To Kraepelin belongs much credit for the great and grow- ing interest in this subject, due to a serious effort to clear up the previous confusion. In the later editions of his text-book, and especially in the sixth,^ he gives a brilliant and comprehensive clinical characterization of dementia praecox, in- cluding most of the abnormal symptoms of this age that issue in degeneration, on the basis of 296 cases and under three forms — hebephreniac, katatonic, paranoid. The age liability of his * On the Question of Dementia Praecox. Jour, of Mental Pathology, YoL 2, No. 4. Abstracted from a paper published in Russian, Jan., 1902.
^Ddmence pr^coce et Katatonic. Nouvelle Iconographie de la Salp^tri^re, * Psychiatric, 1899, vol. ii, ch. 5. Die Dementia Prsecox, pp. 137-214.
THE PSYCHOLOGY OF ADOLESCENCE cases is represented in the following cut, but of the first form seventy-two, of the second sixty-eight, of the third forty per cent, and of all together over sixty per cent occur before the twenty-fifth year. Its manifestations are ex- tremely diverse and include symptoms of almost all other insanities. In the hebephreniac form the development is to- ward final stupidity more or less pronounced, with subacute, more often than acute, mental disturbance. The katatonic form is more likely to be characterized by negativism, stereotyped movements, and suggesti- bility of expression and acts, while the paranoeic type, which he has added later, is marked by delu- sions, sometimes slightly systematized, especially in older cases, and by sensory illusions, which may per- sist for years along with tolerable sanity in other respects. In the most youthful cases the progress is toward simple dementia, while in katatonic and especially paranoeic forms illusions are more likely to play the dominant role in the later adolescent stages; for this differ- ence he can offer no explanation, but illusions seem germane to the somewhat later age, which he found a little more prone to them when will and ideation are more developed. The degen- eration, which marks all form of this disease, he thinks can not be explained as mere arrest, for he strangely asks what do we conceive to be arrested, and so he proposes autointoxication, perhaps due to sexual elements as a chemical agent, to account for the fact and the rapidity of deterioration. Kraepelin's former student, Trommer,^ has summarized these views with additional clinical details and theoretical suggestions, while 1 -^ — — H 1 — _ -J h 0 l-l-^ Age 13 20 25 90 35I4O 15 50 55 * Das Jugendirresein, von E. Trommer. Samm. Abh. Nerven- und Geistes- krankheiten, Vol. 3, Part 5. Halle, 1900.
DISEASES OF BODY AND MIND Ilberg,^ whose twenty cases began on the average at twenty-one and a half years, perhaps best describes the earlier stages of the disease.
As to the frequency of dementia praecox, we have the fol- lowing very diverse data: Hecker found 14 cases among 500 insane, or 3.0 per cent.
Schiile 5 K. Ebing Sterz Finck 17 Tschisch 14 Scholz 6 Christian Kraepelin <( (5-6 hebephreniac and katatonic and the rest paranoeic forms.
Meyer t€ 173 women.
f imple and paranoeic.
40 women, Katatonic.
Kraepelin's work in this field has proved a very fresh and invigorating stimulus to younger alienists. It marks some ad- vance from an artificial toward a natural system in a field where, unlike that of most somatic diseases, temporary symptoms are protean and misleading, so that it is difficult to diagnose to the basal processes, because in its relatively long duration there are so many phases that are hard to differentiate from other mor- bid types, especially neurasthenia, which it often resembles, al- though the latter cases are more readily controlled intellectually by physicians and less prone to issue in mental weakness. Some of its manifestations suggest general paralysis, but this more affects the memory and brings special defects. The latter trou- ble, which now has a well-estabHshed pathology, is one of the best differentiated of diseases, while dementia praecox has far more varied forms and less specific symptoms, and its neural pathology, despite several hopeful tentatives, remains yet to be 1 Das Jugendirresein, von G. Ilberg. Volkmann's Samm. Klin. Vert. No. 224,1898. See also: Ueber Hebephrenic, etc., von Daraskiewicz. Dorpat, 1892; De la D^mence Pr^coce des Jeunes Gens, von J. Christian. Ann. M^d. -Psychol., 1899. Beginning Jan.-Feb,, 1899, and continuing through five numbers; Die Katatonie, von Tschisch. Monatsch. f. Psychiatric u. Neurologic, 1899. See also a convenient compend in a small volume by G. Deny and P. Roy. La D^mence 304 THE PSYCHOLOGY OF ADOLESCENCE developed. As compared with epilepsy, too, its symptoms are far less sharply marked, while its relations with all the prob- lems of psychic development constitute so vast a field that no single investigator can repeat here the triumphs of Hughlings Jackson, although many think that it should now take its place with these two morbid symptom groups as already next best established. Dr. Adolf Meyer, our most competent American authority, says in a personal letter that " the adaptation to the sexual life of the adult age is very often a prominent difficulty in these cases," and that " the disorder is frequently fore- shadowed in the teens or may come on before in rare cases, but the majority develop mental derangement between twenty and twenty-five." In general, periodic types of insanity seem more endogenous to the third decennium of life; paranoea to the third and fourth; general paralysis to the fourth and fifth; melan- cholia to the climacteric; and senile dementia to a still later stage of life. To fully understand these, as well as the diseases most liable to earlier periods of life, now under consideration, we must have as a basis the fullest possible knowledge of the normal life in each age.
While no alienist has so carefully studied, presented, and grouped clinical symptoms on a basis of so many cases as Krae- pelin, and while, in showing from this standpoint the peculiar liability of the transformation stage of adolescence to fail of achieving psychic maturity and to lapse toward dementia, he has made a contribution of great value to our knowledge of this age, neither these nor his experimental studies have enabled him to escape the fallacy of modern psychiatric specialization and recognize the larger relations of the morbid to the normal changes of which most of the former are only exaggerated forms. In this respect the broader and robust common sense of Maudsley, the more numerous and comparative methods of Marro, and in some respects even the conservatism of Wille, show sounder psychological insight. Hughlings Jackson's genius, which as some one has said makes even his guesses more valuable than many a man's demonstrations, while shown in his theory of levels, has contributed no less to establish his type of epilepsy by tracing its diathesis through all its gradations up into experiences common in every normal life. This is always possible and must always be the clinician's goal, and just in pro- DISEASES OF BODY AND MIND 305 portion as normal psychology is developed on a sound empirical and genetic basis, it will become the indispensable clue to guide and the shibboleth and touchstone by which to test every con- clusion of the alienist, who even without the genius of insight will walk sure-footed just in proportion to his knowledge of it.
The terms dementia prsecox, insanity of youth, primary dementia, hebephrenia, and katatonia are all partial and none of them are entirely satisfactory. These troubles do not by any means invariably issue in dementia, but if all did, the processes that produced and preceded the lesions, and not their effect, should furnish a truly scientific principle of characterization and nomenclature. Hegel said of Schelling's absolute, as many since might have said of Hartmann's unconscious, that it was not a true philosophic principle, because " all cows look alike in the dark," meaning that a purely negative principle can never be an adequate explanation. We may say the same of dementia prsecox, which faintly suggests the propriety of giving to general paresis, which almost always has a fatal termination, a designation like thanatic dementia, based upon this fact. Early mental death is a result of the morbid processes we have here to study, but so it is of others. With senile dementia both the facts and the propriety of the name are very different.
There are two missing links indispensable to a full acquaint- ance with the many forms of precocious mental decay; first and chiefly, knowledge of the actual changes during the stage of puberty and later adolescence, which go on within the limits of sanity. This age has often been characterized as that of mental and moral inebriation and of psychic madness, and from my studies of its phenomena I am convinced that nearly all of its symptoms can be paralleled in the inner and outer life of youth who do not lapse toward the terminal imbecility, but develop to sane and eflicient maturity. Here we may de- mand that the normal psychologist shall help to contribute a sound basis to the student of disease, while the alienist, who deals only with salient, flagrant, or ostensive instances where natural tendencies are " writ large " and who does not know the genetic and natural history of the soul, can not solve the most fascinating problems presented by clinical pictures.
The other gap is the absence of record or available knowl- edge of the early stages in the development of the disease be- Si / / 3o6 THE PSYCHOLOGY OF ADOLESCENCE fore cases come to asylums, for of this disease even more than of many others it is certain that, if all were known, its mani- festations would be found to be numerous in proportion as they are mild, and that the vast majority who are slightly impaired by the ferment of this storm and stress period of life never come under any kind of medical observation. For one, I in- cline to the opinion that just in proportion as these gaps are filled, we shall have less need of recourse, with Kraepelin, to toxic or to other chemical causes. Since in both these fields and in the disease itself, sexual factors often play a very im- portant role, a leading contingent of our knowledge of these cases must come with every advance in the psychology of sex, now so lamentably undeveloped and till lately neglected. On the other hand, the paradigms of premature decay reveal a body of phenomena of the highest importance for normal genetic psychology, and it should already be asserted that no parent, judge, family or army physician, and especially no teacher, should be ignorant of these morbid forms, which in their mild degrees are so common and the key to so much that is normal, but which are generally concealed to others and often uncon- scious to self.
Dr. Meyers^ suggests that like alcohol this may be nature's way of weeding out the unfit, and that as general paresis is now by many traced to infection, so early dementia may be in part due to preventable causes. He protests against the frequent acceptance of hereditary tendencies or fatalism which even the young sometimes now use as an excuse for their bad conduct. He would distinguish sharply between forms due to consti- tutional inferiority and poor endowment and those due to adolescence itself and its disharmonies of thoughts, habits, and interest. This cause of stunting and perversion is less due to overwork or stress of diseases of metabolism. He says: " Before all I miss a sense for actuality, a living with life as it is and an enjoying of the opportunities that are within reach. Where flights of thought rise above indifference in such individuals, they naturally suffer from not being adapted to actuality. In the ambitious we see the features of day- dream rather than of strength. Virtue and social emotions remain abstract and in exalted words. Many of these weaklings become conscious of the con- * Address at Child Study Section of the New England Association, July, 1903.
DISEASES OF BODY AND MIND 3^7 trast between their words and their nature. They become self-conscious, suspicious of being discovered, and drift into solitude. Abnormal hanker- ings fail to be corrected there by a healthy spirit of social and other activity; the touch with actuality is lost more and more, and over a shock or some dis- appointment or a setback in general health the poor frame of judgment gives way, and the person loses balance. The eagerness with which hypnotism, mesmerism, mystic powers, and the unreal are elaborated into delusions and depended upon for explanation of the peculiar sensations connected with dis- ordered circulation, nervous heart, the nervous excitability shown by in- creased reflexes, feelings of uneasiness and anxiety, and unusual intestinal and sexual sensations, seem sto me to show the great danger of all half-under- stood things which are not brought to the test of actuality. An aversion to actuality seems to lie in the trend of much modem teaching.
" The emphasis of nature study does perhaps much to bring a healthy turn into education. But we need more; we need greater wholesomeness in the training for human relations and aspirations; a better knowledge of what is likely to rouse a sound interest even in those who are naturally careless and indifferent and otherwise tickled merely by the sensational or by what grati- fies crude emotions; we need a preparation for actual life, not for dream ex- istence. What is called ' new thought,' though to a large extent a mere revival of the food for the eternal gullible, does much good where it incidentally en- courages healthy instinct. But it is hke strong wine, a questionable article of food, sometimes a useful drug, but really unfitting one for a good digestion and assimilation of what makes man the master of nature. Too many suffer from the effects of intoxication or the untimely use of these mental stimulants.
" The greatest stumbling-block is undoubtedly that which stands in the way of the development of sexual maturity in that broad and lofty sense of becoming the originators of a better race. That which in actuality is the center of the highest altruistic possibilities of mankind is allowed to be a social playground of chance, fed by dime novels and hterature of doubtful adventures; fashions in dress and in social customs usher the young precociously into a world in which even too many adults fail. Abnormal responses lead to ab- normal seclusiveness, and quack literature nurtures a fear and hopelessness, and frequently wrecks the chances of a timely reconstruction.
" Do not let us say that this is merely one of nature's methods of weeding out the unfit. Among the 25,000 persons who are to-day in the public and private institutions of New York State alone, there are many brilliant hopes buried, largely owing to a lack of knowledge of what some people need in the way of social and personal hygiene. Remember that some of the most illus- trious members of the race have been dangerously near the borderland of in- sanity and seem to have been great although they showed obvious traces of the same misled instincts that have completely wrecked others. Are such people not worth our help? Should not the home, the press, and the school mind some of the dangers and shape their ethics and methods accordingly?
" This is the practical lesson to be drawn from the theory of degeneracy which is spread into immature minds as a doctrine of fatalism, so that even high-school pupils excuse themselves in some such way as: * I can't help this. It is hereditary in the family.' Part of this may be sadly true. But it is the duty of pedagogy and of psychiatry to distinguish what is to be accepted with fatalism from what is open to correction. We have faith in gymnastics for the correction of physical defects. Let us devise more efficient gymnastics which lead us to heartily enjoy actuality, to instinctively shrink from anti- social ideas and abnormal friction, and to get time for an unsophisticated growth."
308 THE PSYCHOLOGY OF ADOLESCENCE Many of the phenomena are those of overaccentuation of processes normal at puberty, which I have for years called ephebeitic, although this term can with less propriety be applied to many of the negative symptoms of defect. The germs of many of these disturbances lie in the common faults of child- hood, which are now studied under the name of pedagogical pathology, to be treated in the next chapter. Some are the premature Phaethon flights of genius spoiled by the heat of its own fermentation, and others are definite symptom groups seen in the schoolroom and not always yet incompatible with its work.^ Conformably to this view-point we must seek the key to these perversions by addressing ourselves to the larger, underlying, and preliminary problem of determining the natural forms of psychic and somatic transitions from childhood to maturity, and study what puberty and adolescence really mean as developmental stages of human life, which it is the purpose of this work to investigate.
Adolescence begins with the new wave of vitality seen in growth; in the modifications of nearly every organ; the new in- terests, instincts, and tendencies; increased appetite and curios- ity, so that, as elsewhere described, it is a physiological second birth. The floodgates of heredity seem opened and we hear from our remoter forebears, and receive our life dower of en- ergy. On the other hand, the expenditures of energy are greatly increased, so that it is a crucial period for the recomposition of all the hereditary forces. Passions and desires spring into vigorous life, but with them normally comes the evolution of higher powers of control and inhibition. The momentum of in- heritance may be insufficient, and Binschwanger conceived the psychic morbidities of this age as due to exhaustion or lack of capital. Thus, while on the other hand the will to live is greatly reenforced, there is often an overcompensation of waste from debilitating causes, so that the higher plateau that should be attained by the knitting together of all the new and old factors of personality under the law of prepotence may not be reached, and nature may seem to refuse or be inadequate to this final step. New prepotencies give a new direction and a new distribution of the factors of organic and psychic evolution, and * See many of these in Spitzner, Psychogene Storungen der Schulkinder, Leip- DISEASES OF BODY AND MIND 3^9 just as an infant who grew equally in all directions would be a monster, so the pubescent who developed all the faculties which are normally given at this age without due subordination and unity would be at once many kinds of both criminal and lunatic. Indeed, one need accept in detail none of the current theories of the nature of genius to understand that it largely consists of keeping alive and duly domesticating by culture the exuberant psychic faculties, of which this is the nascent period, and that just as domestic animals and plants easily revert to wildness, so our faculties if not duly recomposed and harmonized to the new and higher life of altruism must retrograde. Personality is always more or less multiplex and at best is a kind of moving equilibrium of forces which check each other, so that ado- lescence means a new system of tensions where many a nisus, innervation, and tendency is offset by others, and all in the normal mind are so well integrated that their separate elements are commonly lost to consciousness, which shows only result- ants and diagonals of composition of many forces. The adult knows nothing of the crude raw forms in which psychic data are so copiously given at this age. Youth is a period of associations between many factors and contents of life, and this conception is the only cue which can aid us in threading the labyrinthine mazes of this aggregate of diseases.
Roux's conception of a competitive struggle among the different organs or tissues of the body for nutrition in order to explain excessive or premature growth of bone, sexual parts, limbs, etc., with complementary defect elsewhere, is also sug- gestive here and has some explanatory power in the psycholog- ical interpretation of these phenomena. Early adolescence brings sudden spring freshets of growth impulse in all di- rections, and these initial momenta, now given like an inher- itance turned over to a ward on attaining his majority, are at first more or less incoordinated in all, and in defectives especially prone to be perverted and unbalanced, so that we have the obvious picture of offsetting deficiencies, each of which tends to intensity almost inversely as the strength of the other. As Taine has shown, every concept or presentation strongly tends to become vivid until it reaches delusional intensity, so that sanity is a complex system of mutually arrested and repressed illusions. Herbart, despite the fantastic, mechanical, and 310 THE PSYCHOLOGY OF ADOLESCENCE mathematical affectations of his system, deserves credit for the effort of attempting to work out the sum' of arrests which ideas acting and reacting upon each other produce, with all the various degrees of contradiction from diametrical up to perfect agree- ment and reenforcement. At this stage of life, the earlier con- sciousness of childhood is to a great extent deciduous and a new one is being slowly organized. Youth tends to do every- thing physically possible with its body considered as a machine in the tentative, to explore every possibility of action and in- nervation, and to give the soul a newer and higher control. It is plastic to every suggestion; tends to do everything that comes into the head, to instantly carry out every impulse; loves nothing more than abandon and hates nothing so much as restraint. It is the age that can withstand no dare or stump; loves adventure and escapade; tends to let every faculty go to its uttermost; and seems to have a special tendency, as the pre- vious curve of morbidity, which here reaches its highest point, shows is true of somatic troubles, to every psychic disease. There is over-innervation'and tonicity, which may issue in any fulminating and furibund manifestation, and which responds to all new and intensified impulsions from within and suggestions from without.
We see traces of these molimena of nature toward a higher level, this hunger for a fuller and larger life even in the midst of degenerative phenomena. Youthful dements wrestle with great problems and ideas; their delusions are of royalty, celes- tial and infernal beings, telepathy, hypnotism, spiritism, great inventions, the highest themes of politics and religion, but their powers are inadequate and they grow mentally dizzy, confused, and incoherent. Again, as if they unconsciously felt the need of control, we see the reticence normal to this age of conceal- ment, when the soul strives to segregate itself and protect and nurse a new individuality, overdone to taciturnity or reflected in constrained acts and postures; or the new impulses to action may crop out in exaggerating or fantastically varying the most common movements of walking, eating, dressing, speech, wri- ting, etc. In many of the rich clinical details which Kraepelin has so admirably gathered, it is easy to see the germs of genius of many kinds, for this is the crude ore of which the great pro- ductions of art, invention, heroism, and moral and religious DISEASES OF BODY AND MIND 311 reform would be made if the processes of elaboration and the supreme Greek virtue of temperance or avoidance of excess were adequate. The soil is always rich to profusion, insemi- nation abundant, choice exotics and all the flora of culture strike root, but weeds are rank and choke them, and decay may be the direct resultant of superfetation. There are spots or periods of excessive fecundity offset by intervals or desert areas of arrest or decay; hence the psychic diseases of youth abound in surprises and contrasts.
Sometimes intellectual defect first appears. The student can not command his attention or fails to comprehend, under- stand, and associate, and despite every effort falls behind his mates; is oppressed with a sense of weakness and inability to meet the expectations or ambitions of friends and parents. Here probably belong most of the two hundred and eighty-nine Prussian school children who committed suicide between 1883 and 1888, from fear of examinations, punishment, non-promo- tion, etc.^ In these cases the first outcrop of disease often ap- pears to be depressive or melancholic. Sometimes impulsion fails and the subject grows apathetic, indifferent, loses interest, and does not respond to ordinary ambitions for his own future, all inner impulse and spontaneity abate, and he ceases to care. The leading motive of life and the mainspring of all high en- deavor is gone. Then, sometimes, the very absence of the ten- sions previously felt has the psychical action of a vacation, and produces an exalted and hilarious state of mind. Whichever the prodromal stage of incubation, there is always great strain or anxiety at first, generally reflected in loss of flesh, which is gained later when the weakened faculties and decimated activi- ties settle to some kind of adjustment on a lower plane.