1 BBBBBI 11 1 iEbbbbi IB 1 niBBBBI IB 1 ~baBaaai IB IB 1 zEBHaan IB 1 ~iBaBBaBi IB 25 BBBBBBBBIM Age ■ 12 ■ 13 B 14 1 15 a a 16 a a 17 a a 18 a a 19 a a 20 a a 21 I I ' La D^mence pr6coce. Rev. de Psychiatric, June, 1902.
DISEASES OF BODY AND MIND 30 1 by general neurasthenia, hysteria, perhaps preoccupation and other neuropathic manifestations; the second is acute or de- lirious, perhaps with ideas of greatness, persecution, hallu- cination, excitement, etc., and the third is terminal dementia. The clinical species or groups and the distinction between primary and secondary symptoms is a work of the future, but the tendency is now everywhere to substitute clinical species with well-determined stages of evolution for merely symptomatic groups. This alone can give a natural in place of an artificial classification.; I j ^; _. j V. Serbski ^ would restrict the term to those forms that have the following traits: First, where the onset is not later than the adolescent period, and, second, where there is distinct development of enfeeblement. He points out the important fact that it may be secondary to some other acute psychic dis- ease and lays little stress on physical signs. It is very hard to diagnose and especially to differentiate from secondary dcr mentia of adolescence. Kraepelin's theory of autointoxicatioii by products of the sexual organs, he deems mistaken., J. Seglas ^ agrees with KraepeHn that katatonic symptom$ are of psychic origin and not, as Kahlbaum thought, simple muscular spasms. They are automatic, independent of the con- sciousness of the patient, and without relation to any illusions or delusions, but automatisms can only be corollaries. The substratum always is insufficiency of cohesion between the ele- ments of personality. He, too, holds that negativism goes well with aboulia.