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diff --git a/old/54611-0.txt b/old/54611-0.txt deleted file mode 100644 index 954630b..0000000 --- a/old/54611-0.txt +++ /dev/null @@ -1,18945 +0,0 @@ -The Project Gutenberg EBook of Mental diseases; a public health problem, by -James Vance May - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Mental diseases; a public health problem - -Author: James Vance May - -Release Date: April 26, 2017 [EBook #54611] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK MENTAL DISEASES *** - - - - -Produced by MWS, Ralph, Bryan Ness and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - -Transcriber's Note: - -Punctuation and possible typographical errors have been changed. -Archaic and variable spelling have been preserved. -Footnotes appear at the end of the text, after the Index. -Cover image created by the transcriber and placed in the public domain. - - - - - MENTAL DISEASES - - _A Public Health Problem_ - - - BY - - JAMES V. MAY, M.D. - - Superintendent, Boston State Hospital, Boston, Mass.; Fellow, and - Chairman of the Committee on Statistics, of the American Psychiatric - Association; Fellow of the American Medical Association, etc. - - Formerly, Superintendent, Grafton State Hospital, North Grafton, Mass.; - Medical Member, The New York State Hospital Commission, Albany, N. Y.; - and Superintendent, Matteawan State Hospital, Beacon, N. Y. - - WITH A PREFACE BY - - THOMAS W. SALMON, M.D. - - Professor of Psychiatry, Columbia University; Medical Advisor to the - National Committee for Mental Hygiene, New York City - - [Illustration] - - - BOSTON - - RICHARD G. BADGER - - THE GORHAM PRESS - - - - - COPYRIGHT, 1922, BY RICHARD G. BADGER - - All Rights Reserved - - - Made in the United States of America - - The Gorham Press, Boston, U. S. A. - - - - -PREFACE - - -Interest in mental disorders is no longer confined to the relatively -small number of persons whose duties or family ties bring them into -daily contact with the mentally ill. Disorders that so profoundly -affect human conduct were certain, sooner or later, to attract the -attention of those who are interested in the study of human behavior -in its broadest relations or who have special responsibilities with -reference to the conduct of individuals and require all the information -that they can secure on factors that modify the reactions of men, -women or children in the social environments in which they live and -die. Uncertain of themselves until they made sure of the sciences -upon which their future work was to develop, social workers since the -commencement of organized social work in this country demanded of the -sciences concerned with the human mind some information that might aid -them in dealing with the difficult problems in human adaptation which -they found constituted the chief part of social work. Judges and those -who are interested in penology have within recent years turned also -to the students of abnormal human behavior for light upon problems of -crime and delinquency. With mental hygiene becoming firmly established -as a practical field of preventive medicine, another group of persons -not directly concerned with the care of the mentally ill has become -deeply interested in the forms, types and causes of mental illness. -It is by such readers, quite as much as physicians, medical students -and nurses, that Dr. May's work in bringing together the main facts -regarding mental diseases and the people who suffer from them will be -appreciated. For those whose interest in the subject is incidental -and not part of a life-long study, the information here presented will -be of special value. There are, it is true, many technical works on -mental diseases in their medical, social and legal relations, but it -is doubtful whether elsewhere there can be found in a single volume as -much varied information as that which Dr. May has brought together. - -There is probably no group of diseases about which there is such -widespread popular ignorance or misinformation as those that affect -the mind. People who would be ashamed not to have accurate information -regarding the more important infectious diseases and more than -general knowledge of the means by which they are transmitted speak -of "insanity" as if there were a single disorder to which that name -could properly be applied, and are without the slightest knowledge -of the different forms of mental diseases, the periods of life in -which they appear, their main characteristics and the means by which -they terminate. Statistics relating even to those persons with mental -disorders who are cared for in special institutions are usually -quite unfamiliar to persons who have more than an ordinary amount of -information regarding the prevalence of other diseases. Such a book as -this will go far toward supplying the extraordinary lack of knowledge -of conditions that have exceedingly important social and economic -relations and from the study of which many lessons can be drawn that -are applicable to human affairs far removed from those relating to -patients in our hospitals for the insane. - - THOMAS W. SALMON. - - Larchmont, New York, - January 11, 1922. - - - - -CONTENTS - - - PART I. GENERAL CONSIDERATIONS. - - CHAPTER PAGE - - I. THE SOCIAL AND ECONOMIC IMPORTANCE OF MENTAL - DISEASES 15 - - II. THE EVOLUTION OF THE MODERN HOSPITAL 34 - - III. LEGISLATION AND METHODS OF ADMINISTRATION 50 - - IV. THE STATE HOSPITALS—THEIR ORGANIZATION AND - FUNCTIONS 68 - - V. THE HOSPITAL TREATMENT OF MENTAL DISEASES 84 - - VI. THE DEVELOPMENT OF THE PSYCHOPATHIC HOSPITAL 104 - - VII. THE MENTAL HYGIENE MOVEMENT 121 - - VIII. THE ETIOLOGY OF MENTAL DISEASES 138 - - IX. IMMIGRATION AND MENTAL DISEASES 155 - - X. MENTAL DISEASES AND CRIMINAL RESPONSIBILITY 169 - - XI. THE PSYCHIATRY OF THE WAR 185 - - XII. ENDOCRINOLOGY AND PSYCHIATRY 202 - - XIII. THE MODERN PROGRESS OF PSYCHIATRY 217 - - XIV. THE CLASSIFICATION OF MENTAL DISEASES 234 - - - PART II. THE PSYCHOSES - - I. THE TRAUMATIC PSYCHOSES 253 - - II. THE SENILE PSYCHOSES 266 - - III. THE PSYCHOSES WITH CEREBRAL ARTERIOSCLEROSIS 280 - - IV. GENERAL PARALYSIS 293 - - V. THE PSYCHOSES WITH CEREBRAL SYPHILIS 308 - - VI. THE PSYCHOSES WITH HUNTINGTON'S CHOREA, - BRAIN TUMOR AND OTHER BRAIN OR NERVOUS - DISEASES 323 - - VII. THE ALCOHOLIC PSYCHOSES 344 - - VIII. THE PSYCHOSES DUE TO DRUGS AND OTHER EXOGENOUS - TOXINS 363 - - IX. THE PSYCHOSES WITH PELLAGRA 378 - - X. THE PSYCHOSES WITH OTHER SOMATIC DISEASES 392 - - XI. THE MANIC-DEPRESSIVE PSYCHOSES 409 - - XII. INVOLUTION MELANCHOLIA 427 - - XIII. DEMENTIA PRÆCOX 440 - - XIV. PARANOIA AND THE PARANOID CONDITIONS 461 - - XV. THE EPILEPTIC PSYCHOSES 475 - - XVI. THE PSYCHONEUROSES AND NEUROSES 489 - - XVII. THE PSYCHOSES WITH PSYCHOPATHIC PERSONALITY 504 - - XVIII. THE PSYCHOSES WITH MENTAL DEFICIENCY 524 - - INDEX 537 - - - - -AUTHOR'S PREFACE - - -In presenting a preliminary consideration of the subject of mental -diseases as a public health problem the author is actuated by no other -motive than that of stimulating the undertaking, at some future time, -of a comprehensive investigation and survey of an important field which -has never been systematically and adequately studied in the past. -Under existing circumstances the facts necessary for an intelligent -discussion of this question are unfortunately not obtainable. We -have, as will be shown, practically no information whatever as to the -incidence of mental diseases in the community. Hospital statistics are -still in such a chaotic state that we are not even in a position to -speak authoritatively of that part of the population which is entirely -within our supervision and control in institutions. Before any progress -can be hoped for we must at least have at our disposal accurate data -relative to the patients within the walls of our hospitals. This -presupposes a uniform scheme of statistical reports based upon some -common viewpoint. Adequate preparations for this undertaking have been -made by the American Psychiatric Association and the National Committee -for Mental Hygiene. Every hospital for mental diseases in the country -has been urged to cooperate in this movement. To show the necessity for -more actively prosecuting this research has been one of the principal -purposes of this book. - -In elaborating somewhat briefly the conception of the various psychoses -generally accepted by American psychiatrists, and for that reason -included in the classification adopted by the Association, every effort -has been made, as far as possible, to show the steps which have led up -to present developments. The author has endeavored to confine himself -to reflecting the views of others throughout and has used actual -quotations from recognized authorities as far as was deemed advisable. -In the discussion of the various psychoses frequent references will be -noted to the description of the various clinical groups contained in -the manual prepared by the Committee on Statistics for the American -Psychiatric Association. As is shown in the manual, these definitions -and explanatory notes were formulated by Dr. George H. Kirby. - -Special reference should be made to the important contributions to -the literature of psychiatry of such well-known American writers as -Meyer, Hoch, Kirby, White, Barrett, Campbell, Southard, Peterson, -Diefendorf, Jelliffe, Paton, Salmon, Russell, Buckley, Rosanoff, -Orton, Singer and many others. The work of Kraepelin, Bleuler, Nissl, -Alzheimer, Freud, Jung, Stekel, Janet and others abroad has exercised -an influence on the psychiatry of the day which must be recognized. We -are very largely indebted to Pollock and to Furbush for the available -information relating to the incidence of the various psychoses in this -country. To the American Psychiatric, for many years the American -Medico-Psychological, Association we owe an exhaustive historical -review of the institutional care and treatment of mental diseases in -the United States and Canada. - -Obviously this work was not intended as a textbook, nor was it designed -to serve the purpose of one. It is an appeal to those who are already -familiar with the fundamental principles of psychiatry. For that -reason the interpretation of mental mechanisms given so much space in -textbooks has been entirely omitted and no reference is made to the -treatment of the individual psychoses. Such reliable statistical data -as could be gathered from recent hospital reports and publications -have been utilized in full. The following institutions were represented -in this study: - - - 1. MASSACHUSETTS—fourteen hospitals (1919-1920): Boston State - Hospital, Boston; Bridgewater State Hospital, State Farm; Danvers - State Hospital, Hathorne; Foxborough State Hospital, Foxborough; - Gardner State Colony, Gardner; Grafton State Hospital, North Grafton; - McLean Hospital, Waverley; Medfield State Hospital, Harding; Monson - State Hospital, Palmer; Northampton State Hospital, Northampton; State - Infirmary, Tewksbury (Mental Wards); Taunton State Hospital, Taunton; - Westborough State Hospital, Westborough; Worcester State Hospital, - Worcester. - - 2. NEW YORK—thirteen hospitals (1912-1919): Binghamton State - Hospital, Binghamton; Brooklyn State Hospital, Brooklyn; Buffalo - State Hospital, Buffalo; Central Islip State Hospital, Central Islip; - Gowanda State Homeopathic Hospital, Collins; Hudson River State - Hospital, Poughkeepsie; Kings Park State Hospital, Kings Park, L. I.; - Manhattan State Hospital, Ward's Island, New York City; Middletown - State Homeopathic Hospital, Middletown; Rochester State Hospital, - Rochester; St. Lawrence State Hospital, Ogdensburg; Utica State - Hospital, Utica; Willard State Hospital, Ovid. - - 3. Twenty-one hospitals in fourteen other states: - - ARKANSAS—State Hospital for Nervous Diseases, Little Rock (1917-1918). - - COLORADO—Colorado State Hospital, Pueblo (1917 and 1918). - - CONNECTICUT—Connecticut State Hospital, Middletown (1917 and 1918); - Norwich State Hospital, Norwich (1905-1918 inclusive). - - MARYLAND—Springfield State Hospital, Sykesville, 1919; Spring Grove - State Hospital, Catonsville, 1918 and 1919. - - MICHIGAN—Pontiac State Hospital, Pontiac, 1917 and 1918; State - Psychopathic Hospital, Ann Arbor, 1917 and 1918; Traverse City State - Hospital, Traverse City, 1917 and 1918. - - MONTANA—Montana State Hospital, Warm Springs, 1917 and 1918. - - NEW JERSEY—Essex County Hospital, Overbrook, 1918. - - PENNSYLVANIA—State Hospital Southeastern District of - Pennsylvania, Norristown, 1919. - - SOUTH CAROLINA—South Carolina State Hospital, Columbia, 1918. - - UTAH—State Mental Hospital, Provo, 1918. - - VERMONT—Vermont State Hospital, Waterbury, 1917 and 1918. - - VIRGINIA—Central State Hospital, Petersburg, 1919; Western State - Hospital, Staunton, 1919. - - WASHINGTON—Eastern State Hospital, Medical Lake, 1917 and 1918; - Northern State Hospital, Sedro Woolley, 1917 and 1918. - - WEST VIRGINIA—Spencer State Hospital, 1917 and 1918; Weston State - Hospital, Weston, 1917 and 1918. - -These institutions may, I think, be looked upon as fairly -representative of the hospitals of this country. Based on their -official reports an analysis has been made of over seventy thousand -consecutive first admissions. - -There is no disposition on the part of the writer to overestimate the -value of statistical studies. Our conclusions should, however, be -based as fully as possible on facts rather than on abstract theories -or individual observations alone. The social, economic and clinical -aspects of mental diseases must all be given adequate consideration if -psychiatry is to fulfill its obligation to the community and assume a -dignified rôle in the advancement of modern medicine. - - JAMES V. MAY. - - Boston, Mass., - December 15, 1921. - - - - - PART I - - GENERAL CONSIDERATIONS - - - - - MENTAL DISEASES - - - - -CHAPTER I - -THE SOCIAL AND ECONOMIC IMPORTANCE OF MENTAL DISEASES - - -The importance of mental diseases as a factor in the social and -economic welfare of the community has not been given adequate -consideration, notwithstanding the remarkable progress of modern -psychiatry. Nor is this influence, unfortunately, one which can be -easily estimated or accurately determined. We have, as a matter of -fact, no data at hand to show the prevalence of disease, either -physical or mental, with any degree of exactness even under our most -elaborately organized forms of government. There is no complete -information available which will enable us to determine the frequency -of such important conditions as appendicitis, cardiac or renal -diseases, peritonitis, septic infections, diseases of the eye, ear, -skin or nervous system. It is true that there are, in the majority of -states, records of contagious or readily communicable diseases which -are probably fairly reliable. Aside from this, the only information at -our disposal is confined to mortality statistics. - -This suggests a further consideration of the advisability, if not -absolute necessity, of more extensive statistical studies of diseases, -both mental and physical, if the welfare of the community is to be -safeguarded and the future of medical science assured. Every physician -should be required by law to make careful reports to the Board of -Health of his state showing all medical conditions requiring treatment -by him or coming to his professional notice. The value of such -information to medical science would much more than compensate for the -comparatively small cost of such an undertaking. Nor is this procedure -more radical either in theory or practice than was the proposal to -report all communicable diseases only a few years since. The data thus -made available in the various states should be correlated and published -by the Public Health Service. - -The mortality statistics of the United States Census Bureau furnish -us with a valuable index of the relative frequency of the various -disease processes which determine the death rate of the community. -They are based on the transcripts of death certificates received -from the so-called registration area, which in 1920 had an estimated -population of 87,486,713. The total number of deaths reported in 1920 -was 1,142,558, a rate of 13.1 per 1,000 of the population. It is true -that the epidemic of influenza was still a factor of some importance at -that time. The rate for 1916, however, was fourteen, for 1917 fourteen -and two-tenths, for 1918 eighteen and one-tenth and for 1919 twelve -and nine-tenths per 1,000 of the population. The registration area -now includes thirty-four states:—California, Colorado, Connecticut, -Delaware, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, -Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, -Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North -Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, -Tennessee, Utah, Vermont, Virginia, Washington and Wisconsin. It -is interesting, at least, to note the states not included in the -registration area:—Alabama, Arkansas, Arizona, Georgia, Idaho, Iowa, -Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, West -Virginia and Wyoming. The results obtained from a study of the reports -from such an extensive district must be looked upon as thoroughly -representative of the country at large. The last complete statistics -available are those for 1920. Influenza was still an important factor -at that time, it being responsible for a death rate of 71 per 100,000. -The influenza rate was 98.8 in 1919, 302.1 in 1918, 17.3 in 1917, 26.5 -in 1916, 16 in 1915, 9.1 in 1914 and 10.3 in 1912. - -The important causes of death in 1920 were as follows: - - _Rate per _Percentage_ - 100,000_ - Typhoid fever 7.8 .6 - Malaria 3.6 .3 - Measles 8.8 .7 - Whooping cough 12.5 1.0 - Diphtheria and croup 15.3 1.2 - Influenza 71.0 5.4 - Tuberculosis of the lungs 100.8 7.7 - Other forms of tuberculosis 7.8 .6 - Cancer and other malignant tumors 83.4 6.4 - Simple meningitis 6.0 .5 - Cerebral hemorrhage 80.9 6.2 - Organic diseases of the heart 141.9 10.9 - Pneumonia (all forms) 137.3 10.5 - Other diseases of the respiratory system - (tuberculosis and pneumonia excepted) 11.6 .9 - Appendicitis and typhlitis 13.4 1.0 - Hernia, intestinal obstruction 10.6 .8 - Cirrhosis of the liver 7.1 .5 - Acute nephritis and Bright's disease 89.4 6.8 - Puerperal septicaemia 6.6 .5 - Other puerperal accidents of pregnancy and labor 12.5 1.0 - Congenital debility and malformation 69.8 5.3 - Violent deaths (suicide excepted) 78.5 6.0 - Suicide 10.2 .8 - Unknown or ill-defined diseases 17.7 1.4 - -The pneumonia rate (all forms) for 1920 was quite unusual, 137.3 per -100,000, as compared with 123.5 in 1919, 286.6 in 1918, 150.5 in 1917, -137.8 in 1916, 133.1 in 1915, 127.3 in 1914, 132.6 in 1913, 132.4 in -1912, etc. - -The following table shows the average rate per 100,000 of some of the -more important general diseases during a period of eight years (1912, -1913, 1914, 1915, 1916, 1917, 1918 and 1919): - - Typhoid fever 13.86 - Measles 9.01 - Scarlet fever 4.87 - Whooping cough 10.11 - Diphtheria and croup 16.30 - Tuberculosis (all forms) 144.52 - Cancer and other malignant tumors 80.27 - Cerebral hemorrhage, apoplexy 78.91 - Acute endocarditis and organic diseases of the heart 153.65 - Pneumonia (all forms) 152.98 - Acute nephritis and Bright's disease 101.63 - -The death rate from diseases of the nervous system is of particular -interest. The average annual rate per 100,000 of the population for the -years 1916, 1917, 1918 and 1919 was as follows: - - Encephalitis 1.0 - Meningitis (total) 8.17 - Locomotor ataxia 2.27 - Other diseases of the spinal cord (total ) 8.57 - Cerebral hemorrhage, apoplexy 80.57 - Softening of the brain 1.25 - Paralysis without specified cause 7.65 - General paralysis of the insane 6.77 - Other forms of mental alienation 2.17 - Epilepsy 4.07 - Chorea .10 - Other diseases of the nervous system 3.85 - -This shows a total death rate for nervous and mental diseases of 126.44 -per 100,000. It is a fairly reasonable assumption that of the above, -the following, at least, may be classified as having been definitely -associated with psychoses: - - _Rate per 100,000_ - Encephalitis 1.0 - Meningitis 8.17 - Softening of the brain 1.25 - General paralysis of the insane 6.77 - Other forms of mental alienation 2.17 - -We may, therefore, reasonably conclude that there was an average number -of at least 19.36 per 100,000 (from 1906 to 1910 this amounted to -32.1) in which the primary cause of death was associated with mental -diseases, an exceedingly conservative estimate. This does not take into -consideration the deaths due to senility (15.5) or suicide (12.8), -conditions which might very logically be included for obvious reasons. -It is, of course, well known that the psychoses rarely, if ever, appear -in the death certificates as a primary cause of death. As a matter of -fact, they are not always shown in the secondary causes. Information -on this subject is still less satisfactory from a statistical point of -view. During the year 1917 (contributory causes have not been reported -since that year) there was a total of 1,066,711 primary causes of death -shown in the registration area and only 372,291 contributory causes. Of -this number the following may be classified as having been associated -with psychoses: - - _Disease_ _Primary _Contributory - Cause_ Cause_ - Encephalitis 620 904 - Meningitis (total) 6,673 6,815 - Softening of the brain 888 722 - General paralysis of the insane 5,248 648 - Other forms of mental alienation 1,651 3,895 - —————— —————— - Total 15,080 12,987 - -The contributory causes definitely showing mental diseases constitute -only 3.4 per cent of the whole number, and the death rate for 1917, -including both primary and contributory causes suggestive of probable -psychoses, was 37.2 per 100,000. This would indicate that the number -of deaths from mental diseases shown in the primary causes represents -only about fifty-three per cent of all mental cases which are actual -factors in determining the death rate of the community. A comparison -of these figures with the number of cases dying in hospitals shows -that they cannot be looked upon as determining the percentage of the -general population showing psychoses. Of the 1,952 persons dying -in the institutions for mental diseases in Massachusetts in 1919, -approximately nineteen per cent showed the psychoses in the primary -causes of death. This percentage would probably be fairly constant -throughout the country. It is, of course, a well recognized fact that -the death certificate at best is not beyond suspicion and does not -furnish information regarding the cause of death which can be accepted -without question. - -Dr. Richard C. Cabot[1] has made an elaborate study of errors in -diagnosis as shown by autopsies. His work shows the following -percentage of diagnostic accuracy: - - _Per cent._ - Diabetes mellitus 95 - Typhoid fever 92 - Aortic regurgitation 84 - Lobar pneumonia 74 - Cerebral tumor 72.8 - Tubercular meningitis 72 - Gastric cancer 72 - Mitral stenosis 69 - Brain hemorrhage 67 - Aortic stenosis 61 - Phthisis, active 59 - Miliary tuberculosis 52 - Chronic interstitial nephritis 50 - Hepatic cirrhosis 39 - Acute endocarditis 39 - Bronchopneumonia 33 - Acute nephritis 16 - -It must be admitted that Cabot's findings are discouraging. They -are not so bad as they would seem, however, at first thought. Death -certificates, unfortunately, do not have the significance which they -should have. Physicians are well known to be entirely too careless -in their preparation and inclined to look upon them merely as legal -formalities which cannot readily be avoided. It is furthermore -difficult, as every doctor knows, to point to one immediate primary -cause of death in every instance. Very often there is a combination -of factors concerned and it is possible at practically every autopsy -to find lesions not represented in any way whatever in the death -certificate. It is unquestionably true that statistics of any kind -must be based on information some of which we know to be inaccurate. -This should not be used as an argument for discontinuing, absolutely, -our search for knowledge. It is merely a reason why our clinical -standards should be improved. - -An exceedingly important contribution to our rather limited fund of -accurate information regarding the general health of the country was -the publication recently issued by the Metropolitan Life Insurance -Company[2] on the mortality statistics of wage earners and their -families. This covers a period of six years (1911 to 1916) and -represents a study of 635,449 deaths. The cases reported came from -every state in the union with the following exceptions: Mississippi, -North Dakota, South Dakota, Wyoming, Colorado, Texas, Nevada, Arizona -and New Mexico. Canada and many other localities outside of the -"Registration Area" of the United States Census Bureau were included. -The facts presented in this report are unique in that they render -available for the first time a careful and detailed consideration -of the diseases which may be looked upon as representative of the -industrial population of the country. The various occupations shown in -the order of their numerical importance were as follows:—Laborers, -teamsters, drivers and chauffeurs, machinists, textile mill operatives, -clerks, office assistants, etc. It covers a study of ten million policy -holders and nearly fifty-four million years of life in the aggregate. -The age groups studied range from one year to seventy-five in ratios -not very different from those exhibited in the general population. The -death rate for all persons exposed was 11.81 per 1,000 as compared with -a rate of over thirteen per 1,000 (white) of the general population of -the registration area during the same period of time. The death rate -per 100,000 from 1911 to 1916 of some of the more important general -diseases was as follows: - - Typhoid fever 16.8 - Diphtheria and croup 24.3 - Scarlet fever 8.6 - Acute articular rheumatism 6.3 - Diabetes 14.4 - Cancer and other malignant - tumors 70.0 - Bronchopneumonia 30.2 - Diarrhea and enteritis (over - two years old) 13.9 - Cirrhosis of the liver 15.0 - Puerperal septicemia 8.1 - Accidents of all forms 75.1 - Ill-defined diseases 10.1 - Measles 8.9 - Influenza 15.0 - Tuberculosis (all forms) 205.1 - Tuberculosis (pulmonary) 173.9 - Alcoholism 4.7 - Diseases of the arteries, - including atheroma, - aneurysm, etc. 17.0 - Pneumonia (lobar and - undefined) 77.5 - Intestinal obstruction 5.9 - Bright's disease 96.8 - Suicide 12.2 - Homicide 7.0 - -The death rate for syphilis, locomotor ataxia and general paralysis of -the insane, combined, was 14.3 per 100,000. The percentage of deaths -due to diseases of the nervous system, many of which must be looked -upon as probably having been associated with mental disturbances, is -somewhat surprising, as shown by the following table: - - Encephalitis 1.0 - Meningitis 7.8 - Locomotor ataxia 1.5 - Acute anterior poliomyelitis 3.5 - Other diseases of the spinal cord 4.0 - Cerebral hemorrhage (apoplexy) 68.1 - Softening of the brain .9 - Paralysis without specified cause 5.2 - General paralysis of the insane 4.1 - Other forms of mental alienation 1.4 - Epilepsy 3.5 - Convulsions (non-puerperal) .2 - Chorea .2 - Neuralgia and neuritis .6 - Other diseases of the nervous system 2.5 - -This shows a total rate of 104.5 per 100,000 due to diseases of the -nervous system. If to this we add those dying of senility and the -suicides as probably representing psychoses it would bring the total -up to 123.2 per 100,000. It must be confessed, however, that such -speculations mean comparatively little. - -Practically the only other source of information at our disposal -relative to the incidence of general diseases in the community is the -tabulation of communicable diseases by Boards of Heath. The annual -report of the United States Public Health Service for 1919 shows a -case rate for diphtheria of 137 per 100,000 of the population based -on the reports of thirty-seven states. The case rate for measles in -thirty-seven states was 170. Poliomyelitis in thirty states showed a -rate of 2.5 and scarlet fever a rate of 110 in thirty-seven states. The -smallpox rate was sixty-eight and represented thirty-six states. The -typhoid fever rate for thirty-seven states was only forty. The case -rate for tuberculosis, all forms, was 346.7 in 1918. It was 274.2 in -New York, 271.6 in the District of Columbia and 271.3 in New Jersey. -These were the highest reported in the United States during that year. -Unfortunately these statistics relate to communicable diseases only. -This difficulty is due largely to the fact that comparatively few -states have made attempts to keep elaborate records. The reports of -Massachusetts are probably as comprehensive as any. The case rate per -100,000 of the population of all reportable diseases during the year -1920 was as follows: - - Influenza 938.5 - Measles 830.7 - Pneumonia, lobar 143.6 - German measles 12.5 - Pulmonary tuberculosis 173.1 - Tuberculosis, other forms 20.7 - Diphtheria 194.2 - Gonorrhea 186.7 - Whooping cough 258.3 - Scarlet fever 265.2 - Chicken pox 138.4 - Mumps 154.1 - Syphilis 77.2 - Ophthalmia 42.3 - Typhoid fever 24.2 - Dysentery 1.0 - Epidemic cerebrospinal meningitis 4.7 - Malaria 1.6 - Pellagra .4 - Smallpox .7 - Trachoma 2.2 - -The case rates for influenza and pneumonia cannot be looked upon as -representative, owing to the epidemic of 1919 and 1920. During 1917 -the death rate from influenza was 12.9 per 100,000 and from pneumonia -163.8. The death rate from heart diseases (organic diseases of the -heart and endocarditis) in Massachusetts in 1920 was 178 per 100,000 -of the population, from apoplexy 108.4, cancer and other malignant -diseases 116.7, Bright's disease and nephritis 92.4, diarrhea and -enteritis 52.9, violence 76.3, automobile accidents and injuries 11.9 -and suicides 10.1. - -It must be admitted that it is exceedingly difficult to establish a -definite basis for a comparison of our statistics relating to mental -disorders and those dealing with the frequency of other diseases -in the community. As has been shown, our information on the latter -subject, such as it is, has to do only with communicable diseases -and the reported death rates. In making an analysis of the reports -of mental diseases we are limited almost entirely to the institution -population. It is true that these statistics are much more reliable -than the others, as we are dealing with a stable population entirely -under control. The cases, furthermore, are almost invariably subject -to a prolonged observation and careful study. The diagnosis in almost -every instance is based on elaborate mental examinations and exhaustive -personal and family histories. It is, of course, true that there are -innumerable cases of mental diseases outside of institutions. There -were 18,268 patients at home on visit from the state hospitals alone -on January 1, 1920. Those not requiring hospital treatment or custody -in an institution can, however, be eliminated for the purpose of -comparative studies. The fact that an analysis of death rates alone -does not throw any light whatever on the frequence of psychoses for -reasons already given will, I think, be conceded. For statistical -purposes, at least, it may be assumed that the frequence of mental -diseases as shown by a study of the hospital population is fairly -representative of conditions existing in the community. - -For purposes of comparison we may contrast the admission rate of mental -diseases per 100,000 of the population in Massachusetts in 1920 with -the case rate of communicable diseases as follows: - - Mental diseases 101.7 - Chicken pox 138.4 - Diphtheria 194.2 - German measles 12.5 - Gonorrhea 186.7 - Measles 830.7 - Mumps 154.1 - Scarlet fever 265.2 - Syphilis 77.2 - Tuberculosis, pulmonary 173.1 - Tuberculosis, other forms 20.7 - Typhoid fever 24.2 - Whooping cough 258.3 - -The total institution population (mental cases) at the end of the -year 1920 represented a rate of 395.49 per 100,000 of the population. -It should be borne in mind that, with the exception of tuberculosis -and syphilis, the communicable diseases reported above represent, -as a rule, the total number of cases in the state during the year. -Comparative studies should, therefore, be based not on the number -of mental cases in the hospitals at any one given time, but on the -total number under treatment during the year. This would indicate _an -incidence of mental diseases of 566.98 per 100,000 of the population_. - -On January 1, 1916, there were 147 state and federal institutions -for the care and treatment of mental diseases in the United States, -as shown by the Census Bureau reports. There were at this same time -twenty-seven institutions for the feebleminded, nine for epileptics, -three for inebriates, forty-five for tuberculosis, twenty-eight for the -blind, thirty-three for the deaf, twelve for the blind and deaf and -eighty-four for the dependent classes.[3] - -The appropriations for the maintenance of these institutions for 1915 -amounted to $33,557,058.29. This constituted 7.6 per cent of the -appropriations made by those states for all purposes. In Massachusetts -it represented 14.8 per cent, in New Hampshire 10.1, in New York 12.7, -in Ohio 12, in Indiana 10.7, in Illinois 13.4, and in a number of other -states over ten per cent of the appropriations for all purposes. It was -equivalent to an average of $431.16 per million of the total assessed -valuation of these states. In Massachusetts it was as high as $653.62 -and in New York $567.37. This means thirty-three cents per capita for -all states, eighty-four cents for Massachusetts and sixty-eight cents -for New York. - -The actual expenditure for the maintenance of these institutions was -$36,312,662.20. For purposes of comparison, attention should be called -to the fact that the maintenance of the tuberculosis hospitals of the -United States for the same year cost $3,539,454.95, institutions for -criminals $21,244,892.00, for the feebleminded $3,341,442.85, for -epileptics $1,345,821.57, for the blind $1,066,973.14, for the deaf -$1,893,490.09 and for the dependent classes $9,675,932.37. - -The value of the property invested in the state and federal hospitals -for mental diseases in 1916 was estimated at $187,028,728.00. The -valuation of these institutions per 100,000 of the population -was $184,795.81. This does not include establishments for mental -defectives. The average value per patient was $938.43. In Massachusetts -it was $1,097.85 and in New York $1,039.85. In Arkansas it was as high -as $2,264.00. The total acreage of land was 109,503.2, an average of -744.9 acres per hospital. There were 33,124 persons employed, an -average of 226.9 for each institution. This represented one employee -for every six patients. - -The census taken by the National Committee for Mental Hygiene[4] -in 1920 shows 156 state hospitals for mental diseases, two federal -institutions, 125 county or city hospitals and twenty-one institutions -of a temporary care type. In the public and private hospitals for -mental diseases on January 1, 1920, there were 232,680 patients under -treatment. Of these, 200,109 were in public and 9,238 in private -hospitals. This represented an increase of 8,723 in two years. It is -interesting to note that city and county institutions cared for 21,584 -persons. - -The first authoritative information relative to the institution care of -mental diseases was obtained from the federal census reports of 1880. -In that year there were 40,942 patients in the public hospitals. In -1890 there were 74,028; in 1904, 150,151; in 1910, 187,791; in 1917, -232,873 and in 1918, 239,820. The rate per 100,000 of the population -increased from 81.6 in 1880 to 229.6 in 1918. From 1910 to 1918 the -general population increased 13.6 per cent and the hospital population -27.7 per cent. The rate per 100,000 of the population in institutions -in Massachusetts[5] on January 1, 1920, was 373.8, in New York 374.6, -in Connecticut 317.8, in Iowa 248.1, in Wisconsin 300.6, in California -297.2, in Pennsylvania 215.2, in Ohio 212.1, in Illinois 229.5 and in -Michigan 210.8. The admission rate per 100,000 of the population in -1917 was 151.6 in Massachusetts, 109.2 in Illinois, 124.8 in Montana, -97.3 in New York, 80.9 in Connecticut and 85.7 in California. - -The cost of maintenance in the state hospitals increased to -$43,926,888.88 in 1917 with an average per capita cost of $207.28. -The number of cases cared for in some of the more populous states is -of interest. On January 1, 1920, the institution population of New -York was 38,903, Pennsylvania 18,764, Ohio 12,217, Illinois 14,884, -Massachusetts 14,399 and California 10,184. - -Based on the estimated population of Massachusetts on July 1, 1920 -(3,869,098), the 1,475 deaths in institutions for mental diseases -would represent a death rate of 38.12 per 100,000 of the population. -The death rate for other diseases for that year was: diphtheria 15.4, -measles 9.0, pulmonary tuberculosis 96.7, typhoid fever 2.5, whooping -cough 14.0, scarlet fever 5.5, syphilis 5.8, lobar pneumonia 71.9 -and influenza 43.9. The importance to be attached, however, to such -comparisons is very uncertain at best. From the standpoint of social -and economic importance to the community there is another factor under -consideration which should not be overlooked. The duration of other -diseases, as a general rule, is comparatively short. A study of over -ten thousand deaths in New York state hospitals for mental diseases -shows the average hospital residence of these cases to have been over -six years. At the rate of admission to public institutions for 1917 -(62,898) and the average per capita cost for that year ($207.28) the -care of persons admitted annually, during their years of hospital life, -would mean an expenditure of over seventy-eight millions of dollars. - -If we figured the earning capacity of the 62,000 persons admitted to -institutions for mental diseases in the United States as averaging only -one thousand dollars per year, it would represent an economic loss to -the country of sixty-two millions of dollars annually. Estimated in -the same way, the total population of the hospitals would represent -the staggering sum of nearly two hundred and forty million dollars. -This, of course, does not take into consideration at all the cost of -maintenance or the property investment represented by hospitals. - -To avoid any possibility of confusion, no reference has been made -heretofore to statistical studies of mental deficiency or epilepsy. -From a public health point of view, however, and as social and -economic problems, they are questions which cannot be disregarded -in a consideration of mental diseases. As a matter of fact, they -are very closely correlated in many ways. A survey made by the -National Committee for Mental Hygiene shows that on January 1, 1920, -there were in this country thirty-two state institutions for mental -defectives, eleven admitting both feebleminded and epileptics and -twenty exclusively for the latter class.[6] In addition to this, one -city institution was reported. Of the private hospitals twenty-seven -care for the feebleminded only, and six for epileptics, while -nineteen admit either of these classes. The total number of mental -defectives in institutions on January 1, 1920, was 40,519. At that -time 34,836 were in state, 2,732 in other public institutions and -2,951 in private hospitals. In the following states they are cared -for in hospitals for mental diseases, no other provisions having -been made for their treatment:—Alabama, Arizona, Arkansas, Florida, -Louisiana, Mississippi, Nevada, South Carolina, Tennessee, Utah and -West Virgina. The states reporting the largest number are New York -5,762, Pennsylvania 4,281, Massachusetts 3,192, Illinois 3,147, Ohio -2,435, Michigan 1,849, Iowa 1,704, New Jersey 1,762, Wisconsin 1,624, -Minnesota 1,502, Indiana 1,264 and Missouri 1,047. At the same time -there were 14,937 epileptics under treatment, 13,223 in state, 859 in -other public institutions and 855 in private hospitals. Colorado, -Delaware, Georgia, Nebraska, New Mexico and Washington take care of -the epileptics in their hospitals for mental diseases. The intimate -relation between mental diseases and epilepsy is shown by the fact -that as nearly as can be determined at this time approximately thirty -per cent of all of the epileptics in our state institutions have been -committed as insane. This, however, nowhere nearly includes all of the -cases which actually show mental disorders of one kind or another. The -states showing the largest numbers of epileptics are New York with -1,683, Ohio 1,680 and Massachusetts 1,227. No other states report -over one thousand, although Michigan and Pennsylvania have over eight -hundred and Illinois and Missouri over seven hundred. - -Although the incidence of mental as compared with other diseases -prevalent in the community cannot be established with absolute -accuracy, sufficient evidence has been presented to warrant the -statement that from the standpoint of the public health we are dealing -with no other problem of equal importance today. The state care of -mental defects, epilepsy, tuberculosis and the deaf, dumb and blind is, -for various reasons, of much less consequence to the community than -the hospital treatment of mental diseases. The defective, delinquent, -criminal and dependent classes combined do not equal in number the -population housed in our state hospitals for mental diseases. Nor -does the number of cases cared for in the general hospitals of the -state, county or municipal type compare in any way with the mental -cases coming under state or federal supervision. It can, I think, be -said without any fear of contradiction that no other disease or group -of diseases is of equal importance from a social or economic point -of view. Perhaps nothing emphasizes this fact more strongly than the -report recently issued from the Surgeon General's office relative to -the second examination of the first million recruits drafted in 1917. -Twelve per cent of these were rejected on account of nervous or mental -diseases. The number disqualified for service finally reached a total -of over sixty-seven thousand. - -Mental integrity is now looked upon as a military necessity and is -insisted upon as one of the important requirements of the soldier. It -has been demonstrated conclusively that only men of the most stable -mental equilibrium can withstand the stress and strain of modern -methods of warfare. Nor are peacetime requirements any less exacting. -In commercial competition the law of the survival of the fittest is -practically absolute. The feebleminded often inherit wealth, but they -rarely acquire it. Vaccination for the prevention of smallpox is -compulsory and the isolation of communicable diseases dangerous to the -public welfare is rigidly enforced. At the same time we allow many -paranoics the freedom of the country and they occasionally assassinate -a President. Psychopaths are not infrequently elected to public office -and epileptics are not disqualified from driving high-powered and -dangerous motor vehicles. The engineers of our fastest trains must -not be color blind, but they occasionally are victims of the most -fatal of all mental diseases,—general paresis. The navigating officer -of a transatlantic liner, responsible for the lives of hundreds of -passengers, must pass an examination for a license, but he may be -dominated by delusions which escape observation because they are -not looked for. Important trials, where human lives were at stake, -have been presided over by insane judges. Army officers in command -of troops in time of war have been influenced by imaginary voices. -Insurance companies issue large policies to individuals suffering from -incipient mental diseases which could be detected by even a superficial -psychiatric examination. - -Serious consideration should be given to the advisability of subjecting -to a careful mental examination such persons, at least, as are to be -charged with an entire responsibility for the lives of others. It is -a question as to whether this procedure is not indicated in the case -of other important public trusts where the interest of the community -should be safeguarded. - -The correlation of psychiatry and psychology as scientific aids to -industrial efficiency promises to open up entirely new and important -sociological fields of research which have only recently attracted -attention.[7] This is a subject of far reaching importance. The extent -to which the industrial classes of the country are affected is shown -by the following analysis of the occupations represented by 104,013 -admissions to New York state hospitals: 1. Professional—(clergy, -military and naval officers, physicians, lawyers, architects, artists, -authors, civil engineers, surveyors, etc.) 1,926 or 1.8 per cent; -2. Commercial—(bankers, merchants, accountants, clerks, salesmen, -shopkeepers, shopmen, stenographers, typewriters, etc.) 7,572 or -7.2 per cent; 3. Agricultural—(farmers, gardeners, etc.) 5,942 or -5.7 per cent; 4. Mechanics—at Outdoor Vocations—(blacksmiths, -carpenters, enginefitters, sawyers, painters, etc.) 8,564 or 8.2 per -cent; 5. Mechanics at Sedentary Vocations—(bootmakers, bookbinders, -compositors, tailors, weavers, bakers, etc.) 7,501 or 7.2 per cent; -6. Domestic Service—(waiters, cooks, servants, etc.) 21,037 or 20.2 -per cent; 7. Educational and Higher Domestic Duties—(governesses, -teachers, students, housekeepers, nurses, etc.) 21,861 or 21 per cent; -8. Commercial—(shopkeepers, saleswomen, stenographers, -typewriters, etc.) 1,140 or 1.09 per cent; 9. Employed at Sedentary -Occupations—(tailoresses, seamstresses, bookbinders, factory workers, -etc.) 4,310 or 4.1 per cent; 10. Miners, Seamen, etc., 581 or .56 per -cent; 11. Prostitutes, 81 or .08 per cent; 12. Laborers, 12,962 or 12.4 -per cent; No occupation, 7,820 or 7.5 per cent; Unascertained, 2,715 or -2.6 per cent.[8] This certainly indicates an enormous economic loss to -the community. - -The intimate relation between mental diseases, alcoholism, ignorance, -poverty, prostitution, criminality, mental defects, etc., suggests -social and economic problems of far reaching importance, each one -meriting separate and special consideration. These problems, while -perhaps essentially sociological in origin, have at the same time an -important educational bearing, invade the realm of psychology and -depend largely, if not entirely, upon psychiatry for a solution. - - - - -CHAPTER II - -THE EVOLUTION OF THE MODERN HOSPITAL - - -The medical treatment of mental diseases had its inception, in this -country, in the wards of the Philadelphia Hospital, established in -1732 and referred to officially for over a century as an almshouse. It -included an infirmary for the "sick and insane," although it apparently -had no distinct and separate hospital department for many years. "In -1742," to use the words of Dr. D. Hayes Agnew, "it was fulfilling a -varied routine of beneficent functions in affording shelter, support -and employment for the poor and indigent, a hospital for the sick, -and an asylum for the idiotic, the insane and the orphan. It was -dispensing its acts of mercy and blessing when Pennsylvania was yet -a province and her inhabitants the loyal subjects of Great Britain." -In 1772 it housed as many as three hundred and fifty persons. In 1769 -the General Assembly passed an act authorizing the "Managers of the -Contributions for the Relief and Employment of the Poor," who had -charge of the almshouse, to issue bills of credit for the purpose of -relieving their indebtedness. This paper currency was issued in three -denominations—one shilling, two shillings and a half crown. The law -provided that counterfeiters or persons altering the denomination of -these bills should be "sentenced to the pillory, have both his or her -ears cut off and nailed to the pillory and be publicly whipped on his -or her back with thirty-nine lashes, well laid on, and, moreover, -every such offender shall forfeit the sum of one hundred pounds, to be -levied on his or her land, tenements, goods and chattels."[9] This -certainly must have discouraged counterfeiting. It was not until after -the institution was removed to the Hamilton estate in Blockley (now -a part of West Philadelphia) in 1834 that it came to be known as the -"Philadelphia Hospital and Almshouse," although there was no change -made in its organization or functions. In 1902, after one hundred -and seventy years of continuous existence, it was finally divided -officially for administrative purposes into The Philadelphia Home or -Hospital for the Indigent, The Philadelphia General Hospital and The -Philadelphia Hospital for the Insane. At that time the hospital was, as -it is today, the largest on the American continent. The institution, -which has admitted mental cases uninterruptedly since 1732, had over -seventeen hundred patients in the department for the insane. In 1917 -this number had increased to nearly three thousand. - -One of the reasons set forth by sundry petitioners in 1751 for a -"small Provincial Hospital" in Philadelphia, which at that time had -made provision for the care of indigent cases only, was "THAT with the -Numbers of People, the Number of Lunaticks or Persons distempered in -Mind and deprived of their rational Faculties, hath greatly increased -in this Province. That some of them going at large are a Terror to -their Neighbours, who are daily apprehensive of the Violences they may -commit; And others are continually wasting their Substance, to the -great Injury of themselves and Families, ill disposed Persons wickedly -taking Advantage of their unhappy Condition, and drawing them into -unreasonable Bargains, etc. That few or none of them are so sensible -of their Condition, as to submit voluntarily to the Treatment their -respective Cases require, and therefore continue in the same deplorable -State during their Lives; whereas it has been found, by the Experience -of many Years, that above two Thirds of the Mad People received into -Bethlehem Hospital, and there treated properly, have been perfectly -cured."[10] This resulted eventually in the opening of the Pennsylvania -Hospital in 1752. This institution is a general hospital supported -by private funds and has always received mental cases. A separate -department for mental diseases was established in West Philadelphia in -1841. Before this was done considerable difficulty was experienced on -account of the annoyance of the patients by curious-minded citizens -of the neighborhood. This developed into such a nuisance in 1760 that -it was suggested "That a suitable Pallisade Fence, either of Iron or -Wood, the Iron being preferred, shall be erected in Order to prevent -the Disturbance which is given to the Lunatics confined in the Cells -by the great Number of People who frequently resort and converse with -them."[11] It was also deemed advisable to employ "Two Constables or -other proper Persons, to attend at such times as are necessary to -prevent this Inconvenience until ye Fence is erected." The public -was notified later "that such persons who come out of curiosity to -visit the house should pay a sum of money, a Groat at least, for -admittance."[12] The Pennsylvania Hospital has played a very important -part in the history of the care and treatment of mental diseases in -this country. In 1919 it had over three hundred patients. - -The first institution designed and used exclusively for mental diseases -in this country was the Eastern State Hospital at Williamsburg, -Virginia. It was incorporated by the House of Burgesses in 1768 and -opened for patients on October 12, 1773. It is interesting to note -that the act of incorporation, except in the title, makes no use of -the word lunatic, refers frequently to the care and treatment of the -patients, authorizes the appointment of physicians and nurses, and -specifically designates the institution as a hospital and not an -asylum. The original building was one hundred feet long by thirty-two -feet two inches wide. During the first year thirty-six patients were -admitted. The first pay patient was received in 1774 at a rate of -fifteen pounds per annum. An allowance of twenty-five pounds per year -was made by the legislature for the maintenance and support of each -person admitted. Visiting physicians prescribed for the patients, and -the "keepers" for the first few years were not graduates in medicine. -The superintendents were, however, physicians after 1841. Known for -many years as the "Publick Hospital," the legislature made the mistake -of changing this designation to The Eastern Lunatic Asylum in 1841 -and it was not until 1894 that it again officially became a hospital. -Virginia opened its second institution, The Western State Hospital for -the Insane, at Staunton on July 25, 1828. Its third hospital was opened -at Weston on September 9, 1859. Virginia is thus entitled to the credit -of being the first commonwealth to furnish state care for mental cases -and make adequate provision for them. - -The next step in the evolution of hospital treatment of mental diseases -was taken by Maryland in incorporating a hospital for "The Relief of -Indigent Sick Persons and for the Reception and Care of Lunatics" in -1797. The hospital was formally opened in 1798 under the management of -the city of Baltimore, which leased the establishment in 1808 to two -physicians, who conducted it as a private institution until 1834. It -then reverted to the state and was operated as the Maryland Hospital. -The institution was removed to Catonsville in 1872 and is now known as -the Spring Grove State Hospital, the Johns Hopkins Hospital occupying -the site of the original building in Baltimore. Another interesting -event in the history of this institution was the founding of what -subsequently became the Mount Hope Retreat by the Sisters of Charity, -who withdrew from the Maryland Hospital in 1840. - -The earliest hospital care of mental diseases in New York was in the -wards of the New York Hospital which was opened in 1791. A separate -building for mental cases was ready for the reception of patients in -1808. The total number of cases treated up to July 1820 was 1,553. The -Bloomingdale Asylum replaced this in 1821, on a piece of property which -now belongs in part to Columbia University. Public patients were cared -for at the expense of the state until the opening of the New York City -Asylum in 1839. Church services were inaugurated in 1819. The hospital -buildings furnished accommodations for about three hundred patients. In -1894 the property on Bloomingdale Road was abandoned and the hospital -removed to White Plains in Westchester County. It is still known as the -Bloomingdale Hospital and is supported entirely by public contributions -and the income derived from the care of patients. It has about three -hundred and fifty beds. - -The activities of the "Religious Society of Friends," which were -indirectly responsible probably for the inception of the Pennsylvania -Hospital, ultimately led to the establishment of the Friends' Asylum -for the Insane at Frankford, Pennsylvania, in 1817. It was under -sectarian control until 1834, when its doors were thrown open to -all, without regard to religious belief. It claims to be the first -institution "erected on this side of the Atlantic in which a chain was -never used for the confinement of a patient."[13] The hospital is still -in a flourishing condition and has accommodations for over two hundred -patients. - -Massachusetts at the beginning of the nineteenth century had no -hospitals of any kind. In 1764, on the death of Thomas Handcock, it was -found that provision had been made in his will for the establishment of -a hospital for mental diseases in Boston. An expenditure of six hundred -pounds was authorized for the purpose of "erecting and furnishing a -convenient House for the reception and more comfortable keeping of such -unhappy persons as it shall please God, in His Providence, to deprive -of their reason in any part of this Province."[14] The Selectmen of -Boston declined this legacy on the grounds that there were not enough -mental cases in the vicinity to warrant the existence of such an -establishment. This proved to be an error of judgment on their part. -In 1811 the Massachusetts General Hospital was incorporated and a fund -of over $93,000 was subscribed for building purposes. As it was deemed -more urgent, the department for mental diseases in Charlestown was -opened first. It was ready for the reception of patients on October 6, -1818, when it admitted a young man supposed to be possessed of a devil. -This department became the McLean Asylum in 1826 as the result of a -legacy of $25,000 left to the institution by a Boston merchant of that -name. The corporation finally received in all an amount approximating -$120,000 from the McLean estate. As early as 1822 the first published -report of the hospital[15] called attention to the fact that the various -amusements offered the patients included "draughts, chess, backgammon, -ninepins, swinging, sawing wood, gardening, reading, writing, music, -etc." A carriage and pair of horses for the use of patients was -purchased in 1828. In 1835 the first pianos and billiard tables were -installed and a library of one hundred and twenty volumes placed in -the wards. Hot water heating was introduced in 1848. It is interesting -to note that in 1827 the visiting committee reported that the rates -for the maintenance of patients should not be less than three dollars -or more than twelve dollars per week. In 1882 the McLean Hospital -established the first training school for nurses connected with any -institution for mental diseases in this country. The first class was -graduated in 1886. In 1895 the hospital was removed to Waverley, -Massachusetts. A chemical laboratory was opened in 1900 and a -psychological laboratory in 1904. Hydrotherapy was first used in 1899, -and a gymnasium was built in 1904. In 1913 the hospital owned three -hundred and seventeen acres of land and had a capacity of two hundred -and twenty beds, with a plant valued at nearly two million dollars. - -The first provision for the care of mental diseases in Connecticut was -a direct result of the activities of the State Medical Society. It was -on their petition that the Hartford Retreat was chartered in 1822. -Over two thousand persons subscribed to a fund for the opening of the -hospital. These subscriptions included "$30 payable in medicine," "One -gross New London bilious pills, price $30" and two lottery tickets.[16] -About fourteen thousand dollars was subscribed in all, the citizens of -Hartford contributing four thousand. The hospital building, designed to -accommodate forty patients, was opened on April 1, 1824, and has always -been conducted on an unusually high plane. It now averages about one -hundred and seventy-five patients. - -Mental cases were first provided with hospital care in Kentucky when -the Eastern State Hospital was opened in Lexington on May 1, 1824. -Governor Adams, who suggested the establishment of this institution, -in a message written in 1821 expressed the opinion that it would be of -great benefit to the students of Transylvania University, "which would -in time repay the obligation by useful discoveries in the treatment of -mental maladies." - -The State Hospital at Columbia, South Carolina, was opened in December, -1828. A curious fact in connection with its history is that in 1829 the -management, having received no patients as yet, advertised for them in -the newspapers of South Carolina and adjoining states. - -In 1829 the necessity of making further provision for mental diseases -in Massachusetts became the subject of a legislative investigation and -a committee was appointed "to examine and ascertain the practicability -and expediency of erecting or procuring, at the expense of the -Commonwealth, an asylum for the safe keeping of lunatics and persons -furiously mad."[17] The report of this committee, of which Horace -Mann was Chairman, is exceedingly interesting. The following is an -illustration:—"To him whose mind is alienated, a prison is a tomb, -and within its walls he must suffer as one who awakes to life in the -solitude of the grave. Existence and the capacity for pain alone are -left him. From every former source of pleasure or contentment he is -violently sequestered. Every former habit is abruptly broken off. -No medical skill seconds the efforts of nature for his recovery, or -breaks the strength of pain when it seizes him with convulsive grasp. -No friends relieve each other in solacing the weariness of protracted -disease. No assiduous affection guards the avenues of approaching -disquietude. He is alike removed from all the occupations of health, -and from all the attentions everywhere but within his homeless abode -bestowed upon sickness. The solitary cell, the noisome atmosphere, -the unmitigated cold and the untempered heat, are of themselves -sufficient soon to derange every vital function of the body, and this -only aggravates the derangement of his mind. On every side is raised up -an insurmountable barrier against his recovery. Cut off from all the -charities of life, endued with quickened sensibilities to pain, and -perpetually stung by annoyances which, though individually small, rise -by constant accumulation to agonies almost beyond the power of mortal -sufferance; if his exiled mind in its devious wanderings ever approach -the light by which it was once cheered and directed, it sees everything -unwelcoming, everything repulsive and hostile, and is driven away -into returnless banishment."[18] The investigation conducted by this -committee led to the establishment of the Worcester Lunatic Hospital, -later the Worcester State Hospital, opened on January 19, 1833. The -original building was designed to care for one hundred and twenty -patients. After many years of agitation on the part of the public, -the hospital was removed to a site overlooking Lake Quinsigamond in -the outskirts of Worcester in 1877. It was soon found that it was -impracticable to dispense with the use of the old building on Summer -Street and it became the Worcester Insane Asylum, later the Worcester -State Asylum, and finally the Grafton State Hospital. In 1919 it again -became a part of the Worcester State Hospital. The original building is -in excellent condition today and promises an indefinite continuation of -an unusual career of usefulness. Many men destined to occupy positions -of importance in the psychiatric world were trained within its walls. - -The death of a prominent politician in 1806 is said to have led -indirectly to the establishment of the first hospital for mental -diseases in Vermont.[19] His medical advisers treated him for some -form of mental alienation by submerging him in water until he became -unconscious. It was thought that this "would divert his mind and, by -breaking the chain of unhappy associations, thus remove the cause of -his disease." As this plan failed he was given opium as "the proper -agent for the stupefaction of the life forces." In spite of this -vigorous treatment he died. The immediate event which made possible -the incorporation of the Vermont Asylum for the Insane in 1835 was a -legacy of ten thousand dollars rendered available for this purpose -by the will of Mrs. Anna Marsh of Hinsdale. The hospital was opened -in Brattleboro in 1836 and became the Brattleboro Retreat after the -establishment of the State Hospital at Waterbury. The state care of -mental diseases began in Ohio with the establishment of the Columbus -State Hospital, which was opened on November 30, 1838. This was the -first of a number of institutions now under the supervision of the Ohio -Board of Administration. - -The study of the development of the state hospital system of care -now takes us back to Massachusetts. Notwithstanding the fact that -the state already had two institutions for mental cases, McLean and -the Worcester Lunatic Hospital, further accommodations were urgently -indicated. This was largely on account of the needs of the metropolitan -population centering in the city of Boston. To meet this situation the -city established a hospital of its own in South Boston in 1839,—the -first municipal institution for this exclusive purpose in America. -Originally known as the Boston Lunatic Hospital and afterwards as the -Boston Insane Hospital, it finally became the Boston State Hospital in -December, 1908. Charles Dickens on the occasion of his visit to America - was very profoundly impressed by the hospital and made the following -references to it in 1842[20]:—"At South Boston, as it is called, in -a situation excellently adapted for the purpose, several charitable -institutions are clustered together. One of these is the hospital for -the insane; admirably conducted on those enlightened principles of -conciliation and kindness which 20 years ago would have been worse -than heretical, and which have been acted upon with so much success in -our own pauper asylum at Hanwell...." "At every meal, moral influence -alone restrains the more violent among them from cutting the throats of -the rest; but the effect of that influence is reduced to an absolute -certainty, and is found, even as a measure of restraint, to say nothing -of it as a means of cure, a hundred times more efficacious than all the -straight waistcoats, fetters and handcuffs that ignorance, prejudice -and cruelty have manufactured since the creation of the world." ... "In -the labor department every patient is as freely trusted with the tools -of his trade as if he were a sane man. In the garden and on the farm -they work with spades, rakes and hoes. For amusement they walk, run, -fish, paint, read, and ride out to take the air in carriages provided -for the purpose. They have among themselves a sewing society to make -clothes for the poor, which holds meetings, passes resolutions, never -comes to fisticuffs or bowie-knives as sane assemblies have been known -to do elsewhere; and conducts all its proceedings with the greatest -decorum. The irritability which would otherwise be expended on their -own flesh, clothes and furniture is dissipated in these pursuits. They -are cheerful, tranquil and healthy." ... "It is obvious that one great -feature of this system is the inculcation and encouragement, even among -such unhappy persons, of a decent self-respect." The institution was -removed to the Dorchester district of Boston in 1895, where it now -houses in the neighborhood of two thousand patients. The Boston State -Hospital was the first institution of its kind in the United States to -establish a separate psychopathic department, which was opened in 1912. - -Influenced doubtless by the attention given to this subject in other -states, Maine opened its first state hospital at Augusta in 1840. -There were between two and three hundred mental cases in the state -at that time. A second hospital was opened at Bangor in 1889. This -humanitarian movement naturally extended to New Hampshire. Governor -Dinsmore in 1832[21] called attention to the condition of the insane, -seventy-six of whom were in confinement. Of this number seven were in -cells or cages, six in chains and irons and four in jail. Of those not -in confinement at the time, some had been handcuffed previously, while -others had been in cells or chained. After much unavoidable delay the -New Hampshire State Hospital was opened at Concord on October 29, 1842. -The next hospital development appeared in Georgia. After an active -campaign inaugurated by the physicians of the state and continued for -several years, the Georgia State Sanitarium was opened in Milledgeville -in December, 1842. It now houses over four thousand patients. - -By this time it became evident that further procedures on behalf of -the persons requiring treatment for mental diseases in New York were -imperative. The Bloomingdale Hospital, although taxed to its utmost -capacity, was not able to meet the needs of the situation. In 1830 -the population of the state had increased to nearly two million. -The report of a legislative committee showed that there were 2,695 -insane persons in the state in 1830, with hospital accommodations at -Bloomingdale and one other private hospital at Hudson for only two -hundred and fifty of these cases. An extensive system of state care -was inaugurated by the opening of the Utica State Hospital on January -16, 1843. In addition to numerous other industries and occupations, a -printing office was established in the hospital and the publication -of the "American Journal of Insanity" was undertaken in 1844. This -was the first journal in the world to be devoted exclusively to the -subject of mental diseases. "The Opal," edited, published and printed -by the patients of the hospital, was started at the same time. In the -early days, strong rooms, padded cells and mechanical restraint of all -kinds were used extensively. The "Utica Crib" has received a great -deal of attention. This consisted of an ordinary ward bed enclosed in -wooden slats, making it impossible for the patient to escape. These -were eliminated for all time by Dr. G. Alder Blumer in 1887. Attendants -were first required to wear uniforms in 1887. During the following -year female nurses were assigned for the first time to male wards. -Annual field day exercises for the benefit of the patients have been -held since 1887. Baseball games, steamboat excursions, Fourth of July -celebrations and Christmas entertainments have been in vogue since -1888. With the development of a large department on the "Marcy" site, -nine miles from the city, the Utica State Hospital promises to add new -accomplishments to an already dignified history. - -The early care of mental cases in Rhode Island, as shown by a report -to the legislature by Thomas R. Hazard in 1851, was perhaps no worse -than that of other states, although the conditions he described -so graphically have not been attributed to other New England -communities by historians. The following extract from a codicil to -the will of Nicholas Brown, who died in 1843, is proof of the fact -that this unfortunate state of affairs had not entirely escaped -notice[22]:—"And whereas it has long been deeply impressed on my mind -that an insane or lunatic hospital or retreat for the insane should -be established upon a firm and permanent basis, under an act of the -Legislature, where that unhappy portion of our fellow beings who are, -by the visitation of Providence, deprived of their reason, may find -a safe retreat and be provided with whatever may be most conducive -to their comfort and to their restoration to a sound state of mind: -Therefore, for the purpose of aiding an object so desirable and in the -hope that such an establishment may soon be commenced, I do hereby set -apart and give and bequeath the sum of $30,000 towards the erection -or endowment of an insane or lunatic hospital or retreat for the -insane, or by whatever other name it may be called, to be located in -Providence or its vicinity." Supplemental contributions by Cyrus Butler -made it possible for the incorporators to found the Butler Hospital in -Providence. The first patients were received on December 1, 1847. - -More than any other one person, Miss Dorothea L. Dix of Massachusetts -was undoubtedly directly responsible for the inauguration of the state -care of mental diseases in this country. She is credited with having -memorialized twenty-two different state legislatures on this subject. -One of her first accomplishments consisted in inducing the New Jersey -legislature to make an appropriation for the establishment of the state -hospital at Trenton. This institution was opened in 1848, after some of -the hardest campaigning that Miss Dix conducted. The last years of her -life were spent as an honored guest of the hospital and she died there -in 1887 at the advanced age of eighty-five. - -Indiana inaugurated a system of state care by the establishment of the -Central Hospital for the Insane in 1848. The East Louisiana Hospital -at Jackson was opened in the same year. Missouri made its first -provision for mental cases by opening a hospital at Fulton in 1852. -Notwithstanding the fact that the first hospitals for mental diseases -in this country were located in Philadelphia, the Commonwealth of -Pennsylvania did not make any provision for a state institution until -the State Hospital at Harrisburg was opened in 1851. This was only -undertaken after a vigorous campaign on the part of Dorothea Dix had -made some legislative action almost imperative. This is probably the -only hospital in the country which has found it necessary to demolish -all of the original buildings and replace them by others. In 1847 Miss -Dix visited Tennessee and started a movement which resulted in the -opening of The Central Hospital for the Insane at Nashville, the first -institution of the kind in the state. California entered the state -hospital field in 1853 with the establishment of an institution at -Stockton. The St. Elizabeths Hospital in Washington, D.C., the first -federal institution for mental diseases, was opened for patients in -1855. It receives cases from the United States Government Services and -from the District of Columbia. Dorothea Dix was largely instrumental -in its origin. The St. Elizabeths Hospital was an early invader of the -field of scientific research. A pathologist was appointed in 1883. It -was one of the first institutions to use hydrotherapy extensively. It -now cares for nearly four thousand patients. Mississippi established -its first state hospital for mental diseases in 1856, North Carolina -in 1856, West Virginia in 1859, Michigan in 1859, Wisconsin in 1860, -Texas in 1861, Kansas in 1866, Minnesota in 1866, Connecticut in 1868, -Rhode Island in 1870 and Vermont in 1891. The Sheppard and Enoch Pratt -Hospital, a well known private institution in Baltimore, was also -opened in 1891. - -It is hardly worth while at this time to emphasize the fact that the -necessity of providing adequate facilities for the care and treatment -of mental diseases, a problem which received little consideration -of any kind for many years, gradually led to the elaboration of an -extensive system of state hospitals. These are to be found now in every -part of the country. They have long since passed through the purely -custodial stage and have developed into highly specialized modern -hospitals of most advanced type. Their function is to provide proper -treatment for persons who cannot for financial or other reasons be -cared for in the private hospitals which are to be found in almost all -localities. These institutions, originating in Virginia in 1773, now -represent one of the most important activities conducted by any state -government. The extent of the field which they cover is illustrated by -the fact that Kansas, Kentucky, Nebraska, North Carolina, Oklahoma, -Tennessee, Texas, Washington, West Virginia and Wisconsin each maintain -three state hospitals for mental diseases; Iowa, Maryland, Missouri -and Virginia each have four institutions of this type, Minnesota five, -California, Indiana and Michigan six, Pennsylvania seven, Ohio and -Illinois nine, Massachusetts twelve and New York fifteen. In addition -to this eight other states have two hospitals each and seventeen find -one such institution sufficient for their needs. It is worthy of note -that every state without any exception has now recognized the necessity -of making provision for the care and treatment of mental diseases. - - - - -CHAPTER III - -LEGISLATION AND METHODS OF ADMINISTRATION - - -The administration of the earlier hospitals for mental diseases -was placed very wisely in the hands of local boards of directors, -managers or trustees. These were made up of persons prominent in the -community in which they lived, well known as having a keen interest -in humanitarian movements, and fully deserving of the confidence -reposed in them by the public. They received no compensation other -than the satisfaction of having served in a worthy cause. The state -hospital at Williamsburg, Virginia, the first of its kind in America, -was controlled by a court of directors which was made up of some of -the most prominent Virginians of colonial days. It included Thomas -Nelson, Jr., a signer of the Declaration of Independence who served -with distinction in the Revolutionary War, Peyton Randolph, the -President of the first Continental Congress, and George Wythe, the -preceptor in law of both Marshall and Jefferson, as well as a signer -of the Declaration of Independence and professor of law at William -and Mary College, together with various other distinguished citizens, -some perhaps of less prominence, but all men of the highest standing -in Virginia. The first "court" consisted of fifteen members. The -second state institution, the Maryland Hospital, under the management -of the city of Baltimore for some years, was eventually placed under -the control of a board of visitors in 1828. Kentucky's first hospital -was from the beginning in the charge of a board of ten commissioners. -When the second Virginia institution was opened at Staunton, the -form of organization adopted at Williamsburg was duplicated and a -court of directors appointed. There were, however, thirteen instead of -fifteen members. The state hospital at Columbia, South Carolina, was -originally, and still is, under a board of regents. The Massachusetts -hospitals, dating from the opening of Worcester in 1833, have always -had trustees. The Vermont Asylum, later the Brattleboro Retreat, was -also managed by a board of trustees, as was the New Hampshire State -Hospital at Concord. The Georgia State Sanitarium, opened in the same -year, adopted a similar form of control. The Utica State Hospital has -been conducted from the first by a board of managers, a term which is -generally used by the New York institutions. When the Trenton State -Hospital was founded it was placed under a board of ten managers, -more or less along the lines followed at Utica. The State Hospital at -Raleigh, North Carolina, had a board of directors. For many years the -earlier institutions for mental diseases were under no other form of -control, the powers of the trustees being absolute. This is still the -case in a few states. Usually, however, there is some additional form -of supervision. - -Boards of trustees, managers, directors, or some other local -governing body, exist in the following states but without exclusive -control:—Alabama, California, Connecticut, Delaware, Georgia, Idaho, -Indiana, Louisiana (administrators), Maine, Maryland, Massachusetts, -Mississippi, Missouri, New Jersey, New Mexico, New York, Pennsylvania, -South Carolina (regents), Texas and Virginia.[23] - -In the following states the hospitals have no local boards of any -kind:—Arizona, Arkansas, Colorado, Florida, Illinois, Iowa, Kansas, -Kentucky, Michigan, Minnesota, Montana, Nebraska, Nevada, New -Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode -Island, South Dakota, Tennessee, Utah, Vermont, Washington, West -Virginia, Wisconsin and Wyoming.[24] - -As the state hospitals increased in number and importance, steps -were taken to coordinate their activities and for various obvious -reasons they were soon grouped together in departments. In the states -having a sufficient number of hospitals to warrant such a procedure, -separate specialized administrative units were established under -lunacy commissions, etc. In less populous communities where there were -only a few hospitals there soon developed a tendency to associate -them with the charitable, correctional and, in some instances, penal -institutions. Seventeen states, as has been shown, now have only -one hospital for mental diseases, eight have two and ten only three -institutions. This led either to placing the hospitals under boards of -charities and corrections or to the organization of new departments -known as boards of control. The hospitals for mental diseases are under -the supervision of boards of charities and corrections in the following -states:—Colorado, Connecticut, Indiana, Louisiana, Maine, Nebraska, -North Carolina, South Carolina, South Dakota and Virginia.[24] - -Boards of control exist in Arkansas, California, Iowa, Kentucky, -Minnesota, North Dakota, Oregon, Vermont, West Virginia and -Wisconsin. California has, in addition to this, a board of charities -and corrections and a commission in lunacy. Vermont has a director -of state institutions. In New Hampshire the board of trustees of -the state hospital constitutes a commission in lunacy. A number of -states have special departments for the supervision of hospitals -for mental diseases and in some instances for the control of -all institutions. Delaware has a board of supervisors of state -institutions. This is essentially a board of control. This is true -of the board of commissioners of state institutions in Florida. -Illinois has a department of public welfare, which places the control -of the charitable, penal and corrective institutions, as well as the -hospitals for mental diseases, largely in the hands of one man, a -layman. Michigan and Pennsylvania also have departments of public -welfare. Kansas has placed its hospitals under the control of a board -of administration of state charitable institutions. Maryland has a -lunacy commission and Missouri a board of managers. Montana and Nevada -each have a board of commissioners for the insane. New Jersey has a -state board of control of institutions and agencies, the direction of -the state hospitals being delegated to a commissioner of charities and -corrections. New York has the largest department in the country having -exclusive state hospital functions. It is under the supervision of a -hospital commission. Ohio has a board of administration which manages -and governs all of the charitable, corrective and penal institutions -of the state. This is, of course, a board of control pure and simple. -Oklahoma has a commissioner of charities and corrections who is an -elective officer, and has, in addition, a lunacy commission and a board -of public affairs. Rhode Island has a penal and charitable commission -of nine members. Utah has a board of insanity and Wyoming a board of -charities and reform. Massachusetts has a department of mental -diseases under the direction of a medical commissioner, with four -unpaid associates. In addition to the hospitals for mental diseases -the department has under its jurisdiction the institutions for the -feebleminded and the epileptics. - -The necessity of some form of central supervision or control, of -state institutions in general and hospitals for mental diseases in -particular, has long been a subject of serious consideration and -discussion. The administration of hospitals, prisons, reformatories, -etc., by a central board of control may be indicated in states -where there are only a few institutions and the creation of highly -specialized and expensive departments obviously would not be warranted. -The question may very properly be raised as to the necessity of any -supervision other than that by local boards of trustees in such -communities. A study of methods of supervision made some years ago by -the medical director of the National Committee for Mental Hygiene[25] -shows that the board of control system leaves much to be desired. -He has expressed himself on this subject in no uncertain terms, -as is shown by the following:—"Under Boards of Control, politics -influence the care of the sick to a degree unknown under different -types of supervision and the scientific and humane aspects of the -work undertaken are generally subordinated to doubtful administrative -advantages. With hardly an exception, these Boards of Control have not -endeavored to secure better commitment laws, to lead public sentiment -so that higher standards of treatment will be demanded or to deal with -the great problems of mental disease in any except their narrowest -institutional aspects. There has been striking absence of evidences -of any feeling of personal responsibility in these matters; indeed -many members of these boards would doubtless unhesitatingly state that -their duties do not involve such considerations. What the results -would have been if efficient and fearless local boards of managers had -been retained when these states created Boards of Control cannot be -stated. It is an essential part of the policy which places the care -of the insane under this form of administration that there shall be -no "division of responsibility" and, seemingly, there is no place -in such a scheme for bodies which are as much interested in the -personal welfare of the wards of the State as they are in governmental -"efficiency" and, which, moreover, are directly accountable to their -neighbors—the friends and relatives of patients. It is interesting to -compare some of the conditions mentioned with those existing in States -in which the care of the insane is entrusted to Boards created for that -special purpose. In these States,—California, Maryland, Massachusetts -and New York,—it can be said truly that the care of the insane reaches -its highest level." - -The experience of the past has shown that the injection of politics -into the administration of state institutions is almost invariably -due to the over-centralization of power in state departments, the -local boards of trustees or managers either being abolished or largely -deprived of their authority. The greatest menace to the future welfare -of the hospitals for mental diseases is, in the opinion of many, the -unfortunate result of a popular and more or less legitimate demand for -the reorganization of state governments, reducing their administrative -activities to a few separate departments, each one under the entire -charge of a director responsible only to the Governor. The argument -for this procedure is that it does away with innumerable commissions, -boards and departments working along independent lines without any -reference to the desirability of coordinating the activities of the -state as a whole and places the affairs of the commonwealth on an -efficient, systematic and economical basis. There is no question as to -the theoretical advisability of such methods. The difficulty is, that -in putting into practical operation this unquestionably commendable -undertaking, the humanitarian aspect of the charitable enterprises -conducted by state governments for more than a century, is likely to -be lost sight of. It is almost invariably urged that the directors -of these various departments should be experienced business men of -recognized ability and that in only such a way can the affairs of the -state be put on a "businesslike basis." It must be confessed that -this argument is one which appeals very strongly to the taxpayer, -who naturally has not given the matter very careful thought. There -are other important considerations, however, where the question of -administering hospitals is involved. As Commissioner Kline[26] has -said:—"If it be conceded that the care and treatment of the mentally -sick is a highly specialized medical problem, requiring the services -of medical experts, and that the institutions function primarily -for the welfare of the patient, then the supervision and control of -institutions should be in the hands of medical men especially trained -for the purpose." - -In some instances where the state governments have been reorganized and -the proposed consolidation of departments effected, the administration -of the state hospitals has come under the direction of a single -individual without hospital or institution experience of any kind and -without any special knowledge of medicine or psychiatry. There is no -escaping the fact that the administration of a hospital is a medical -problem. Nor is there any question as to the advisability of some -central supervision and financial control of institutions. The hospital -departments in our more populous states are, however, so extensive and -so important that they cannot be merged with other interests without -sacrificing to a considerable extent the welfare of the patients. It -should be remembered, moreover, that the administration of hospitals -for mental diseases is a specialty and a large one, not specifically -related to the problems arising in the management of charitable -institutions or prisons. The best results have been obtained where -there is a division of responsibility between local boards of trustees -or managers and a central body charged with the supervision, and a -limited or complete financial control, of institutions for mental -diseases only. The head of such a department should unquestionably be a -medical man with psychiatric hospital experience. This policy has been -responsible for the high standards maintained in the state hospitals of -Massachusetts and New York. - -It is, unfortunately, true that the care of mental diseases is not -exclusively a function of the state or private hospitals. In thirteen -states, county or municipal institutions are maintained and in -twenty-five, persons suffering from mental diseases may legally be -cared for in almshouses or poorhouses. - -There is little uniformity in the laws of the various states relative -to the hospital care of mental diseases, aside from the fact that -almost without any exception they are designed to provide solely for -the legal custody of the so-called "insane" and the protection of the -public. "Insanity," as a matter of fact, is a purely legal and not a -medical term, and may be said to relate to mental diseases only in so -far as they come within the jurisdiction of the courts. - -Statutory enactments relative to the forms of mental disease which -render the individual subject to legal custody and detention in an -institution are illustrated by the provisions of the Civil Code of -Illinois. This defines an "insane" person as one "who by reason of -unsoundness of mind is incapable of managing his own estate, or is -dangerous to himself or others, if permitted to go at large, or in such -condition of mind or body as to be a fit subject for care and treatment -in a hospital or asylum for the insane." In Alabama a person is legally -insane "if he has been found by a proper court deficient or defective -mentally so that for his own or others' welfare his removal is required -for restraint, care, and treatment." As a general rule, provision by -law is made 1, for an application for commitment; 2, for a medical -certificate of two or more properly qualified physicians showing the -person to be insane and a proper subject for care and treatment in an -institution, and 3, for the order of the Judge of a Court of Record for -commitment to a state hospital. The necessity of some form of legal -authorization for detention is a result of the fundamental principle -in English procedure that no man, against his will, may be deprived -of his liberty without due process of law. This right was recognized -and perpetuated by the Magna Charta signed by King John in 1215 and is -very definitely referred to in at least two different articles in the -Constitution of the United States. - -As a rule the application for commitment can be made only by certain -persons definitely specified in the law,—parents, near relatives, the -guardian or various public officials such as overseers of the poor. -In Massachusetts any person may sign such a petition. In Florida a -request must be jointly made by five reputable citizens. This would -not appear to be a material point in law. Some courts require that a -notice of the application be served upon the person whose commitment -is requested. In New York a notice must be served at least one day -prior to the hearing of the case unless the judge personally certifies -that substituted service has been made upon some other person or that -personal service was considered inadvisable for some adequate reason -noted and has therefore been dispensed with. The Arizona law requires -the judge to hold a hearing and have the alleged insane person before -him for examination. In California a jury trial may be requested and -a commitment made only on a verdict of insanity requiring a vote of -at least three-fourths of the jurors. A trial by jury may be asked -for in Colorado, Connecticut and many other states and must be -granted. Trial by jury is necessary in all cases in Georgia. Provision -is usually made for an appeal to some higher court. In many states -hearings are mandatory, in others they are optional with the court. In -Iowa each county has a board of three commissioners of insanity, one -of whom must be a physician. They have full authority under the law -to make commitments to institutions. Hearings are required in Kansas -but inquests in lunacy may be either by jury or commission at the -discretion of the court. In Kentucky inquests in lunacy must be held by -the Circuit Court of a county. The hearings are always in the presence -of a jury. In Louisiana two physicians must examine the patient in the -presence of the court. If the physicians do not agree the judge himself -decides the case. In Maine parents and guardians may send insane -minors to an institution without a commitment. Other insane persons -are subject to examination by the municipal officers of towns. In -Mississippi the Chancery Courts have jurisdiction over writs of lunacy -and an inquest may be made by jury. Nebraska has three commissioners in -insanity in each county, appointed by the judge of the District Court. -In the case of persons found insane they issue a warrant authorizing -admission to a state hospital. Each county in New Jersey has a -commissioner in lunacy, who has jurisdiction over the steps relating -to admission to institutions. Commitments are made by the judge of a -Court of Record. All orders for commitments in North Carolina must be -made by the clerk of a Superior Court. No person who has moved into the -state while insane is deemed a resident. North Dakota has a board of -three commissioners of insanity in each county, the county judge being -a member. The commissioners authorize hospitals to receive persons -found to be insane. Appeal may be made to a commission of three persons -to be appointed by the county judge. A jury trial is provided for, on -demand, in Oklahoma. In cases of appeal the county judge must appoint -a commission of three, one of whom is a physician, for the examination -of the patient. Examination by a commission of three is required in -Pennsylvania before commitment by a justice of a Court of Common Pleas -or Quarter Sessions. South Dakota has a board of three commissioners -of insanity in each county, the county judge being a member. An insane -person may be received in a hospital in Vermont on the certificate of -two physicians or by the order of a County or Supreme Court without -a physician's certificate. Appeal may be made to the state board -of control. In Virginia the committing judge and two physicians -constitute a commission for the examination of alleged insane persons. -In West Virginia there is a county commission of lunacy composed -of the president and clerk of the County Court and the prosecuting -attorney. Commitments are ordered by the commission. On the arrival -of the patient at a hospital a board composed of the Superintendent -and assistant physicians must be convened for the examination of the -patient. Application for commitment must be made in Wisconsin by three -reputable citizens. The determination of insanity in Wyoming must be -made in all instances by a jury of six men. - -When an insane person has been committed to an institution it is -sometimes the duty of an officer of the court to accompany the patient -to the hospital. The order of the court in Massachusetts includes -the following:—"Now, Therefore, You, the said Sheriff, Deputies, -Constables or Police Officers, and each of you, with necessary -assistance, ... are hereby commanded, in the name of the Commonwealth -of Massachusetts, forthwith to convey the said —— to the hospital -aforesaid, and to deliver h— to the Superintendent thereof, and make -due return of a copy of this precept with your doings therein." This -practically amounts to a warrant of arrest and makes the removal of -the patient to the hospital to all intents and purposes analogous to a -criminal proceeding. - -Attention should be called to one of the very excellent and humane -provisions of the New York Law:—"All county superintendents of the -poor, overseers of the poor, health officers and other city, town or -county authorities, having duties to perform relating to the poor, -are charged with the duty of seeing that all poor and indigent insane -persons within their respective municipalities, are timely granted -the necessary relief conferred by this chapter. The poor officers or -authorities above specified, except in the city of New York and in the -county of Albany, shall notify the health officer of the town, city -or village of any poor or indigent insane or apparently insane person -within such municipality whom they know to be in need of the relief -conferred by this chapter. When so notified, or when otherwise informed -of such fact, the health officer of the city, town or village, except -in the city of New York and the county of Albany, where such insane or -apparently insane person may be, shall see that proceedings are taken -for the determination of his mental condition and for his commitment -to a state hospital. Such health officer may direct the proper poor -officer to make an application for such commitment, and, if a qualified -medical examiner, may join in making the required certificate of -lunacy. When so directed by such health officer it shall be the duty -of the said poor officer to make such application for commitment. When -notified or informed of any poor or indigent insane or apparently -insane person in need of the relief conferred by this chapter such -health officer shall provide for the proper care, treatment and nursing -of such person, as provided by law and the rules of the commission, -pending the determination of his mental condition and his commitment -and until the delivery of such insane person to the attendant sent to -bring him to the state hospital, as provided in this chapter." - -In New York City these responsibilities are delegated to the trustees -of Bellevue and Allied Hospitals and in the county of Albany to the -Commissioner of Public Charities. In New York City a medical examiner -or nurse from the psychopathic wards of Bellevue Hospital, or both, -may be sent "to the place where the alleged insane person resides -or is to be found." If in the opinion of this examiner medical care -is necessary, the patient is taken to the psychopathic ward for -observation for a period of not to exceed ten days. When a person has -been committed to a state hospital in New York, the Superintendent -is required by law to send a trained nurse or attendant to bring the -patient to the institution. The desirability of having such cases under -the immediate care of nurses who have had psychiatric training would -seem to be obvious. There is no reason why persons suffering from -mental diseases should be subjected to the same form of supervision -that is given to criminals. The New York plan of holding the health -officer responsible for providing proper hospital care and treatment -for mental cases not coming directly under the legal jurisdiction of -other persons or officials is well worthy of serious consideration. -There would appear to be no reason why the health officer should not -be responsible for mental conditions in somewhat the same way that he -is for communicable diseases. Nor is there any public official to whom -the supervision of the insane pending commitment can more logically be -delegated. - -In twenty-nine states voluntary patients may be received by state -hospitals. The provisions of the law usually are that the patient must -make application on his own initiative, that his mental condition -must be such as to understand the purpose of this proceeding and -the need of treatment and that he must be released on a demand in -writing in from three to seven days of such request. In the twelve -following states the temporary care of the insane in jails, usually -as an emergency measure, is still authorized:—Arkansas, Colorado, -Georgia, Indiana, Iowa, Nebraska, North Dakota, Oklahoma, South Dakota, -Virginia, West Virginia and Wisconsin. Arrangements of some kind -for the emergency care of cases pending examination and commitment -are provided for in Connecticut, Illinois, Maine, Massachusetts, -Michigan, Minnesota, New Jersey, New York, North Carolina, Oklahoma, -Pennsylvania, South Carolina, Tennessee, Washington and Wisconsin. -Massachusetts has the most comprehensive provisions for temporary care -and observation. The Superintendent of a state hospital may receive and -detain, for not more than five days without a court order, any person -whose case is "certified to be one of violent and dangerous insanity -or of other emergency" by two qualified medical examiners. Officers -authorized to serve a criminal process, or police officers, must, on -the request of the applicant or one of the examining physicians, bring -such a person to the hospital. The applicant for this form of admission -must within five days arrange for the commitment of the person so -received, or for his removal from the hospital. - -Under the provisions of the Massachusetts Law a person found by two -qualified examiners to be in such mental condition that his admission -to a hospital for the insane is necessary for his proper care or -observation may be committed for a period of thirty-five days "pending -the determination of his insanity." The superintendent must discharge -such a person within thirty days if not insane or report to the -committing judge his opinion that the patient's mental condition is -such as to require a further residence in the hospital necessary. - -Under the provisions of the so-called "Boston Police Act" (chapter 307 -of the Acts of 1910) all persons suffering from delirium, mania, mental -confusion, delusions or hallucinations, under arrest or "who come under -the care or protection of the police of the city of Boston" shall be -taken to the Psychopathic Hospital "in the same manner in which persons -afflicted with other diseases are taken to a general hospital." Cases -suffering from delirium tremens or drunkenness may be refused by -the hospital authorities; otherwise, all such persons are admitted, -observed and cared for "until they can be committed or admitted to the -hospital or institution appropriate in each particular case" unless the -patient recovers or is discharged. - -Under the provisions of the Massachusetts Law "No person suffering from -insanity, mental derangement, delirium or mental confusion, except -delirium tremens and drunkenness, shall, except in case of emergency, -be placed or detained in a lockup, police station, city prison, house -of detention, jail or other penal institution, or place for the -detention of criminals. If, in case of emergency, any such person is -so placed or detained, he shall forthwith be examined by a physician -and shall be furnished suitable medical care and nursing and shall not -be so detained for more than twelve hours." In Boston these cases are -sent to the Psychopathic Hospital. In other parts of the state they -are cared for by the board of health of the city or town in question -until they can be committed to a hospital or cared for by relatives or -friends. - -The superintendent of a state hospital, under the authority of chapter -123 of the General Laws, "When requested by a physician, by a member of -the board of health or a police officer of a city or town, by an agent -of the institutions registration department of the city of Boston, or -by a member of the district police 'may' receive and care for in such -hospital as a patient, for a period not exceeding ten days, any person -who needs immediate care and treatment because of mental derangement -other than delirium tremens or drunkenness." Such cases are received -on application in writing filed at the time of the reception of the -patient or within twenty-four hours thereafter and must be discharged -or committed within ten days unless they make a request for voluntary -care. During 1920 there were 1,929 temporary care cases reported by the -various Massachusetts state hospitals, as follows: - -Boston State Hospital (Psychopathic Department) 1,049, Danvers 217, -Northampton 188, Worcester 159, Taunton 154, Westborough 68, Foxborough -56, Medfield 33, Grafton 2, and Gardner State Colony 3. - -Nowhere else in the country has this particular form of legislation -been used so extensively. It is something more than a mere -authorization for the reception of mental cases in observation or -detention wards. Under its provisions, at the request of any reputable -practicing physician and without further legal formalities, mental -cases may be cared for in a state hospital until their condition -can be definitely determined and arrangements made for their proper -disposition and treatment. The criticism to which this plan is open is -that the period of time, ten days, is not long enough. It should be -extended to thirty days at least. - -The provision of the Massachusetts Law for the determination of the -mental condition of persons under arrest or held under criminal charges -is an excellent one and well worthy of consideration. This is covered -by chapter 123 of the General Laws:—"If a person under complaint -or indictment for any crime, is, at the time appointed for trial or -sentence, or at any time prior thereto, found by the Court to be -insane or in such mental condition that his commitment to a hospital -for the insane is necessary for the proper care or observation of -such person pending the determination of his insanity, the Court may -commit him to a State hospital for the insane under such limitations -as it may order." The Court may in its discretion employ one or more -experts to examine such persons. These cases are on recovery returned -by the hospital authorities to the custody of the Court. One of the -interesting features of the Massachusetts Law is the provision relating -to persons indicted for murder or manslaughter but acquitted by a jury -by reason of insanity. Such cases are committed to a state hospital -for life and can be discharged only by the Governor of the state, with -the advice and consent of the Executive Council, when he is satisfied, -after an investigation by the Department of Mental Diseases, that such -a person may be discharged "without danger to others." Persons charged -with a crime "other than murder or manslaughter" and acquitted by a -jury by reason of insanity may also be committed by the Court to a -state hospital "under such limitations as it deems proper" and such -orders may be revoked at any time. - -A recent enactment (Chapter 415, Acts of 1921) provides that "Whenever -a person is indicted by a grand jury for a capital offense or whenever -a person, who is known to have been indicted for any other offense more -than once or to have been previously convicted of a felony, is indicted -by a grand jury or bound over for trial in the superior court, the -clerk of the court in which the indictment is returned, or the clerk of -the district court or the trial justice, as the case may be, shall give -notice to the department of mental diseases, and the department shall -cause such person to be examined with a view to determine his mental -condition and the existence of any mental disease or defect which would -affect his criminal responsibility. The department shall file a report -of its investigation with the clerk of the court in which the trial -is to be held, and the report shall be accessible to the court, the -district attorney and to the attorney for the accused, and shall be -admissible as evidence of the mental condition of the accused." - -The whole question of methods of commitment was made the subject of an -extended study by the National Committee for Mental Hygiene in 1919. A -comprehensive report covering such legislation as was deemed necessary -was submitted by a committee consisting of the following:—Dr. George -M. Kline, Commissioner, Massachusetts State Department of Mental -Diseases; Dr. Charles W. Pilgrim, Chairman of the New York State -Hospital Commission; Dr. Owen Copp, Superintendent, Pennsylvania -Hospital, Department for Nervous and Mental Diseases: Dr. Frank P. -Norbury, of the Board of Public Welfare Commissioners of Illinois; -and Dr. Frankwood E. Williams, Associate Medical Director, National -Committee for Mental Hygiene. In addition to the ordinary form of -commitment by a court of record in a civil proceeding, they recommended -legislation in all states authorizing temporary and emergency care, -observation pending the determination of insanity, and voluntary -admissions. In a general way, the legislation recommended followed the -lines of the present laws of Massachusetts and New York. - - - - -CHAPTER IV - -THE STATE HOSPITALS—THEIR ORGANIZATION AND FUNCTIONS - - -The efficiency of the hospital is very largely a reflection of its -organization, administration and personnel, but the material equipment -of the institution and the financial resources available are factors of -no less importance. The future of a hospital is often settled for all -time by the degree of judgment exercised in determining its location. -The founders must be guided to a very great extent by the purposes -which they hope to accomplish. In the location of a public institution -of any considerable size, however, there are certain considerations -which, if overlooked, will eventually lead to serious difficulties. The -initial cost of the property is unfortunately a factor which cannot be -disregarded. It is usually considered desirable for obvious reasons -to choose a site somewhat removed from great centers of population. A -sufficient acreage must be obtained to guarantee an adequate amount of -land for farming and gardening on a fairly large scale. This not only -insures a ready occupation for patients, but will materially reduce -the cost of maintenance. A point which should never be lost sight of -is the necessity of choosing a location which can be reached easily by -railroads, trolley cars and motor trucks. The hospital must be readily -accessible to the relatives and friends of patients. It is equally -important that it should be convenient for employees; otherwise an -adequate force of nurses and attendants can only be maintained with -great difficulty. Above all, the hospital should be in the community -which it is destined to serve. The patients should not be removed -to any great distance from their homes. In numerous instances severe -hardships have been inflicted upon all persons concerned owing to the -fact that state institutions have been located in districts where they -are not needed by the community and where they cannot be easily reached. - -Every large public hospital should be in almost immediate contact with -a railroad. Otherwise thousands of dollars must be expended annually -for the transportation of coal, food and other necessary supplies. -The fertility of the soil to be used for agricultural purposes is -only second in importance to the necessity of obtaining satisfactory -building sites. A practically unlimited supply of pure water is -absolutely essential. The possibility of utilizing some existing system -of sewerage or providing the institution with one of its own should be -given serious consideration. Drainage must be provided for and sanitary -surroundings obtained. There should always be opportunity for future -expansion of the plant. Practically every state of any importance -has at least one institution which has been seriously handicapped -throughout its entire existence by an unfortunate neglect of one or -more of these important considerations. - -In 1917 a special commission was appointed by the Governor of New York -for the purpose of preparing an intelligent and comprehensive plan for -the future development of the institutions of the state. In a report -presented during the following year the commission called attention -to a phase of hospital construction the importance of which cannot be -too strongly emphasized.[27] "Nearly all of the state hospitals suffer -from the fact that as originally planned they were smaller institutions -and of a different type from those that are now desired, and the -additions which have been made from time to time during the past -twenty-five years, in order to meet the immediate demands for increased -space, have not always been made with a completed and well rounded -institution in mind. The results are badly balanced institutions, -lacking in efficiency and ease of administration.... In planning a -hospital for the insane the ultimate maximum capacity should be decided -upon even if it is not possible to build the entire institution at -once. A well co-ordinated plan should then be developed, which would -permit the building of various sections as appropriations become -available, with the idea of finally having a complete institution, -harmonious in arrangement, and so planned as to attain the most -desirable classification and the maximum of efficiency and economy in -administration." The classification of the population which an average -state hospital should provide buildings for is shown by the commission -as follows:—Reception building, six per cent; convalescents, four -per cent; hospital buildings, two per cent; buildings for the infirm, -eight per cent; noisy, disturbed, etc., twenty per cent; epileptics, -three per cent; working patients, forty per cent; quiet, clean and -appreciative chronic class, fourteen per cent; and tuberculous, -three per cent. They also suggest that every hospital should have a -small isolation building for the care of contagious diseases. Their -recommendation as to the amount of floor space per patient in the -various buildings is exceedingly interesting and no less important. -"First, That single rooms should have about eighty square feet of -floor space. A room seven feet by eleven or eight by ten, while large -enough for one bed, a bureau and a chair, is not large enough to permit -placing two beds end to end or alongside of each other. If a room -measures ten feet by twelve, there is always a temptation to place -two beds in it if the hospital becomes crowded, and the advantage -of single rooms is wholly lost. The number of single rooms in an -institution should be from fifteen per cent to twenty per cent of the -population, varying with the character of the cases to be cared for. -Second, Dormitories should have above fifty square feet of floor space -per patient, and no dormitory should have more than fifty beds nor -less than six. This, of course, applies to the wards for the chronic -cases. An adequate system of ventilation throughout the hospital is -presupposed. Third, The day space allotted should provide forty to -fifty square feet per patient. Fourth, The dining room allowance should -be from fourteen to sixteen square feet per patient, in order to permit -the use of small tables and to provide adequate passages for the -expeditious service of food." - -In former years much time and space was devoted to a discussion of the -respective merits of the congregate type of hospital construction, the -so-called "Kirkbride" or block plan (although it was in use long before -Kirkbride described it) and the arrangement of buildings in groups. -There is no question but what an institution that is all under one roof -can be administered much more economically and operated at a lower -maintenance cost. Very little, if any, advantage is derived by the -patient from the group scheme. In its practical operation in the state -hospitals almost the only point of difference, as far as the patient -is concerned, is that he must go out of doors as a rule to get to the -dining room in the summer as well as in the winter, in good weather and -bad. This has been responsible for much discomfort and has resulted in -a great increase in the number of escapes. When buildings are arranged -in groups they should be connected with a central dining room either -by corridors or tunnels. Small cottages, except for special purposes, -are out of the question as far as state institutions are concerned, on -account of the cost involved. As a matter of fact, in the development -of a large hospital all types of construction must be ultimately -employed. The reception building should be separate and detached -from the other parts of the hospital, as should, of course, the wards -for the tuberculous cases, the contagious building, the building for -convalescents, the farm cottages, etc. The noisy and violent patients -certainly should be in separate buildings far enough away so that they -will not disturb others. The hospital wards, for the exclusive care of -bed patients, may well be detached. The larger part of the hospital -population, consisting of the quiet, orderly, chronic, custodial cases, -can be cared for just as well in the large buildings as in groups or -cottages. - -The reception building, from the standpoint of the patient, is the -most important building in the hospital. It should be equipped to care -for from five to ten per cent of the hospital population, depending -entirely upon the location and special problems of the institution in -question and the community which it serves. In any event it should -include both large and small dormitories, the larger accommodating -from fifteen to thirty patients, and the smaller not more than six or -eight, adequate day-room space, numerous single rooms and commodious -enclosed verandas. There should, of course, be ample dining room -facilities as well as diet rooms to provide for those whose condition -makes it necessary or advisable for them to be served in the wards. -Special provision should be made for the separate care of the noisy, -violent, disturbed, etc., and they should be in a part of the building -which can be isolated. The suicidal cases must be given special care -and separate supervision. A well equipped hydrotherapeutic department -is an essential part of the reception building. Continuous bath and -pack rooms are equally necessary. No less important are admission and -examination rooms, a pharmacy, laboratories, rooms for the special -treatment of eye, ear, nose and throat conditions, recreation rooms, a -library, space for occupational therapy, provision for social service -and psychological departments, etc. At least two physicians should -reside in the building. It is unfortunate that reception buildings as -a rule are entirely too small. They should be large enough so that the -acute and recoverable cases, as well as those found on observation not -to require hospital treatment, can be returned to their homes without -any further contact with the hospital or the necessity of a protracted -residence with the chronic and purely custodial cases. - -The experience of many years has shown quite conclusively that the -supervision and general direction of a hospital for mental diseases -should be delegated to a medical superintendent with such clinical and -administrative assistants as the nature and size of the institution -may indicate. The dual system of management frequently suggested -by politicians, with a layman as the executive head and a medical -director subordinated to his authority, has proved to be a failure -in every instance in which it has been tried. The administrative -details necessary to the successful operation of a large institution -are such as to require the entire time and attention not only of the -superintendent but usually of an assistant superintendent. In a large -hospital the activities of the medical staff should be under the -immediate supervision of a specialist whose training and experience -qualify him to direct the clinical and psychiatric work of others. -This is a quite sufficient task to require the constant attention and -undivided energies of a clinical director who has no other interests -or responsibilities. In this way recent graduates with proper -qualifications may be interested in entering the psychiatric field. -Every state hospital, in addition to fulfilling its entire duty to the -patients in its charge, should be a training school for psychiatrists, -social workers, psychologists, occupational therapists and psychiatric -nurses. The hospital staff, as well as providing for the services of -physicians well trained in psychiatry, must include other specialists. -A hospital of any size should have a staff of consulting and visiting -physicians including several internists and surgeons, a gynecologist, a -neurologist, a dermatologist, an ophthalmologist, a laryngologist and -an otologist. These consultants should visit the hospital regularly and -direct and supervise the work of the resident staff along the lines -of their specialty. It is hardly necessary to suggest today that a -hospital of any size without a resident dentist is one which is not -properly equipped to care for its patients. - -Nothing is more important in the modern hospital than the training -school for nurses. It is the nursing care of the patients more than -any other one thing perhaps that has made the difference between the -old time asylum and the psychiatric hospital of the highest type. The -state hospital training school of the present day offers its pupils -a three years' course of instruction, including a year of practical -experience in an affiliated general hospital. Its graduates, moreover, -are trained not only in psychiatric and general nursing, as well as -the care of neurological cases, but in hydrotherapy, occupational -therapy, reeducational, industrial and social work. The nurse of the -future who has had no psychiatric training and experience is one whose -education is not complete. Every effort should be made to encourage the -training schools of general hospitals to send their senior nurses to a -hospital for mental diseases for a service of at least three months. -The specialized care and treatment of cases suffering from tuberculosis -has been neglected in many institutions. It should not be necessary to -suggest that such cases have no place in a ward with other patients -who have not contracted that disease, and yet in many of our large and -important hospitals there are no separate buildings for that purpose. -It has been shown by statistical studies that persons suffering from -dementia praecox have an unusual and remarkable susceptibility to -tuberculosis. Unfortunately, it has never been possible to completely -segregate the epileptics in our public hospitals for mental diseases. -They constitute a special problem and should receive a different diet -as well as an entirely different type of treatment. Their presence in -the wards with mental cases is highly detrimental to both. This is -equally true of drug cases and mental defectives, and especially the -so-called defective delinquents. - -There are many reasons why every hospital of any consequence that -is engaged in the care of mental diseases should be provided with a -well trained and experienced pathologist. Examinations of urine and -sputum must be made daily. Widal tests are sometimes necessary for -the diagnosis of typhoid fever. Analyses of water and milk should -be made at frequent intervals. Bacteriological vaccines should be -available at any time. Only laboratory investigations can throw any -light on the source of the frequent infections which are found in large -institutions. Diphtheria is a disease which must be guarded against -constantly. Lumbar punctures, Wassermann tests, the colloidal gold -reaction, cell counts, etc., are daily necessities in a large hospital. -We lose much information of value to us if autopsies are neglected. A -definite program of pathological research work should be carried on in -every hospital for mental diseases. It has been suggested frequently -that the microscope has no part to play in studying the etiology of -the psychoses and that they are purely functional in origin. Many of -them are functional. It is nevertheless equally true that we have a -definite pathological basis for the traumatic psychoses, the senile -conditions, cerebral arteriosclerosis, general paresis, brain syphilis, -cerebral growths, mental deficiency and many other brain and nervous -diseases. The psychosis most clearly understood from the standpoint of -etiology, pathology, symptomatology and diagnosis is general paresis. -Our definite knowledge of that condition was obtained entirely from the -laboratory. Further information may be secured in the same way. While -it is true that we have not had any great amount of success as yet with -the treatment of general paresis with salvarsan, the positive knowledge -that the disease is of syphilitic origin should encourage us in our -efforts to solve the problem of curing it. Histological, pathological, -bacteriological, chemical, clinical and psychological researches must -be pushed vigorously if psychiatry is to keep pace with the general -progress shown by modern medicine in other fields. - -In connection with this subject some reference should be made to -the general neglect of statistical studies. They should be based on -detailed, accurate and exhaustive clinical records, which unfortunately -are not now available to the extent that they should be. It is true -that in a general way some progress has been made. The studies -instituted by the American Psychiatric Association will ultimately -tell us quite definitely the frequency of the various psychoses, -the recovery and death rates to be expected, etc. We should not be -satisfied with that alone. The great wealth of material which we have -in our hospitals, together with the excellent clinical and laboratory -facilities at our disposal, should enable us to accomplish much more. -An analysis of our case records, if properly made, would give us -definite information as to the clinical aspects of the mental diseases -we are dealing with. These should be made the subject of exhaustive -study by the scientific institutes and other research departments -conducted by the various state authorities to an extent never yet -undertaken or even attempted. If it cannot be done by the states it -should be instituted by the federal government. - -The fact that the field of influence of our public institutions should -extend far beyond the walls of the hospital is one which has received -general recognition only within the last few years. Every hospital -has a large number of patients still within its legal custody but who -have been allowed to return temporarily to their homes or occupations -while still under observation pending their final discharge. These -are now, to a very limited extent, under the supervision of social -workers. The hospitals have unfortunately, owing to a lack of funds, -never had a sufficient number of social workers to look after them -properly. The hospitals as a rule now maintain out-patient departments -where those who have been allowed to go home on visit or resume their -occupations are encouraged to come for assistance and advice. The -public is gradually learning to take advantage of this opportunity to -obtain expert advice on matters relating to mental hygiene and secure -professional opinions as to the disposition and treatment of members -of the family showing symptoms of incipient mental disorders. This -field of influence extends even further. Clinics have been established -in various locations outside of the hospitals in the larger cities -in several states. In New York they are conducted by state hospital -physicians in Binghamton, Brooklyn, Buffalo, Plattsburg, Dunkirk, -Jamestown, Olean, Salamanca, Poughkeepsie, Peekskill, Yonkers, Mount -Vernon, Mineola, Newburgh, Kingston, Rochester, Middletown, Ogdensburg, -Malone, Watertown, Utica, Schenectady, Ovid, Ithaca and New York City. -Physicians and social workers are in attendance at all of these places. -The last published report of the New York State Hospital Commission -(1919) shows that 7,203 visits were made to these clinics during the -year. Paroled patients made 5,102 of these, discharged patients 265 -and others who had no connection with the hospitals at all, 1,836. -In addition to this the hospital social workers made 3,496 visits to -paroled patients as well as four hundred and sixty-two visits to other -patients for the purpose of preventing mental diseases. Situations -were obtained for one hundred and sixty-seven discharged patients. An -enormous amount of work was also done in history taking, etc. Numerous -clinics have been established in Massachusetts by the Department of -Mental Diseases.[28] During the year ending November 30, 1919, a total -of 4,333 visits were reported. Of these 3,057 were first visits. The -number reported by the various hospitals was as follows:—Worcester -State Hospital 1,278, Taunton State Hospital 182, Northampton State -Hospital 458, Danvers State Hospital 282, Westborough State Hospital -177, Grafton State Hospital 129, Gardner Colony 65, Monson State -Hospital 70, Foxborough State Hospital 27, Massachusetts School for -the Feebleminded 541, Boston State Hospital (Psychopathic Department) -2,112. Clinics were maintained in the following localities:—Athol, -Boston, Brockton, Danvers, Fitchburg, Foxborough, Gardner, Grafton, -Gloucester, Greenfield, Haverhill, Lawrence, Lynn, Malden, Medfield, -Monson, New Bedford, Newburyport, Northampton, Pittsfield, Salem, -Springfield, Taunton, Waverley, Westborough, Worcester and Wrentham. - -This is a gratifying evidence of progress. There are indications of an -awakening. The hospital treatment of mental diseases will eventually be -conducted on a much higher plane and along lines more nearly comparable -to those of the general hospital. A study of legislation relating to -mental disease shows that efforts are being made very generally to -make their treatment a medical problem rather than a legal question. -It has been no easy matter to obtain treatment for mental diseases, -assuming a desire on the part of the individual to take advantage -of such an opportunity. A review of our legal enactments shows that -as a general rule it means a formal application, properly verified, -an elaborate examination by two qualified physicians, an order of -commitment by the judge of a court of record, a legal notice and an -opportunity for a hearing if one is demanded. Pennsylvania as early -as 1883 made provision for the immediate admission of such cases as -required it, pending the usual court procedure. As has been shown in -another chapter, arrangements have been legalized in many states for -the emergency reception of mental cases, at least for those persons -who are known to be dangerous to themselves or others. Temporary care -enactments have been written into the law in various communities, -making it possible to keep mental cases under observation for a limited -period of time. In a large number of states it is now possible for -a person requesting treatment voluntarily to receive it on his own -application without any other legal formalities. Perhaps the greatest -advance is the custom, not so infrequent now, of sending persons held -by courts under a criminal process to a hospital for observation as to -their mental condition. The fact should not be lost sight of that it is -still possible to find "insane" persons in jails, poorhouses and county -institutions in many parts of the country. Worse than this, however, is -the custom of delegating their care to police officers. Nevertheless, -distinct progress has been made. - -As has already been shown, a study of methods of care in this country -indicates that every state has passed through several very definite -preliminary stages. These may be summarized as follows:— - - 1. A period of home care only. During the colonial days mental cases - were cared for at home or not at all. There was nothing else that - could be done for them at the time. - - 2. Confinement with criminals. In cases of unusual violence, dangerous - persons were confined in jails, lockups and prisons. If necessary, - under certain circumstances the law in some states even authorized the - use of chains. - - 3. Almshouse care. There has been a time in practically every state - when the poorhouse has been looked upon as the proper place for the - insane. - - 4. Asylum care. As a result of the agitation of Dorothea Dix and - others, mental diseases were eventually given custodial care in - asylums. - - 5. Modern hospital care. - -In 1894 Dr. S. Weir Mitchell[29] delivered the annual address at -the semi-centennial meeting of the American Medico-Psychological -Association in Philadelphia. It was a very painful occasion for many. -His remarks may be summed up as a vigorous arraignment of the asylum -methods of that day. He severely criticized the public, the state -legislatures, boards of management and the hospital superintendents. -His principal charge was that they were operating asylums along the -lines of the past and were perfectly satisfied with what they had -accomplished. He pointed out the necessity of properly qualified -physicians, more scientific methods and modern treatment. "We have -done with whip and chains and ill usage, and having won this noble -battle have we not rested too easily content with having made the -condition of the insane more comfortable?" It seems incredible that -in the case records of that day he should have found no evidences "of -blood counts, temperatures, reflexes, the eye-ground, color fields, all -the minute examinations with which we are so unrestingly busy." One -institution was unable to furnish Dr. Mitchell with a stethoscope or -an ophthalmoscope! One of his criticisms was that few institutions for -mental diseases had a training school for nurses or any provisions -for hydrotherapy. His last words were almost a prophecy: "Fifty years -hence, when we must all have been swept away, another will possibly -stand in my place and tell your history, and to him and the bountiful -wisdom of time I leave it to be declared whether I was right or wrong." -Dr. Mitchell's description of the asylums and their methods was -bitterly resented. Who is there today who would not feel that he was -fully justified? - -The time has come when we must again look to the future and prepare for -it. The purely custodial care of mental diseases has led to a dread of -asylums on the part of the public. There are unfortunately too many -hospitals that are asylums in everything but name. The establishment -of psychopathic hospitals and psychiatric clinics and the way in which -they have been welcomed by the public is suggestive. The problems of -mental diseases, as far as possible, must be approached from a general -hospital point of view and the psychiatric hospital of the future must -have a modern equipment, an efficient staff and adequate facilities -for the employment of the latest methods. Above all, the institutions -must be such that they will be looked upon by the community not merely -as a place to which the insane may be sent for final disposition, but -as hospitals where the development of mental diseases may be prevented -and where recoveries may be reasonably expected if the patient is given -early treatment. This should be the principal object of the state -hospital of the future. "The concept of its beneficent ministration to -the mind diseased as any physical part of the human body," as Copp[30] -has pointed out, "is just appearing in shadowy outline in public -consciousness. The effacement of this barrier to early treatment is -slowly but steadily progressing. Its pace will be hastened if every -mental hospital continues to become, as speedily as may be, the -real hospital in the broadest sense, with emphasis laid upon its -treatment function and subordination of its control relation within -the reasonable limit of caution. The mental hospital and the general -hospital are essentially alike. Mental factors predominate in the -former, but are potent influences in the latter. The difference is -one of degree only. All the imperative requirements of the one must -be met by the other. They are supplementary agencies in curing and -alleviating disease and must be, eventually, viewed in the same light -and administered in the same spirit on even planes of humaneness and -efficiency." - -One thing should be made clear at the outset. A comprehensive and -progressive program for further development means an expenditure of -money. If the state hospitals are to fulfill their obligations to the -community which they serve they must have more physicians. Provisions -must be made for directors of clinical psychiatry, pathologists, -internists, surgeons, dentists, and specialists of various kinds. -Experts in hydrotherapy, massage and electrical treatments are -necessary, as well as dietitians, industrial instructors, occupational -teachers, specialists in reeducational work, psychologists, social -workers, etc. Furthermore, they must be provided in sufficient numbers -if anything is to be accomplished. As a matter of fact, no very great -outlay of funds would be required in making a tremendous increase in -efficiency. Although the institutional expenditures have increased -enormously of late years, largely as a result of war conditions, -increased costs, higher wages, etc., the amount actually invested in -this humanitarian movement by the various states is not commensurate in -any way with the results which are to be obtained. If we leave out of -consideration everything except the saving in dollars and cents to be -effected by methods which will in many instances render a protracted -hospital residence unnecessary, the outlay involved would be well -warranted. It should be brought to the attention of the public that -very few states are expending as much as one dollar per day for the -maintenance of the individual patient. Modern hospital treatment of the -highest type, under these circumstances, is manifestly impossible. The -time has come when we should no longer be satisfied with the purely -custodial care of mental cases. - - - - -CHAPTER V - -THE HOSPITAL TREATMENT OF MENTAL DISEASES - - -The responsibility of the hospital for the future of the patient -begins with his arrival at the institution and the ultimate outcome -of the case often depends entirely upon the developments of the first -few weeks of his residence in the wards. A complete understanding of -the patient's mental condition, the prospects of an ultimate recovery -and the line of treatment to be followed can only be determined by a -thorough and accurate examination on admission. This constitutes the -basis for all further procedure. If satisfactory results are to be -obtained this task should be delegated to a medical officer who has -had an extended psychiatric experience. For purposes of completeness, -as well as uniformity, a definite plan should be followed. The form -used in writing the initial history and in recording the results of the -routine mental and physical examinations at the Boston State Hospital -are described in full in the "Medical Staff Manual" which is furnished -to all assistant physicians entering the service. This has been found -to be of great assistance in the training of new men along proper lines -and insures a uniformity of hospital records which is indispensable. -In a general way the form of examination employed by Meyer and -Kirby[31] for some years has been followed. As this scheme is fairly -representative of the method of procedure used by hospitals for mental -diseases throughout the country it has been thought worth while to -reproduce it in full. - - - HISTORY - - _Name of Physician_: _Date_: - - _Name of Informant, Address, Relation to Patient_: - - It is often desirable to make a note on the intelligence and apparent - reliability of the informant. - - _Residence and Citizenship of Patient_: - - Birthplace? Date of birth? Time in Massachusetts? If foreign born, - date of arrival in U. S.? Naturalized or alien? - - _Family History_: - - It is not sufficient to ask simply the general question: Has any - member of the family been insane or nervous? A great many persons will - answer in the negative, whereas a detailed inquiry will often bring - out a number of instances of nervous or mental troubles. - - Specific inquiry must be made concerning the persons of the direct - ancestral lines as follows: - - (a) Paternal grandparents—nervous or mental disease? - - (b) Maternal grandparents—nervous or mental disease? - - (c) Father: Age, nervous or mental disease, alcoholism? If dead, age - at death and cause of death? - - (d) Mother: Age, nervous or mental disease, alcoholism? If dead, age - at death and cause of death? - - (e) Number of children in family (brothers and sisters of patient). - Nervous or mental trouble in any of these besides patient? - Psychopathic personality, alcoholism, criminality, etc.? - - (f) Collateral branches: mention any known cases of insanity or - nervous diseases in uncles, aunts or cousins. - - - PERSONAL HISTORY OF PATIENT - - 1. _Early Development_: - - Birthplace and age, unusual incidents attending birth, retardation - in talking or walking, infantile convulsions, night terrors, fits of - temper, etc.—Severe illness or infectious diseases in infancy or - childhood—Sequella? Frights, shocks or injuries? - - 2. _Education, Intellectual and Moral Development_: - - Educational opportunities, time spent in school, interest in studies, - progress, marks, behavior, truancy, etc.? - - As an adult, regarded as bright, intelligent or dullminded? Well - informed or ignorant? Reading, memory, judgment? - - Moral responsibility, reliability, religious interests? Church - affiliations? - - Criminal traits, tramp life, police record? - - 3. _Sexual Life_: - - Precocious interests in childhood, masturbation, abnormal practices, - assaults or seduction? - - Love affairs and disappointments? Age at marriage or reasons for - single life. Moderate or excessive sexual desires, irregularities or - prostitution. - - Miscarriages, number of children, date of birth of youngest? If barren, - what explanation; what effect on patient? - - Frigidity, loss of power, refusal of partner, infidelity, measures to - prevent conception. Treatment of partner, abuse, separation, divorce. - - Perversions, abnormal methods of gratification with same or opposite - sex. - - In women, unusual symptoms at menstrual periods; age at menopause, - nervous symptoms accompanying climacterium? - - 4. _Diseases and Injuries_: - - Any previous nervous affection or symptoms, such as headaches, nervous - prostration, chorea, epilepsy, hysterical attacks, etc.? - - Mention severe infections diseases and sequella, if any. Inquire - concerning tuberculosis, rheumatism, heart disease, nephritis, etc. - - Venereal disease, _syphilis and gonorrhea_, full account, if possible, - of how acquired, age, treatment and after affects. - - Severe injuries, particularly head traumata, should be described as - regards their immediate and subsequent effects. - - 5. _Occupation_: - - Kinds of work undertaken, ambition, efficiency, wages, etc. Length of - time in different positions, reasons for change, etc. - - 6. _Alcoholism and Other Toxic Influences_: - - Intemperate, moderate or total abstainer? If intemperate, age at which - drinking began, apparent cause of same, kind of beverage consumed and - approximate amounts. Periodic or steady drinker? Usual reaction to - alcohol? - - Inquire about attacks of neuritis, delirium, hallucinatory episodes, - suspicions, ideas of jealousy. - - _Other toxic influences_: Drug habits, occupational poisons, lead, - arsenic, phosphorus, mercury, etc. Illuminating gas poisoning, nicotine - intoxication. - - 7. _Mental Make-up or Type of Personality_: - - Very important because certain of the non-organic psychoses appear - to be a further development of mental traits or tendencies early - recognized as personal peculiarities or deviations from the normal. In - addition to the points already covered under the preceding headings, - the following important types should always be borne in mind and - appropriate inquiries made: - - _Manic make-up_: Lively, active, sociable, pushing, talkative, - cheerful, optimistic; may be domineering, irritable and inclined to - cruelty; sometimes not very efficient, may be noted as changeable, - lacking in persistence, concentration and application. May show - transient blue spells or lowering of spirits. - - _Depressive make-up_: Gloomy, worrisome, blue natures who feel - continuously inhibited or restrained and unable to make decisions; - easily discouraged. - - _Cyclothymic make-up_: Emotionally unstable, either up or down, have - blue spells or are unduly cheerful and care-free. - - _Shut-in make-up_: Shy, retiring, self-conscious, bashful, quiet, - secretive, seclusive and unsociable. Lack of interest in opposite - sex or definite aversion; often prudish and over-particular. Unusual - religious interest frequent. Inclined to day-dreaming, show fondness - for the abstract and mystical. Odd habits, hobbies or cranky pursuits - are common. - - _Paranoid make-up_: Mistrustful, suspicious, tend to misunderstand; - unduly sensitive, feel discriminated against and have feelings of - self-importance. (These traits may be related to shut-in tendencies.) - - Other types of make-up include the psychasthenic, neurasthenic and - hysterical; also the mentally retarded or undeveloped (feebleminded). - - 8. _Previous Attacks of Mental Disorder_: - - Obtain dates, places where treated, apparent cause, duration of attacks - and general character of symptoms. - - 9. _Precipitating Cause of Present Psychosis_: - - Try to determine what occurrence or situation appeared to bring - about the mental breakdown. Emotional strains, excitement, quarrels, - worries, griefs, disappointments, sexual episodes, separation, deaths, - childbirth, etc., financial loss, overwork, physical disease, etc. - - 10. _Onset and Symptoms of the Psychosis_: - - Take as far as possible a spontaneous account beginning with date - when first symptoms were noticed in the patient. In this connection - particular attention should be given to changes in behavior, in mood, - in manner of speech, in attitude towards others and towards work. - - Appearance of suspicious, unusual interests, peculiar ideas and - delusions? - - Hallucinations in various fields and reaction to them? - - Obtain as much as possible regarding trend of patient's ideas, topics - of conversation and content of hallucinations. What did voices say? - What was seen in visions? - - Forgetfulness, impairment of memory, loss of orientation and clouding - of sensorium. - - Always inquire regarding suicidal inclinations or attempts, threats of - violence, assaults or homicidal tendencies. - - Compare informant's statement with those given in the commitment - certificate. - - What treatment was given at home? Name of physician in attendance? - - Date on which patient was taken to hospital. - - - PHYSICAL EXAMINATION - - I. _GENERAL TYPE, APPEARANCE AND CONDITION_: - - 1. Weight (with or without clothes). - - 2. Height and general frame. - - 3. Malformations (wherever possible state the origin); asymmetries - of skull, face, body, spine, thorax; form of palate (low, high, - asymmetrical, saddle or V-shaped, longitudinal torus). - - Ears (adherent lobules, prominent anthelix, satyr-points, large, - angle, asymmetry, length, etc.). - - Abnormalities of hands, feet, sexual organs. - - 4. Color of the skin. - - Color and quantity of the hair. - - Color of the eyes. - - General complexion. - - 5. General nutrition (panniculus and muscles). - - 6. Condition of the skin and mucous membranes; anemia, jaundice, - dropsy, pallor, flushing and cyanosis; eruptions (describe in detail). - Trophic disorders. - - 7. Scars, bruises and moles (size, location, color and origin). - - 8. Evidence of syphilis: scars, including those of the penis, back - of tongue (patches devoid of villi and fissures) and palate; tibial - crests; glands of elbow, groins and neck. - - 9. Signs of gout and rheumatism, goitre or nodes of the thyroid, etc. - - 10. Temperature, general, and various parts of the body (both sides if - indicated as in hemiplegia). - - - II. _NERVOUS SYSTEM_: - - 1. _General and subjective sensations and facial expression_: - - General feeling of well-being or exhaustion, general complaints, - weakness, etc. - - Vertigo: (constant, occasional, or occurring when the patient walks, - or in the dark). - - Headache: Whole head or limited space; frontal, vertical, occipital, - unilateral, bilateral, deep or superficial; constant or periodic, - aggravated at night or by some special cause, as with heat, with or - without tenderness of head or spine to touch or pressure. Backache - (general or localized). - - Ovarian, infra-mammary, lumbar and vertex pains (in hysteria). - - Neuralgic pains: (fifth nerve, intercostal nerves, sciatic nerve, with - pain points, etc.) and muscular pains. - - General or wandering pains: Pains in bones (legs) afternoon or night. - Girdle pains. Precordial pains (with or without anxiety). - - Zones of hyperesthesia: See below. - - 2. _Eyes_: - - Expression: lids: obliquity, mongol type, lagophthalmus, protrusion - of eyeballs (with or without the Graefe symptom), ptosis; spasm of - palpebral muscles. - - Movement of eyes, nystagmus, strabismus (divergent or convergent); - position and extent of movement of the eyes; double vision (in what - direction does the second object move and incline?). - - Weakness of the internal rectus (in close focussing). - - Conjunctiva, lachrymal canal. Scars of cornea. Arcus senilis. - Reflectory iridoplegia. - - Size and form of pupils. Residuals or formation of adhesion of iris. - Contraction of iris on exposure to strong light; on accommodation (for - near vision) and after shutting the eye. - - Imperfect sight (reading print), improved or not by glasses, dimness - of sight, limitation of field of vision, scotoma, hemianopsia, loss of - color sense; anomalies of refraction. Condition of apparatus (cornea, - lens, vitreous body). Ophthalmoscopy where indicated (for choked disc, - optic atrophy, lesions of the fundus). Field of vision where indicated - and possible (reversal of color fields in hysteria; scotomata). - - 3. _Ears_: - - Discharge, otoscopy. Defect of hearing on one or both sides (use watch - and tuning fork). - - Conduction through skull. Tinnitus aurium (auscultation for actual - sound, over the head). - - 4. _Taste_: - - Test separately the anterior two-thirds of tongue and the posterior - third with weak solution of sugar, quinine, acid, salt. - - 5. _Smell_: - - Test each nostril with oil of cloves, bergamot, peppermint, wintergreen - and lemon. Note the actual answers. - - Parosmia. Put down the actual extent of discrimination and recognition, - with explanation of defect (mental, local, or nervous). - - 6. _Cutaneous Sensibility_: - - 1. Tactile sensibility (use the finger-tip, feather, or pin). Compare - both sides of face, arms, hands, fingers, breasts, inner and outer - aspects of thighs and legs. (Never omit the ulnar side and the area - outside and above the knee). Sole and dorsum of feet. - - 2. Localization of touch (time and space) and tickle. - - 3. Sensibility to pain (cautious pricks with a pin, localization in - time and space), with or without the attention of the patient. - - 4. Sensations of heat and cold (cold water and warm water in a glass - tube). - (a) Sense of position: See below. - (b) Stereognostic sense. - - 5. Subjective sensations (formication, feeling of needles and pins, - numbness). - - 6. Tenderness of nerve trunks and muscles on pressure and percussion. - The distribution to be noted on the drawings of the body surface. - - 7. Biernacki's sign (analgesia of the ulnar nerve); anesthesia of - eyeball; of testicles. - - 7. _Vasomotor and Trophic Conditions_: - - Salivation, seborrhea. - - Cyanosis or pallor; scaliness or loss of hair; change of nails. - - Blushing, dermatographia. General or localized perspiration. - Temperature of paralyzed or anesthetic parts. - - 8. _Motor Functions_: - - Mobility of facial muscles (laugh) (wrinkle the forehead and the nose; - move the ears; show the teeth and shut the eyes); tongue; palate. - - Muscles of the neck, trunk and extremities; gait. - - Functions of the successive segments: In case of paresis or paralysis - define the limits of the condition and indicate the results of the - following tests: For loss of power: for the coordination of movement - (writing, buttoning coat); for muscular sense (discriminating - difference in weight; with eyes shut tell the position of the limbs - and show with one side the position of the other). Balancing power: - (walking along a straight line, stand upright with heels and toes - together and eyes closed). - - Never forget the test of equality of grip, flexor and extensor strength - of elbow, knees and toes. For test of weakness of one lower extremity - have both lower extremities raised and hold to fatigue limit. The - weaker limb will sink a certain number of seconds before the other. - - 9. _Reflexes_: - - 1. Deep reflexes. - Masseteric: elbow, wrist, knee-jerk with or without Jendrassic, with - clonus, or contralateral adductor reflex, knee-cap reflex; ankle - clonus and Achilles tendon reflex. - 2. Superficial reflexes: - Plantar (with full description as to the Babinski reflex), gluteal, - cremasteric, abdominal, epigastric, scapular, corneal, palmar, - sneezing. - - 10. _Condition of the Paralyzed Muscles_: - - Firm and of good tone, or flaccid or deficient in tone. Rigid and - contracted. Note attitude of limb and the limitation of the motion, - active and passive. Atrophy, hypertrophy, electric reaction of nerve - and muscle (galvanic and faradic irritability when required). - - 11. _Fibrillary Twitching_: - - Its distribution. - - 12. _Tremor_: - - Of what parts; rhythm, intensity, rapidity. Condition at rest during - sleep; when first observed. Condition during motion, how influenced by - will. - - 13. _Organic Reflexes and Their Control_: - - Bladder; delay of micturition. Dribbling from empty bladder, from - distended bladder. Peculiar sensations on micturition. - - Sexual reflexes: Frequent involuntary contraction and evacuation. - - Defecation: Is the patient conscious of evacuation? - - 14. _Convulsions_: - - Distribution: Extending over head, trunk, extremities, one side, one - member. - - Character: Which parts first and most attacked, and how do the waves of - the tonic and clonic spasm spread; what movements predominate? - - Average duration, frequency, occurring night or day, or early in the - morning. - - Breathing; pupils; vasomotor condition; froth and bites. - - Sphincters: Consciousness totally or partially lost. - - Aura. - - Equivalents: with or without what automatic movements. - - Physical and nervous symptoms before and after attack. - - Hysterical attacks. - - - III. _THORACIC ORGANS_: - - Respiratory organs: Is there any difficulty of breathing, permanent or - in attacks? Sleep with mouth open? Any pain on deep inspiration? Any - cough or expectoration (where from). Nose and larynx. Shape of chest. - Frequency of respiration. Respiratory movements. (Compare both sides - in deep inspiration and expiration). - - Lungs: Percussion. Auscultation. Expansion. - - In case of dullness or other abnormalities: Fremitus. - - Contents of pleura. - - Circulatory organs: Is there any palpitation? In attacks? Due to what? - Subjective sensation of arhythmia? Heart: The impulse seen and felt - in what area? Relative dullness (right, upper and lateral borders). - Sounds and bruits (localized). Pay special attention to muffling of the - first sound, to duplication; to change of murmurs in inspiration and by - position. Rhythm and accentuation. - - Radial pulse: Rate, quality, on lying and sitting and standing. Special - attention to variability through position or motion or exertion. If - desirable, sphygmogram. - - Condition of radial, brachial and temporal arteries. - - Arcus senilis. - - Sclerosis of veins. Varicosities. - - Blood pressure. - - - IV. _DIGESTIVE AND ABDOMINAL ORGANS_: - - Appetite, thirst, anorexia, nausea: Relative to quantity and quality - of food. Vomiting (time and form), eructations and brashes; pain - (locality, irradiation and time). - - Mouth and teeth. Fetor. Fauces and pharynx. Stomach (position, etc.). - Digestion. Movement of bowels. Any subjective feeling of obstacle? Form - of stools. Flatulence and distensions. Hemorrhoids and fistulas. - - Liver and spleen. - - If indicated, examination of stomach contents. - - - V. _URINARY APPARATUS_: - - Micturition: Urine, amount in 24 hours, specific gravity, color, - reaction, odor, albumen, sugar and indican, etc. - - Macroscopic and microscopic examinations of sediment, clouds and - threads; casts, epithelia, erythrocytes, leukocytes, bacteria, threads, - crystals, amorphous substances. - - - VI. _GENITAL ORGANS_: - - Scars of genital organs. Menstruation: regular; profuse; scanty; - accompanying symptoms. - - Discharges at intervals; constant; profuse; color. - - Internal examination. - - In men: Frequency and character of the sexual functions. Frequency of - emissions, their occasional exciting causes and correlated symptoms. - - Diagnostic summary and indications for further observation and - treatment. - - - MENTAL EXAMINATION - - I. _ATTITUDE AND MANNER_: - - General appearance of the patient, adaptation to surroundings, - patient's general attitude and behavior, attention and cooperation. - Note any peculiarities of conduct or demeanor (peculiarity of dress, - mannerisms, grimacing, affectations, etc.). Note the manner, gestures, - form of intonation, rapidity or slowness of speech, or special - peculiarities. Facial and general expression (sadness, anxiety, fear, - restlessness, excitement, etc.). Psychomotor retardation or excitement - (violence, destructiveness), care of person (whether cleanly or - untidy, etc.). - - - II. _STREAM OF MENTAL ACTIVITY_: - - 1. _Flow of thought_: Give sample of spontaneous expression or - productivity, if possible. If not, give reaction to questioning. - Show any disturbance of train of thought (retardation, confusion, - incoherence, poverty of ideas, volubility, flight of ideas, - distractibility, rhyming, desultoriness, circumstantiality, - perseveration, fabrication, coinage of words, verbigeration, echolalia). - - 2. _Abnormalities in the motor reactions_: Negativism, catalepsy, - echopraxia, stereotypy, automatism, mutism, etc. Show loss of - initiative, lack of spontaneity or slowness in action, etc. - - - III. _EMOTIONAL TONE_: - - Moods and affects. Show the presence of cheerfulness, laughter, - mischievousness, excitement, exaltation, depression, anxiety, fear, - perplexity, tendency to be startled, irritability, constraint, - confusion, indifference or apathy. Show sensitiveness, seclusiveness, - suspicion, emotional instability or suggestibility. - - - IV. _MENTAL CONTENT_: - - 1. Hallucinations; hearing, vision, taste, smell, sensation, etc. - - 2. Delusions; persecution, suspicion, infidelity, poisoning, - electricity, hypnotism, mind-reading, self-accusation, grandeur, etc. - Show whether permanent or transitory, systematized or unsystematized. - - 3. Illusions. - - 4. Obsessions, phobias, etc. - - 5. Nature of sleep, dreams, etc. - - - V. _ORIENTATION_: - - Time, place and person. - - - VI. _MEMORY AND MENTAL GRASP_: - - 1. Recent past. - - 2. Remote past. - - 3. Retention of school knowledge. - - 4. Fund of general information. - - 5. Data of personal identification. - - 6. Counting and calculation. - - 7. Reading and writing. - - - VII. _INSIGHT AND JUDGMENT_: - - The judgment concerning the situation, insight concerning physical - and mental health and efficiency, financial status, plans in case of - discharge? In discussion of abstract and complicated topics? To what - extent is he sensitive to his own errors and to comments? - - - VIII. _SUMMARY_: Physical and mental. - - - IX. _DIFFERENTIAL AND PROVISIONAL DIAGNOSIS_. - - -The question as to what benefit is to be derived by the patient from -a residence in a hospital for mental diseases is one which is often -raised by relatives and friends. They are quite inclined to feel -that if no medicines are being prescribed nothing is being done for -the patient and that he could be cared for just as well at home. -In considering this question it should be borne in mind that the -persons under treatment in a hospital for mental diseases are there, -either because they appreciate the need of hospital care themselves, -or because, as a result of mental disorders, they are incapable of -directing their own affairs, or are, in the eyes of the law, dangerous -to themselves or others. Their property and other legal interests must -be protected during their period of incompetence. Such persons are -liable, if not adequately safeguarded, to enter into improper contracts -or make legal conveyances that mean financial ruin to themselves as -well as others. Unfortunate sexual irregularities frequently occur. -Conduct disorders of various kinds are to be expected and a tendency -towards criminal acts is common to several of the psychoses. It -is a well-known fact that every mentally unbalanced individual is -potentially dangerous, no matter how harmless he may appear. The -suicide rate of the country as shown in one hundred of the largest -cities has not fallen below fourteen per hundred thousand of the sane -population at any time during the last twenty years. The homicide rate -in thirty-one of our large cities has not dropped below eight per -hundred thousand of the population since 1909. Many of these crimes -were undoubtedly committed by persons who should not have been at -large and who were not responsible for their acts. The most important -benefit derived by the patient in the hospital is the constant personal -supervision given him by experts throughout the twenty-four hours -of the day, whether he is asleep or awake. He gets the benefit of -regular hours of rest and exercise, a properly regulated diet adapted -to his needs, a sufficient amount of fresh air, and amusement and -entertainments suited to his mental condition. He receives competent -medical, dental and nursing care and is provided with opportunities -for occupying himself in many different ways. Reading matter is always -available for those who care for it. Even religious services are held -for his benefit. - -The tendency of late years is to dispense with the use of drugs as -far as possible and resort to other methods of accomplishing the same -results. One of the most important therapeutic procedures in common use -in the modern hospital for mental diseases is hydrotherapy. This should -be used intelligently if any results are expected. Sending the patient -to the hydriatic department where identically the same treatment is -applied to all cases whether of excitement, depression, exhaustion, -etc., by an attendant who has no knowledge of either medicine, -psychiatry or nursing may be referred to as the application of water to -the exterior, but it is not hydrotherapy. Hydriatic treatments should -be prescribed by a physician who has a thorough familiarity with that -particular therapeutic procedure and every patient should receive the -form adapted to his individual needs. The treatment should be given -by an expert hydrotherapist. The equipment should provide for hot -air, electric light, vapor and saline baths, Sitz baths, circular, -rain, fan, jet and Scotch douches, dry, hot and cold packs, etc. Much -can be accomplished by tonic, stimulating and eliminative therapy. -Sedative treatments are much used in hospitals for mental diseases. -The hot air bath[32] is given at from 134 to 170 degrees Fahrenheit for -from four to ten minutes, preceded by a foot bath at from 104 to 110 -degrees. The patient enters the electric light and vapor bath at the -room temperature, the baths being continued from four to eight minutes -usually. The needle spray is given at a temperature ranging from 96 -to 102 degrees, with a pressure of from twenty to thirty pounds, and -continued from one to two minutes. The fan douche starts at 90 degrees, -is reduced gradually with a pressure of from twenty to twenty-five -pounds and is continued for from fifteen to twenty seconds. The jet -douche is first used at 90 degrees and gradually reduced, with a -pressure of from fifteen to twenty-five pounds, for from ten to twenty -seconds. The Scotch douche is used at a temperature of 80 degrees -alternating with 110, with from fifteen to thirty pounds pressure. It -should be used with extreme care. The same is true of vapor douches. -The saline bath contains five pounds of ordinary salt to sixty gallons -of water at a temperature of 94 degrees and is continued from ten -to thirty minutes. The dry pack is usually continued from twenty to -forty-five minutes, although it may be used longer with safety. In the -use of the hot blanket pack the inner blanket is wrung out of water at -from 140 to 160 degrees and must be applied with great care. Depending -on the condition of the patient, etc., the cold wet pack is given -with sheets wrung out of water at a temperature ranging from 50 to 60 -degrees, although lower temperature may be used. "Neutral" wet sheet -packs are often used at a temperature of from 100 to 116 degrees for -approximately three-quarters of an hour, as preparatory treatments. -These measures should never be attempted by anyone who has not had an -extended practical experience. Much can be accomplished by hydrotherapy -in the alcoholic and toxic conditions, infective and exhaustive -psychoses, manic excitements, involutional melancholia, hysterical and -neurasthenic conditions, as well as in occasional cases of dementia -praecox. Occupational therapy has been used to great advantage in -connection with the hydrotherapeutic treatments. - -In the reception service and in the buildings for the noisy and violent -cases ample facilities should be at hand for the continuous bath -treatments. Pack rooms are also desirable. There is no means at our -disposal equal in any way to the efficacy of the continuous bath in -controlling excitements. The patient is usually kept in the tub from -five to eight hours at a temperature varying from 92 to 97 degrees and -averaging 96 degrees. In some hospitals they are kept in the tubs for -periods of from two to three weeks. The continuous bath is of no value -unless it means what the name implies—the continuous submersion of the -body in water. In dealing with very excited cases this necessitates -the use of a tub cover and a hammock, although sheet coverings are -often used satisfactorily. Not much is to be gained by the tub bath if -the patient is to be allowed to get out and in as he pleases and only -come into partial contact with the water. The continuous bath is not -without drawbacks. There is danger of chilling, scalding and drowning -either by accident or with suicidal intent, etc. Too much care cannot -be exercised in the supervision of the bath rooms. Every tub room -in the Boston State Hospital has the following rules conspicuously -displayed:— - - - THE CONTINUOUS BATH ROOM - - 1. The nurse on duty in the bath room will be held personally - responsible for the safety of the patients and must be thoroughly - familiar with these rules. The nurse must never leave the room unless - relieved by some other nurse. Eternal vigilance is necessary to - prevent the chilling, scalding or drowning of the patient. - - 2. Patients are to be given continuous baths only on the written order - of a physician. - - 3. Patients going to or from the bath room must wear a nightdress or - bathrobe and slippers when not fully clothed. - - 4. Tubs not in good condition or not properly equipped must not be - used. - - 5. Only patients under treatment are allowed in the room. - - 6. Toilet each patient just before the bath. Patients may be removed - from the tub for toilet purposes when necessary. - - 7. In preparing for the bath, warm the tubs with hot water and then - regulate the temperature so that a small amount of water at 96 degrees - will be flowing continually. - - 8. Adjust the hammock to the tub and place the patient in the bath - resting on the hammock. Adjust the cover to the tub, with patient's - head through the neck opening unless sheets or other covers are used. - - 9. The temperature of the water must be taken in each tub at least - every half hour. Feel the water in each tub frequently. If it seems - too warm or too cold, take the temperature at once. If you find it - varying from 96 degrees adjust to that temperature by adding a small - amount of hot or cold water. If the temperature cannot be kept between - 95 and 97 degrees, let the water out of the tub and remove the patient - immediately. The physician in charge and the chief engineer should be - notified at once. The bath tub key must be fastened to a special cord - worn by the nurse on duty. It must be delivered to the nurse in charge - of the ward when the bathroom is closed. - - 10. If the patient is very noisy, restless or flushed, fasten an ice - poultice to the tub cover so that as the patient lies in the water the - back of the head or neck will rest upon it. Replace with a fresh one - before the ice is entirely melted. - - Intensely excited patients may have cold compresses to the neck, - changed often, for periods of 20 minutes. - - Sponge all faces with cold water once an hour. - - 11. Patients are to be permitted to drink as much cool water (not - iced) as they desire, and must be offered a drink at least once an - hour. - - 12. The nurse must record the following: 1. The water temperature and - the patient's pulse rate (temporal or facial) every half hour. 2. The - amount of sleep in the bath. 3. Bowel movements. 4. Nourishment. 5. - Medicine administered. 6. Hours of each patient in the tub. 7. The - name of each nurse and the exact time of going on or off duty. - - 13. In case the patient shows symptoms of fainting or convulsions, - makes any attempt at drowning, shows suicidal tendencies or becomes - too violent to remain in the tub with safety, let the water out and - remove the patient at once. - - 14. In the event of any serious accident or injury or sudden illness - the patient should be removed from the tub at once and the physician - notified. - - 15. Patients are not to be allowed to feed themselves but must always - be fed by the nurse. The inlets to the bath may be closed for twenty - minutes while patients are being fed. - - 16. During the day the warming closet must always contain one sheet - and one towel for each patient in preparation for drying. It must also - contain washable rugs for patients coming out of the tubs to step - upon; also two blankets for emergencies. - - At least one hour before the patients are to be removed from the baths - the garments they are to wear after the bath must be placed in the - closet. - - 17. The temperature of the room should be kept as nearly as possible at - 76 degrees Fahrenheit. If the temperature of the room cannot be kept - above 68 degrees discontinue the bathing. - - -When the care and treatment of mental diseases was first undertaken in -our state institutions it was soon found necessary to take advantage -in every way of such material assistance as could be offered by the -more intelligent class of ablebodied patients in carrying on the -routine work of the hospital. There were never employees enough to -dispense with their services. In this way it came about that they -were employed in the farms and gardens, assisted with the kitchen and -housework, shared the tasks of the nurses and attendants in the wards -and were busily engaged in almost every department of the hospital -activities. It became apparent that occupation, undertaken originally -for purely economical purposes, constituted one of the most important -therapeutic agents at the disposal of the institution. The next step -was the development of industries. Patients were taught by instructors -to make clothing, underwear, stockings, shoes, brooms, mats, brushes, -mattresses, furniture and many other useful products needed by the -hospital. The end products were in every instance utilitarian. These -accomplishments led to a still further development—purely occupational -in character. Women were encouraged to take up such activities as rug -making of all varieties, basketry, weaving, crocheting, embroidery, -and needlework of every description. Men usually make towelling on -looms, weave rugs, renovate mattresses, do repairing of all sorts and -manufacture small articles which interest the masculine mind. Brass -work, clay modelling and making jewelry of various kinds have been -extensively employed. - -All of these forms of employment mean, of course, that the patient -must leave the ward and go to some place designed for the purpose. The -others, however, have not been overlooked and occupational therapists, -who devote their entire time to stimulating the interest of the -patients who cannot leave the wards, on account of their mental or -physical condition, in some absorbing and diverting occupation, are -an important part of the personnel of every institution. No other -form of treatment employed in hospitals for mental diseases has been -so productive of results. It is interesting to note that the medical -officers of all of the forces engaged in the recent war found that -occupational therapy was of great value in cases of shell shock and war -neuroses. - -The highest development perhaps of occupational therapy has been in -its application to strictly reeducational work in dementia praecox. -This consists in a graduated and systematized reeducation of interests -in apparently deteriorated individuals. The success of these efforts -depends largely on the fact that very simple lines are followed at -first. The patients are interested in marching to music, simple drills, -calisthenics, games, basketball and purely physical exercises. Some -can be induced to sort out raffia and ultimately take part in basket -making. Others cut out pictures or put puzzles together. The women -sometimes are willing to do plain sewing or make paper flowers. They -progress by easy stages to more advanced and elaborate undertakings -leading eventually to occupational work in the wards or possibly in -the industrial rooms. Some of the apparently most hopeless cases have, -as a result of these reeducational efforts, been able to return to -their homes greatly improved. The mental improvement goes hand in hand -with a resumption of their interests in their former work or some new -occupational venture which may have proved attractive. - -Every effort should be made to avoid the possibility of long hours -of idleness in the wards. When not actively employed in occupational -work, ward games, reading, etc., the patients should be taken out -of doors for fresh air and exercise. This, of course, suggests the -necessity and importance of attractive surroundings. Nothing can be -more depressive or detrimental to the welfare of the patient than a -prisonlike appearance either inside of the buildings or on the grounds. -The successful operation of a hospital is dependent in no small measure -on the amount of attention devoted to the preparation of food. There -must be a general dietary for the active ablebodied class, one for the -working patients, an entirely different one for the tuberculous and -epileptic cases and a special diet for the strictly hospital wards. In -an institution of any size this requires the constant supervision of -several dietitians. - -The advances of recent years in our knowledge as to the etiology and -nature of general paresis have led to the introduction of highly -specialized therapeutic methods in the treatment of that disease and of -cerebro-spinal syphilis. This is an important feature of the work of -our hospitals at the present time. The interest recently shown in the -study of the endocrine system has already brought about a new line of -therapy which is destined to receive much attention in the future. - -Even the amusements necessary for the individual are given special -attention in the treatment of mental diseases. This refers not only -to methods of recreation and diversion in the wards day by day but -includes moving picture shows, dances and various other special -entertainments. Not the least important consideration is the patient's -bodily health. This is often a determining factor in bringing about a -restoration of mental integrity. It very often happens that there are -diseases of the eye, ear, nose, throat, skin, nervous system, etc., -which may require attention. Dental, surgical, gynecological and other -special treatments sometimes prevent ordinarily acute and recoverable -psychoses from terminating unfavorably. - -In a word, the modern hospital treatment of mental diseases may be said -to consist of a direct personal supervision of the mental and physical -hygiene of the patient, supplemented by such specialized therapeutic -procedures as may be indicated in the individual case. - - - - -CHAPTER VI - -THE DEVELOPMENT OF THE PSYCHOPATHIC HOSPITAL - - -As has already been shown, the modern hospital treatment of mental -diseases in this country is a development which represents the -progress of nearly two centuries. Satisfactory as this has been -in many respects, it nevertheless leaves much to be desired. All -indications point to much greater accomplishments in the future. We are -emerging from an era of custodial care and entering one of prevention, -scientific investigation, and highly specialized treatment along -entirely different lines. The interest of the public has been aroused -in a subject which has heretofore been one to be avoided by common -consent. Mental hygiene societies are no longer viewed with suspicion -and curiosity. We are approaching a time when mental diseases can -be dealt with, as other conditions are, without prejudice or unjust -discrimination. Psychiatric wards promise to become integral parts of -a completed medical organization. Psychopathic hospitals will soon -be found in all of our great centers of population. The outlook for -specialized institutes for purely research purposes, unfortunately, is -not so encouraging at this time. - -At last there is some evidence of progress in the teaching of -psychiatry in medical schools, hospitals and clinics, although only -a beginning has been made as yet. More noteworthy advances have been -made in other countries. The appointment of Heinroth as a professor -of psychiatry at Leipsic in 1811 promised developments which did -not materialize to any great extent for many years. According to -Sibbald,[33] psychiatric wards or clinics were established at Würzburg -in 1833, Jena in 1848, Vienna in 1853, Berlin in 1865 and at Göttingen -in 1866. Scholz made provision for observation wards in a general -hospital in Bremen in 1875. Fürstner opened a psychiatric clinic at -Heidelberg in 1878. Hitzig accomplished the same thing at Halle in 1891 -and Siemerling at Kiel in 1901. The inception of the modern psychiatric -clinic has generally been attributed to Griesinger.[34] In his preface -to volume one of the "Archiv für Psychiatrie und Nervenkrankheiten" -in 1868 he advocated the establishment of small hospitals in cities -for the intensive treatment of acute and recoverable mental cases. He -recommended a large staff of physicians and accommodation for from -sixty to eighty patients, according to the needs of the community, but -not to exceed one hundred and fifty under any circumstances. "In close -connection with the organization of such institutions there is a crying -need and a new, most important interest—the question of psychiatrical -instruction. This is absolutely indispensable." This he proposed to -accomplish by establishing a highly specialized clinic to be maintained -largely by the teaching staff of a university. Griesinger's ideas -were eventually carried out in full by Ziehen in Berlin, Sommer in -Giessen and Bleuler in Zurich. Perhaps nothing has had more to do with -the development of psychopathic hospitals in the United States than -the well-known clinic established by Kraepelin at Munich in 1905. It -occupies a three-story building accommodating one hundred patients and -cares for between fifteen hundred and two thousand cases annually. -Hydrotherapeutic and electrical treatments are used extensively. -A certain number of beds are reserved for research purposes. -Psychological studies receive a great deal of attention. The -out-patient department is a prominent feature. The teaching of -psychiatry is one of the important purposes of the clinic. Kraepelin's -methods have been followed rather closely here. The remarks made by -Pliny Earle[35] in 1867 were almost prophetic in character. "Carbon -agglomerated is charcoal, carbon crystallized is diamond. What charcoal -is to the diamond, such, I believe, is the psychopathic hospital of -the present compared with the psychopathic hospital of the future.... -When the defects which I have mentioned shall have been thoroughly -remedied by a comprehensive curriculum, a complete organization, a -perfect systematization, an efficient administration, the charcoal now -just ready to begin the process of crystallization will have become the -diamond and the world will possess the psychopathic hospital of the -future." - -Psychiatric research was inaugurated in this country by the -establishment of the Pathological Institute of the New York State -Hospitals in New York City in 1896. Its original field of investigation -was limited to the laboratory. The name was changed to "Psychiatric -Institute" on the appointment of Dr. Adolf Meyer as director in 1902 -and the establishment was removed to Wards Island, where it was -provided with clinical facilities by the Manhattan State Hospital. -It thus became the precursor of the psychiatric clinic movement in -America. The observation wards for the examination and commitment of -mental cases, at the Philadelphia Hospital (1890) and at Bellevue in -New York City were probably the first of the kind in this country. In -1902 the first psychopathic wards connected with a general hospital -were opened by the Albany Hospital. Pavilion F, as it was designated, -admitted 3,132 patients during its first twelve and one-half years. -These included persons awaiting examination and commitment, voluntary -patients and cases of delirium, stupor, etc., transferred from other -wards of the hospital. Of 1,038 cases admitted during a period of six -years, only 17.6 per cent were committed to state hospitals. In a total -of 1,855 cases, twenty-five per cent were found to be suffering from -some form of alcoholism and twenty-six per cent from chronic mental -conditions, while thirty-five per cent were cases of the acute and -recoverable class. About fourteen per cent were psychoses associated -with renal conditions, neurasthenia, hysteria, tuberculosis or -traumatism. - -The Psychopathic Hospital at the University of Michigan, the first -of its kind on this continent, was established at Ann Arbor in 1906 -as a direct result of the activities of Dr. William J. Herdman. The -objects and purposes of the hospital were shown by the provision of -the legislature for the appointment of "an experienced investigator in -clinical psychiatry, who shall be placed in charge of the psychopathic -ward, whose duty it shall be to conduct the clinical and pathological -investigations therein; to direct the treatment of such patients as -are inmates of the psychopathic ward; to guide and direct the work -of clinical and pathological research in the several asylums of -the state, and to instruct the students of the State University in -diseases of the mind." It was thus an integral part of the hospital -of the University of Michigan but fully coordinated with the state -institutions. A subsequent act of the legislature changed its status -to that of a "State hospital, specially equipped and administered for -the care, observation and treatment of insanity and for persons who -are afflicted mentally but are not insane." It also provided that a -clinical pathological laboratory should be maintained for the benefit -of the state hospitals. During a period of eleven years it admitted -an average of 168.82 patients per year. Twenty-four per cent of these -were voluntary cases. The psychoses represented were: manic-depressive -insanity, twenty-four per cent; dementia praecox, seventeen per -cent; paranoid conditions, two per cent; hysteria, seven per cent; -psychopathic personality, two per cent; alcoholic psychoses, four per -cent; morphine intoxication, one per cent; imbecility, two per cent; -general paralysis, eight per cent; cerebral syphilis, one per cent; -epilepsy, two per cent; senile psychoses, one per cent; cerebral -arteriosclerosis, three per cent; unclassified conditions, five per -cent; and not insane, two per cent. Seventy-four per cent of all the -cases admitted were discharged after a residence of three months or -less and eighty-two per cent after a residence of four months or less. -Fourteen and eight-tenths per cent of all cases were discharged as -recovered and 32.7 per cent as improved. Owing to the fact that it -has only sixty-two beds at its disposal, the number of admissions is -necessarily limited and cases are carefully selected. - -The Psychopathic Hospital in Boston, the first institution of the kind -established in this country as a department of a state hospital (The -Psychopathic Department of the Boston State Hospital), was opened for -the reception of patients in 1912. The purposes of the institution were -very clearly shown by the Twelfth Annual Report of the Massachusetts -State Board of Insanity (1910):—"The psychopathic hospital should -receive all classes of mental patients for first care, examination and -observation, and provide short, intensive treatment of incipient, acute -and curable insanity. Its capacity should be small, not exceeding such -requirement. An adequate staff of physicians, investigators and trained -workers in every department should provide as high a standard of -efficiency as that of the best general and special hospitals, or that -in any field of medical science. Ample facilities should be available -for the treatment of mental and nervous conditions, the clinical study -of patients on the wards, and scientific investigation in well-equipped -laboratories, with a view to prevention and cure of mental disease and -addition to the knowledge of insanity and associated problems. Clinical -instruction should be given to medical students, the future family -physicians, who would thus be taught to recognize and treat mental -disease in its earliest stages, when curative measures avail most. Such -a hospital, therefore, should be accessible to medical schools, other -hospitals, clinics and laboratories. It should be a center of education -and training of physicians, nurses, investigators, and special workers -in this and allied fields of work. Its out-patient department should -afford free consultation to the poor, and such advice and medical -treatment as would, with the aid of district nursing, promote the home -care of mental patients. Its social workers should facilitate early -discharge and after care of patients, and investigate their previous -history, habits, home and working conditions and environment, heredity -and other causes of insanity, and endeavor to apply corrective and -preventive measures." - -The building has a capacity of one hundred and ten beds. The -institution may be said to differ from other psychopathic hospitals -in being an establishment essentially of the temporary care type, -not designed primarily either for the reception or for the care and -custody of obviously committable cases, but rather for the observation -and treatment of incipient mental disorders as well as psychopathic -conditions not properly coming within the scope of the state hospitals. -It has been as a rule the policy of the court to commit directly to -other institutions for the insane all cases showing clearly the -necessity of an extended hospital residence. The fact that only forty -per cent of the temporary care cases have been committed shows that a -preliminary period of observation before these cases are definitely -disposed of is unquestionably warranted. The legal status of cases -admitted may be described as follows:—1. Temporary care (not to exceed -ten days); 2. Boston Police cases (Persons suffering from delirium, -mania, mental confusion, delusions or hallucinations, or who come -under the care or protection of the police); 3. Observation cases (for -a period of thirty-five days, pending commitment); 4. Cases pending -examination and hearing; 5. Emergency commitments (not more than five -days); 6. Voluntary admissions; 7. Cases held under complaint or -indictment. - -An analysis of the work done by the Psychopathic Department from 1912 -to 1920 shows a total of 14,922 admissions to the wards,—an average of -1,865 per year. Of these, 59.77 per cent were temporary care (10 day) -cases, 18.56 per cent "Boston Police" cases, 1.38 per cent observation -cases (thirty-five days), .50 per cent emergency cases, .61 per cent -committed "pending examination and hearing," 1.02 per cent under -complaint or indictment and 16.96 per cent were voluntary cases. The -entire temporary care group, including all of the above classes except -the voluntary and criminal cases, constituted 81.34 per cent of the -admissions. It is interesting to note that the principal psychoses -represented by the cases coming into the hands of the Boston Police -are dementia praecox, alcoholic psychoses and mental deficiency. The -number of emergency cases is very small, as is the number committed by -courts for observation. The number of voluntary admissions, an average -of 316 per year, constituting 16.96 per cent of the total, is very -significant as showing the response to be expected from the public to -an opportunity for hospital treatment without the formality of any -legal procedure. Of the 14,922 cases admitted between 1912 and 1920, -38.45 per cent were subsequently committed as insane and 3,797, or -25.44 per cent, were returned to the community as not requiring further -hospital care or treatment. - -It has been shown that the special field covered by the Boston -Psychopathic Hospital consists of temporary care cases. The principal -psychoses represented by 12,252 admissions of that class were as -follows: alcoholic psychoses, 9.25 per cent; dementia praecox, 25.0 per -cent; senile psychoses, 3.16 per cent; general paresis, 6.06 per cent; -manic-depressive psychoses, 10.14 per cent; arteriosclerosis, 3.23 per -cent; epilepsy, 1.85 per cent; and without psychoses, 20.63 per cent. - -This latter class (without psychosis) is looked upon by some as -constituting the most important field of a psychopathic hospital. It -is exceedingly interesting to note the conditions which bring such -individuals to the institution. An analysis of 1,430 cases shows -the principal mental types represented to be as follows:—mental -deficiency, thirty-four per cent; psychopathic personality, 15.17 per -cent; hysteria, neurasthenia and other psychoneuroses, 11.2 per cent; -epilepsy, 8.04 per cent; alcoholism, 6.08 per cent; conduct disorders, -4.2 per cent; syphilis, 2.03 per cent; organic brain diseases, 1.68 -per cent; neurosyphilis, 1.26 per cent; drug addictions, 1.4 per cent; -somatic conditions, 1.19 per cent, etc. - -No less interesting and instructive is a study of the voluntary cases. -An analysis of 1,807 admissions of this type shows the following -distribution of psychoses: alcoholic psychoses, 5.64 per cent; dementia -praecox, 18.43 per cent; manic-depressive, 6.81 per cent; involution -melancholia, .99 per cent; senile psychoses, 1.11 per cent; general -paresis, 7.9 per cent; epilepsy, 1.05 per cent; psychoneuroses, 3.59 -per cent; and without psychosis, 34.64 per cent. - -The work of the out-patient service includes in a general way the study -of cases referred to that department from the wards of the hospital or -by its social service staff; cases referred by courts, schools, social -agencies, and other institutions, as well as those sent by practicing -physicians and individuals coming on their own initiative. The response -on the part of the public to the facilities offered by the out-patient -department is shown by the fact that 9,273 new cases were reported -during a seven-year period, an average of 1,324.7 per year. Fifty-seven -and six hundredths per cent of these cases were adults, 17.8 per cent -were classified as adolescents, 24.25 per cent as children and .89 per -cent as infants. The source of origin of these cases is exceedingly -interesting. Four and eighty-seven hundredths per cent were referred -to the out-patient service by courts; 4.65 per cent, by schools; 11.77 -per cent, by hospitals; 9.77 per cent, by physicians; and 3.55 per -cent, by individuals. Fifteen and five tenths per cent came from the -wards of the Psychopathic Hospital; 9.96 per cent, from the social -service department and 13.3 per cent came on their own initiative. -The question as to why these cases are sent to an institution of the -psychopathic hospital type can now be answered. Fourteen and fifty-two -hundredths per cent were examined solely for the purpose of determining -the existence of probable mental diseases and 21.88 per cent on account -of suspected mental defects. Four and fifty-two hundredths per cent -were sex offenders. In 8.64 per cent the only question at issue was -the possibility of a psychoneurosis and in 7.97 per cent the purpose -of the examination was to ascertain whether or not syphilis was -present. The diagnoses show the nature of the cases encountered in an -out-patient mental clinic. Four and eighteen hundredths per cent were -cases of dementia praecox; 1.7 per cent of alcoholism; 2.26 per cent -of alcoholic psychoses; 2.39 per cent of epilepsy; 15.72 per cent of -mental deficiency; 9.0 per cent of psychoneuroses; 2.14 per cent of -manic-depressive insanity; 2.09 per cent of psychopathic personality; -1.21 per cent of general paresis; and 2.94 per cent were unclassified. -Two and thirty-two hundredths per cent were diagnosed as suffering -from syphilis in some form and 6.27 per cent were either delinquent, -defective, subnormal, retarded or distinctly feebleminded. In 3.76 per -cent no disease was found, either mental or physical. The great bulk of -these cases were diagnosed either as mental deficiency, psychopathic -personality or epilepsy. The ultimate disposition of 2,741 cases, -covering a period of two years, serves as an index of the practical -operation of such a department. In 42.03 per cent of these cases no -care or observation other than that of the out-patient department was -required. In 1.69 per cent of the cases commitment was recommended to -hospitals for mental diseases, in 7.15 per cent, to schools for the -feebleminded and in .11 per cent, to penal institutions. General or -psychopathic hospital care was recommended in 11.31 per cent. In 2.74 -per cent of the cases a report was made to courts; in 1.61 per cent, to -schools; in 18.75 per cent, to social agencies; and in 1.13 per cent, -to physicians. - -The functions of the social service department in a general way may be -summarized as follows:—1. The after care and supervision of patients -at home; 2. Advice to families of patients in regard to their cases; -3. Advice given other members of the family; 4. Financial relief; 5. -Reference to other social agencies or institutions; 6. Information -obtained for case histories; 7. Inquiries relative to home conditions -when discharge of a patient is under consideration, etc. The routine -operation of the department is well illustrated by the annual report -of the Boston State Hospital for 1920. The number under social service -supervision during the year was 428. Of these, 278 were new cases. -Thirty-two and thirty-seven hundredths per cent were referred by the -out-patient physicians; 59.71 per cent by the ward service; 7.19 -per cent by other social agencies; and .73 per cent were brought by -relatives or friends. The principal reasons for their reference to the -social service workers were shown as follows:—For medical history, -50.36 per cent; assistance in securing employment, 9.35 per cent; -financial aid, 3.6 per cent; supervision, 7.2 per cent; advice, 19.42 -per cent; convalescent care, 2.87 per cent; home care, 2.87 per cent, -etc. An analysis of the cases under supervision shows the principal -psychoses represented to be as follows:—Arteriosclerosis, 1.8 per -cent; general paresis, 4.68 per cent; alcoholic psychoses, 1.8 per -cent; manic-depressive psychoses, 4.68 per cent; dementia praecox, -16.55 per cent; paranoid conditions, 4.31 per cent; psychoneuroses, -9.35 per cent; undiagnosed psychoses, 6.84 per cent; and without -psychoses, 44.24 per cent. This latter group was made up mostly of -psychopathic personalities (28.45 per cent) and mental deficiency -(26.29 per cent). The purely social problems presenting themselves -in connection with these cases were reported as follows:—Mental -disease, 75.54 per cent; physical disease, 2.16 per cent; poverty, -2.88 per cent; criminality, 3.24 per cent; juvenile delinquency, 2.52 -per cent; sex offenses, 2.16 per cent; alcoholism, 2.16 per cent; -family dissension, 6.12 per cent; ignorance, 2.52 per cent; and bad -environment, .36 per cent. In addition to this, 299 discharged soldiers -and 543 out-patient cases were reported as being under the supervision -of the department, as well as 532 special cases studied in connection -with the investigation of syphilis. - -The Psychopathic Hospital in Boston started on a new chapter in its -history on December 1, 1920, at which time it was formally separated -from the Boston State Hospital and became a separate institution under -the direction of Dr. C. Macfie Campbell. - -The Phipps Psychiatric Clinic at the Johns Hopkins Hospital in -Baltimore was established in 1913. An integral part of a large -general hospital and intimately associated with a medical school, it -conforms rather closely to the plan of the German psychiatric clinics. -A study of its activities shows that during a period of five years -(ending January 31, 1918) the admission rate averaged 403.8 per year. -Fourteen and three-tenths per cent of the cases were diagnosed as -dementia praecox or schizophrenic reaction and 13.7 per cent conform -apparently to the classification of manic-depressive psychoses. Ten -and five-tenths per cent were diagnosed as neuroses or psychoneuroses; -6.1 per cent as general paresis; fifteen per cent as agitated -depressions; 2.3 per cent as alcoholic psychoses; and 6.1 per cent -as constitutional inferiority or constitutional psychopathic states. -Seven and nine-tenths per cent were cases of anxiety neuroses, agitated -depressions or anxiety psychoses; 2.3 per cent were paranoic states or -reactions; 3.5 per cent were cases of alcoholism, and 3.7 per cent of -drug habits. The dispensary service of the Phipps Clinic has reported -an average of 565 cases per year, representing a total of 2,260.5 -visits annually. - -The work of Drs. Meyer, Hoch and Kirby at the Psychiatric Institute, -of Dr. Barrett at the Psychopathic Hospital at the University of -Michigan, of Dr. Southard at the Psychopathic Department of the -Boston State Hospital, and that of Drs. Meyer and Campbell at the -Phipps Psychiatric Clinic in Baltimore has brought the subject of -psychopathic hospitals very prominently before the public. Various -other establishments of a similar nature have been planned and some -are in process of construction, or already in operation. The State -Psychopathic Institute at Chicago and the Psychopathic Hospital of the -University of Iowa should be mentioned in this connection. Psychopathic -hospitals have been planned for New York City and one is to be built by -the State of California. The legislature of Colorado has already made -an appropriation of $350,000 for the establishment of an institution of -this type in the city of Denver. - -The work already done in this field shows quite conclusively that -general hospital methods are not inconsistent with the developments -of modern psychiatric progress. The large percentage of voluntary -cases received and the number of persons consulting the physicians in -the out-patient departments shows an unexpected demand on the part of -the public for institutions of a new type. As Dr. Adolf Meyer[36] has -pointed out, "Our organized system for the care of mental disorder is -in many respects forbidding. It throws together all kinds of diseases, -and shocks in that way the already sensitive patient who fears the -worst for himself or herself. It comes at once with an outspoken -declaration of insanity in the very commitment to a hospital, an -expression which carries a humiliation to the patient and adds insult -to injury. It often means carrying the patient off to a remote asylum -which is too widely supposed to have the inscription, 'Leave hope -behind all ye that enter here.' Helpfulness rather than coercion -must take the place of all this." What the psychiatric clinic may be -expected to accomplish in remedying this difficulty was summarized by -Dr. Meyer[37] in the following words:—"It is eminently necessary to -get model institutions in which medical students and physicians can -learn how to deal with the many problems of the disorders of the organ -of behaviour from their inceptions into all their ramifications. The -clinic must do the work for at least one limited district, with its -out-patient and social service and consultation department, and with -its hospital wards. Everything must be done to make help in mental -disorders more acceptable and convincingly helpful. More patients must -learn to look to it for help and the organization must be so as to give -the patient and the physician and the public at large a conception very -different from that to-day associated with insanity. It is not so much -the issue of more help to the curable, but the issue of more work near -where the troubles begin, and work against that which breeds trouble. -For this we must learn to put the chief weight on hospitals and -organizations for natural districts for intensive work rather than upon -the mere economy of large hospitals far away from where the troubles -develop." - -Southard has raised the question as to the correct designation of -institutions of the psychopathic hospital type:—"A word is again -necessary as to the meaning of the term 'psychopathic hospital.' -For various reasons the term has become so attractive in propaganda -that a comparatively large number of institutions of whatever scope -have been founded or recommended to receive the term 'psychopathic -hospital,' 'institute,' 'department' or 'ward.' Thus there is -developing a tendency in state hospitals to denominate the receiving -ward 'psychopathic.' There can be no advantage in this designation -other than that of calling old ideas by new names. The idea of the -receiving ward for committed cases destined to receive the ordinary -probate court group of cases is not altered or improved in any manner -by the designation 'psychopathic.' The best opinion seems to be that -a psychopathic hospital or institute shall be an institution in which -all types of mental cases, from the probate court group on the one hand -up to the most dubious and difficult cases of mental disorder on the -other, may be examined; but if an institution is primarily or chiefly -concerned with patients of the medicolegal, committable or custodial -group, to serve merely as a vestibule through which committed cases -pass, such an institution has by no means the broad scope which the -very general term 'psychopathic' implies. The institution is not a -modified or sublimated form of receiving ward for a great district -hospital." - -There is, of course, no reason why the reception service of an ordinary -state hospital should be spoken of as constituting a psychopathic ward. -This accomplishes nothing more, perhaps, than to raise some question -as to what the functions of the rest of the institution may be. The -designation psychopathic hospital has been rather loosely used and -is, as Southard has definitely shown, of American origin. It has been -applied somewhat indiscriminately from time to time to practically -every form of activity related to the care and treatment of mental -diseases outside of the generally recognized state hospital field. -These may be summarized as follows:— - -1. Detention wards, pavilions, etc. Intended for no purpose other than -the custody of the "insane" pending commitment. - -2. Psychiatric wards of general hospitals—such as Pavilion F in -Albany. There would appear to be no reason for the use of the word -psychopathic in such cases, the term psychiatric being much more -clearly applicable. - -3. Institutes designed primarily for research only or for research and -instruction, with or without clinical facilities. - -4. Psychopathic hospitals. Independent units or integral parts of -a general hospital—with or without facilities for research and -instruction. Designed exclusively for mental cases, without regard -to legal status, whether committed or voluntary, their detailed -examination and careful observation with intensive treatment in the -wards for limited periods when indicated, or their supervision and -direction in out-patient departments, serving also in some instances as -receiving and distributing centers supplying other institutions. - -Owing to their limited size, the necessity of treating large numbers in -a short space of time, and the fact that institutional care is already -amply provided for in the existing state hospitals, the obvious field -of the psychopathic hospital is primarily the acute and recoverable -psychoses and the milder forms of mental disorder which may or may -not require a residence in the wards. Only a thorough examination -and a brief period of observation can determine whether or not that -is needed. The question at issue is largely that of determining the -necessity of a more or less indefinite committed status. These problems -arise particularly in dealing with the so-called psychogenic disorders -and the psychopathic states—hysteria, neurasthenia, psychasthenia, -the psychoneuroses in general and the episodes which characterize -the psychopathic personalities. Traumatic psychoses often come into -consideration, as well as cases of cerebrospinal syphilis, toxic -conditions, drug addictions, the psychoses of infection and exhaustion, -and above all, of course, manic-depressive insanity and incipient forms -of dementia praecox. Many of these cases require only a brief hospital -treatment and are able in a short time to return to home surroundings -and resume their former occupations. Often a contact with the chronic -and custodial classes is not only without advantage but actually -detrimental. The psychopathic hospitals thus exercise a sort of -clearing house function and return to the community many patients who -otherwise would be subjected to the stigma, if there is one, of a legal -commitment. While questions relating to the public health cannot be -analyzed in terms of dollars and cents, the saving to the state which -is made by substituting a short period of supervision and treatment, -for a protracted residence in an institution of the custodial class -amounts to millions. In view of the difficulties encountered in -obtaining adequate appropriations for the proper maintenance of the -enormous population now housed in our state hospitals, this is a factor -which cannot be disregarded. - - - - -CHAPTER VII - -THE MENTAL HYGIENE MOVEMENT - - -As the result of an intimate personal knowledge of the subject, -acquired during an extended hospital residence as a patient in both -public and private institutions, Clifford W. Beers, having recovered -his health, resumed his place in the world profoundly impressed with -the feeling that the question of mental diseases as a public health -problem was one which demanded immediate consideration. In no position -financially to institute a campaign for the purpose of interesting -the public in the importance of topics which had not been made the -subject of general discussion in the past, he was confronted with the -necessity of securing the cooperation and support of persons who had -the means to launch such an undertaking. With this object in view -he wrote his book—"A Mind That Found Itself,"[38] now in its fourth -edition and destined, to use the words of the "American Journal -of Insanity,"[39] "to become one of the classics of psychological -literature." There is some question as to the accuracy with which Mr. -Beers analyzed the experiences through which he had passed. Although -there is no reason for questioning his mental condition when the book -was written, his conclusions were apparently formulated when he had not -as yet had sufficient time in which to readjust himself and recover -his perspective. Some of his viewpoints certainly reflect a morbid -coloring of which he was probably unconscious, although at the time -he recognized in himself "symptoms hardly distinguishable from those -which had obtained eight months earlier when it had been deemed -expedient temporarily to restrict my freedom." His work was referred -to as an "autopathography" by Farrar,[40] who made a detailed study -of the various psychological trends manifested. These are more or -less immaterial. The interesting feature of his book is the elaborate -description of a common but exceedingly important psychosis written -by a well educated observer with a collegiate training. Its greatest -value, however, lies in the fact that he brings home to us so -graphically the overwhelming importance of the personal element so -often overlooked by those who are accustomed to dealing with mental -cases in large numbers. "It carries the reader away from the technical -dissertations, and brings him face to face with the feelings and -reactions of a distorted mind, showing him the patient as a human being -with a sentient soul and not as a case."[41] - -That the plan which Mr. Beers had formulated for an organized mental -hygiene movement had a practical application was recognized at once by -Dr. Adolf Meyer,[42] who expressed the following views on the subject -as early as 1907:—"It will be a difficult task to find the not very -common level-headed and well-informed persons in various parts of the -country capable of organizing the public conscience of the people. -Neglected by physicians and dreaded by the fiscal authorities, the -facts are not available today, except in fragments, mixed up with -innumerable extraneous considerations; the hospitals are closed -corporations, the press injudicious in inquiry and reform, and those -capable of judgment unable to get the facts. The crying needs persist -in the meantime. Instead of a land fund (the 12,225,000 acres bill -and ideal of Dorothea Dix) we must have a permanent survey of the -facts and efficient handling of what is not prevented. The experience -with what remains as inevitable experiments of nature, as well as with -people who should know better, must be put into practical form for -communication and teaching, and brought home where it will tell; in -opportunities of work and education for physicians, and cooperation -between our educational forces and those who labor for physical -hygiene and prophylaxis. Most of us are already under too definite -obligations to meet the call for devoted work for the maintenance of -an organization as well as can Mr. Beers. In my judgment, he deserves -the assistance which will make it possible for others to join in the -work which will be one of the greatest achievements of this country -and of this century,—less sensational than the breaking of chains but -more far-reaching and also more exacting in labor. A Society for Mental -Hygiene with a capable and devoted and judicious agent of organization -will put an end to the work of makeshift and short-sighted opportunism, -and initiate work of prevention and of helping the existing hospitals -to attain what they should attain, and further of adding those -links which are needed to put an end to conditions almost unfit for -publication. What officialism will never do alone must be helped along -by an organized body of persons who have set their hearts on serious -devotion to the cause. If Mr. Beers gets the means to pursue his aim he -will secure the body which will guarantee proper judgment in a cause -which has been a mere foster-child in the field of charitable donations -merely because it seemed too difficult. Here is a man who is not afraid -of the task. May he get the help to enable him to surround himself with -the best wisdom of our nation!" - -Encouraged by this and many other such expressions of opinion, Mr. -Beers proceeded to the organization of the first state mental hygiene -society, that of Connecticut, which began its activities in 1908. -The National Committee for Mental Hygiene was formally organized on -February 19, 1909. The first few years were devoted to raising funds -and making comprehensive preparations for further activities which -did not start until 1912. In the meanwhile the cooperation of many -prominent philanthropists, educators, physicians, etc., was assured. -The importance of this movement is illustrated by the prominence of the -persons who were willing to associate themselves with an undertaking of -this nature. The membership of the committee has included, in addition -to many others, Professor William James, Dr. Lewellys F. Barker, -Dr. Rupert Blue, Dr. George Blumer, Dr. G. Alder Blumer, Professor -Russell H. Chittenden, Ex-President Charles W. Eliot, President W. -H. P. Faunce, President John H. Finley, Professor Irving Fisher, Dr. -Charles H. Frazier, Cardinal Gibbons, President Arthur T. Hadley, -Chancellor David Starr Jordan, President Cyrus Northrop, Dr. Stewart -Paton, Dr. Frederick Peterson, Professor Gifford Pinchot, President -Jacob G. Sherman, Rev. Anson Phelps Stokes, Mrs. William K. Vanderbilt, -Professor Henry VanDyke, Dr. William H. Welch and Ex-President Benjamin -Ide Wheeler. Important financial contributions were made by Professor -William James, Mr. Jacob A. Riis, Mr. Henry Phipps, Mrs. Elizabeth M. -Anderson, Mrs. William K. Vanderbilt, Mrs. E. H. Harriman, Mrs. Willard -Straight, the Rockefeller Foundation, etc. With the appointment of Dr. -Thomas W. Salmon as Medical Director in 1912 the committee commenced -active operations with its future success assured in every way. - -The objects and purposes of the National Committee have been very -adequately summarized in the following language used in one of its -publications:—"The National Committee for Mental Hygiene and its -affiliated state societies and committees are organized to work -for the conservation of mental health; to help prevent nervous and -mental disorders and mental defect; to help raise the standards of -care and treatment for those suffering from any of these disorders -or mental defect; to secure and disseminate reliable information -on these subjects and also on mental factors involved in problems -related to industry, education, delinquency, dependency, and the like; -to aid ex-service men disabled in the war; to cooperate with the -federal, state, and local agencies and with officials and with public -and private agencies whose work is in any way related to that of a -society or committee for mental hygiene. Though methods vary, these -organizations seek to accomplish their purposes by means of education, -encouraging psychiatric social service, conducting surveys, promoting -legislation, and through cooperation with the many agencies whose work -touches at one point or another the field of mental hygiene. When one -considers the large groups of people who may be benefited by organized -work in mental hygiene, the importance of the movement at once becomes -apparent. Such work is not only for the mentally disordered and those -suffering from mental defect, but for all those who, through mental -causes, are unable so to adjust themselves to their environment as to -live happy and efficient lives." The first few years of the committee's -existence have demonstrated conclusively that it is the most powerful -factor in promoting the welfare and interests of the insane in this -country since the time of Dorothea Dix. The elaborate surveys which -it has made of conditions existing in various states have resulted in -beneficial legislation which had been needed for years. Surveys have -been completed in California, Tennessee, Louisiana, Pennsylvania, -Texas, Connecticut, Georgia, Wisconsin and South Carolina, and -others are under way. It has brought about an interest in mental -diseases and mental defects such as has never been manifested before -in this country. Its activities during the early part of the war -were responsible largely, if not entirely, for the attention given -by the Army and Navy to matters relating to psychiatry. The National -Committee has taken a very active part in encouraging the establishment -of psychiatric clinics in connection with the state hospitals. It -has been largely responsible for the psychological and psychiatric -examination of defectives in penal institutions and reformatories now -generally recognized as being of vital importance. Its activities -have emphasized the importance of a preliminary mental examination of -obviously defective individuals brought before the courts. One of its -accomplishments has been the publication of a very successful quarterly -magazine, "Mental Hygiene," which was undertaken in 1917 and has long -since passed the experimental stage. A summary of its activities would -not be complete without a reference to the valuable work which the -committee has done in standardizing the reports made of institutions -and compiling accurate statistics relating to mental diseases and -defects which will be of inestimable value to all who are interested in -the progress of psychiatry in this country. - -State mental hygiene societies now exist in Alabama, California, -Connecticut, the District of Columbia, Georgia, Illinois, Indiana, -Iowa, Kansas, Louisiana, Maryland, Massachusetts, Maine, Mississippi, -Missouri, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee -and Virginia. The committee on mental hygiene in New York is a -department of the State Charities Aid Association, which has been -actively interested in matters relating to the care and treatment -of the insane for many years. The chief purposes of the state -organizations have been officially described as follows:—[43] "To work -for the conservation of mental health; for the prevention of mental -diseases and mental deficiency and for improvement in the care and -treatment of those suffering from nervous or mental diseases or mental -deficiency." The interest of the public is stimulated by pamphlets, -reports and publications of various kinds, mental hygiene exhibits of -an educational nature, public lectures, mental hygiene conferences, -etc. The local societies have as a definite object, moreover, the -encouragement of[44] "(a) Out-patient departments for mental cases in -connection with hospitals for mental diseases and general hospitals, -and independent of either of these agencies, such, for instance, as -dispensaries and mental hygiene clinics, (b) Systematic psychiatric as -well as psychological examination of school children, (e) Provision -for incipient and emergency cases in psychopathic wards of general -hospitals, (d) Psychopathic hospitals in which cases of mental disorder -may be treated in their earliest and most curable stages and where -practical work in prevention and social service may be done, (e) -Increased institutional provision for the feebleminded and epileptic." -One of their most important objects is the enactment of laws in the -various states which will take care of the insane pending commitment -out of the hands of the poor authorities and delegate it to health -officers or physicians. As Dr. William L. Russell[45] has pointed out, -the mere provision of institutional care for the mental diseases of a -community is not the only thing to be considered, "Unless the vital -issues occasioned by mental disorders in the homes, the schools, the -industries, and in social relations are intelligently grasped and dealt -with by means of the state system, state institutions are liable to be -looked upon as a resource which is only to be appealed to when complete -separation of the patient from his usual environment has become -imperative. They will still be regarded as asylums. In such case, -their development is likely to be in the direction of great custodial -centers, and economic and so-called business consideration in their -management are likely to prevail over those dictated by science and -humanity. This has happened in more than one state in which state care -has been adopted under conditions of great promise. A system of state -care must, to be effective, not only be adopted, but it must be planned -and developed with reference to the known needs of the sufferers from -mental disorder." - -The Canadian National Committee for Mental Hygiene, the second national -organization of this type, was established at Ottawa on April 26, 1918, -largely as a result of the activities of Dr. Clarence M. Hincks of -Toronto University. Arrangements were at once effected for an active -participation in war work, a comprehensive study of immigration, -elaborate statistical institutional studies, the establishment of a -library, special investigation of delinquency and a series of lectures -to be given in various parts of the Dominion. This organization has -been an exceedingly active one from the beginning. The first number -of the "Canadian Journal of Mental Hygiene" appeared early in 1919. A -survey was made of Manitoba and its needs during the first year. The -University of Toronto announced an extension course beginning April, -1919, for the special training of social workers desiring to enter -the mental hygiene field. Instruction was given in psychiatry, social -and economic problems, neurology, mental tests, case work, social -institutions, occupational therapy, child welfare, home economics -and recreation. In 1919 a mental hygiene survey was made of British -Columbia. Alberta, New Brunswick and Nova Scotia have already requested -similar surveys with the intention of improving the methods of caring -for mental diseases and defects in those provinces. Psychiatric clinics -have been established in connection with the Toronto University and -the Royal Victoria Hospital in Quebec. New institutions have been -planned in British Columbia and a psychopathic hospital is to be built -in Toronto. In 1920 a mental hygiene committee was instituted in -France[46] by the Minister of Hygiene, Assistance and Social Providence. -The committee is made up of about forty members, psychiatrists, -pathologists, physiologists, managers and magistrates. Dr. Dron, -Senator and Mayor of Tourcoing, was elected chairman. The committee -is to make a study of all questions relating to mental hygiene and -psychiatry. It will consider particularly methods of coordinating the -activities of various organizations already at work, the creation of -new interests and spreading broadcast information on mental hygiene -topics. A representative of this society has already made a visit -to this country to study methods employed here. The mental hygiene -movement has even reached South Africa. "Mental Hygiene"[47] has called -attention to the fact that the Cape Province Society for Mental Hygiene -has actively interested itself in the provisions discussed by the -government for the care, education and training of the feebleminded. -Two institutions are to be opened for this purpose. The Cape Province -Society has already instituted a campaign for the purpose of organizing -other local societies as well as a national council. - -When Mr. Beers wrote his well-known book he evidently had in mind -more particularly the amelioration of material conditions existing -in institutions. He was looking forward to provision for the more -humane and scientific care of mental diseases. This is unquestionably -a consideration of vital importance and these objects have not -been neglected in the practical operation of the mental hygiene -organizations. Mental hygiene in its broadest sense, however, has -come to mean much more than that. The foundation of the present-day -conception of mental hygiene may be said to have been laid by Adolf -Meyer in 1906, when he described the fundamental principles which he -believed to be concerned in the development of dementia praecox. He saw -in this disease a disorder of the personality due to a deterioration -of mental habits, in other words, to faulty mental hygiene. While his -views as to the etiology of dementia praecox have not been generally -accepted, they suggested an entirely new avenue of approach to the -problem of mental diseases in general. Hoch's "shut in" personality -and Bleuler's "autismus" were more or less comparable hypotheses -which do warrant to a certain extent the tenability of such theories -as were advanced by Meyer. The same may be said of some of the -mental mechanisms advocated by Freud and others of the more purely -psychological school of psychiatrists. This viewpoint is reflected -somewhat by White[48] in his conception of childhood as the golden -period for mental hygiene. "The outstanding fact that present-day -psychiatry emphasizes is that mental illness is a type of reaction of -the individual to his problems of adjustment which is conditioned by -two factors—the nature of those problems and the character equipment -with which they are met.... Mental illnesses, defects of adjustment at -the psychological level, are therefore dependent upon defects in the -personality make-up, and as this personality make-up is what it is as -a result of its development from infancy onward, it follows that the -foundation of those defects which later issue in mental illness are to -be found in the past history of that development." He protests very -properly against accepting the theory that the characteristics of the -personality are entirely the products of germ-plasm determiners moulded -in strict accordance with the laws of heredity and therefore immutable. - -Copp[49] has called attention to the fact that the dominant figure in -mental hygiene activities must eventually be the family physician, -who has an opportunity to see the beginnings of mental disorders when -they first manifest themselves. He must, therefore, be qualified to -intelligently understand such conditions and be prepared to suggest a -remedy. His is inevitably the first point of contact. Mental hygienists -have found a fertile and almost untouched field in our public school -system. As Professor Burnham[50] suggests, "It is a grave reflection -upon the schools that so many of their graduates have to be reeducated -in the sanitarium or the hospital." The hygiene movement in the school -population, as suggested by Professor Gesell,[51] means something more -than psychological examinations and mental tests, important as they -are. It means a study of the individual. He would have a new type of -school nurse or social worker, one interested particularly in "the -child with the night terrors, the nail biter, the over-tearful child, -the over-silent child, the stammering child, the extremely indifferent -child, the pervert, the infantile child, the unstable choreic, and a -whole host of suffering, frustrated and unhealthily constituted growing -minds, that we are barely aware of in a quantitative sense, because we -do not have the agencies to bring them to our attention as problems -of public hygiene and prophylaxis." They require highly specialized -supervision and training if they are not to become future residents -of our hospitals for mental diseases or possibly of institutions of a -reformatory type. If such reforms as these are to be brought about in -our public school system it is hardly necessary to suggest that the -teacher herself must have very clear conceptions as to the significance -and importance of mental training in youth. - -If these matters are important in the public schools they must be even -more serious factors in higher education. Campbell[52] has raised the -question as to how far the universities "fulfill their responsibilities -with regard to the mental hygiene of the community? It is doubtful -whether they have attained a clear recognition of the fact that a -man's mind may be richly supplied with a great variety of special -information, that he may have attained a high intellectual level, and -yet the man's life may be rendered inefficient because it rests upon -insecure foundations. An education may enable a man to solve abstruse -intellectual problems, and yet leave him so hopelessly unable to cope -with a bereavement, an unsuccessful love affair, difficult marriage -relations, or even simple instructive impulses that he may lose -control of the direction of his life and for a period be dominated by -factors which have been almost entirely repressed in his conscious -life; the disorder may be so marked as to be included under the wide -term "insanity." To rear a superb intellectual structure on such a -foundation is surely not an ideal education; it is like building -a house on the sand, or, to speak more hygienically, it is like -building a superb mansion without paying any attention to the -plumbing." Deplorable as it may seem that such important elements in -the education of the individual have been overlooked, it is not nearly -so surprising as the fact that no instruction of any consequence is -given in psychiatry in the great majority of our medical schools. -This is a matter which is well worthy of attention and is fortunately -beginning to receive some consideration. A rather systematic campaign -has been instituted by the mental hygiene organizations to bring about -some instruction in these topics in our schools and universities,—a -campaign which promises to be productive of results sooner or later. - -An interesting phase of the mental hygiene movement is the relation -which it has been shown to hold to the field of industry. It must be -admitted that this is an intensely practical question. We even have a -Journal of Industrial Hygiene, which has been published successfully -now for some time. The mere taking of intelligence tests for industrial -purposes is only an incident. The important thing, as shown by -Cobb,[53] is the prevention of mental disorder by bringing about a -proper relation of the worker to his environment and the elimination -of causes of discontent. Beyond this there is, of course, the early -treatment of individuals before the opportunity of bringing about a -proper adjustment has been lost for all time. Cobb[54] suggests that, -above all, the physician must "forget orthodox psychiatry (as the -economist seems to be forgetting cut-and-dried political economy) and -interest himself in a dynamic, individual psychology which recognizes -the essentials of human nature and at last begins to analyze for us -the elements of which human nature really consists, looking on each -case as a human experiment in reaction to environment." - -There would appear to be no limit to the possibilities of the mental -hygiene movement. Perhaps no more comprehensive summary of its objects -and purposes can be given at this time than that contained in a -definition recently formulated by Southard:[55] "To stem the tide -of syphilis, to wage war on alcohol, to counsel against marriage of -defectives, to generalize the insane hospitals, to specialize the -general hospitals, to weed defects out of general school classes, -to open out the shut-in personality, to ventilate sex questions, to -perturb and at the same time reassure the interested public—these -are infinitives that belong perhaps in a rational movement for mental -hygiene. They are things the past has taught us more or less clearly to -do and in that sense the movement for mental hygiene is surely not much -more than the elaboration of the obvious." - -It may be suggested that these are functions which properly belong to -the medical profession exclusively. A little reflection will, however, -be sufficient to show that this is not the case. Efforts have been -made for years to prevent the spread of venereal disease. Attempts -were made to accomplish this by legislative enactment. That these -methods of control have been ineffectual is now well known to everyone. -Continental governments have for a long while been trying to regulate -prostitution by police supervision and frequent medical inspections. -The percentage of venereal disease has, however, not been appreciably -reduced by this plan and it has been repeatedly condemned by vice -commissions as a result of official investigations. It may be stated -now, I think, without fear of contradiction that this is a matter -which must be regulated by educating the public and which can be -handled in no other way. It is a well known fact that no law can -be enforced unless it meets with public approval. The will of the -majority rules. When the effects of venereal disease are generally -recognized there will no longer be a necessity for much legislation on -the subject. This is a question of far-reaching importance. When it is -recalled that twelve per cent of the cases admitted to our hospitals -for mental diseases are suffering from general paresis or cerebral -syphilis, the necessity of a more general understanding of these -conditions is readily apparent. The percentage is much higher in the -densely populated metropolitan districts. - -Legislative restrictions in the past were never very successful -in limiting the use of alcoholic beverages. It is true that the -Eighteenth Amendment to the Constitution of the United States and the -Volstead Act have had a very material effect on the number of cases of -alcoholism admitted to our institutions. The influences which resulted -in alcoholism, however, will find an outlet in some other direction -unless they are modified in some way. This again is largely a matter of -education. There never was a time in the history of the country when a -knowledge of the effect of drugs of various kinds on the nervous system -was as important as it is today. - -The history of the movement to prevent the marriage of mental -defectives is more or less familiar to all. The sentiment of the -community is apparently not such at this time as to encourage the -regulation of the marriage of the mentally or physically unfit by -legislative restrictions. Attempts to do so have been almost a -flat failure. Various states have passed laws providing for the -sterilization of defective delinquents. These laws, generally speaking, -have accomplished nothing because public sentiment was not behind -them. All of these matters have been brought to the attention of the -public by prominent speakers on numerous occasions. Frequent articles -have been printed in medical journals, well-known periodicals, and even -in the daily papers. Attention has been called to the mental clinics -established here and there and repeated reference has been made to the -fact that physicians at our state hospitals may be consulted at any -time on questions pertaining to mental diseases or mental defects. - -Something has been accomplished along these lines. It is unfortunate -that, as a rule, people look with more or less suspicion upon -institutions which are even now generally referred to as asylums. There -are many who still believe that every hospital for mental diseases -has its padded cells and underground dungeons. There is a rather -widespread idea that the most common causes of insanity are cigarette -smoking, religion and self abuse. Even in our most progressive -communities it has been difficult, if not impossible, to entirely -prevent the temporary detention, at least, of mental cases in jails -and police stations. Very few general hospitals have psychopathic -wards or any realization as to the necessity of establishing them. -It is not to be denied that in many states the care of the mentally -ill in our public institutions is far from being what it should be in -this enlightened day. These are conditions that cannot be remedied by -the medical profession without the active assistance of leaders of -public sentiment. The fact that the importance of these questions is -recognized by prominent educators, business men, lawyers, and other -persons active in the affairs of the community, and well known to the -public, will accomplish more than articles in the medical journals by -physicians. This constitutes the great field of the mental hygiene -organizations. They will mould public sentiment as nothing else ever -has, in matters which relate to the mental health of the country. They -will influence legislation where it is needed in a way that no medical -society can hope to do. Above all, they can in time bring the public -face to face with the fact that mental diseases should be discussed, -generally understood and prevented, instead of being merely concealed -and misrepresented. Possibly it would not be looking too far into the -future to express the hope that an organization composed largely of -laymen may be able eventually to accomplish something that the medical -profession has never been able to do,—induce those who frame our laws -to provide medical treatment for defective delinquents instead of -merely locking them up for the protection of society. It would seem, -moreover, that the time has come when the public should insist that the -mental condition of persons accused of crime be made a medical rather -than a legal question exclusively. - - - - -CHAPTER VIII - -THE ETIOLOGY OF MENTAL DISEASES - - -In reviewing the history of medicine there is nothing more discouraging -than the references found in literature to the views entertained -from time to time relative to the cause of mental diseases. To a -certain extent this may be looked upon as an index of the progress -of civilization. It must be admitted that it is at the same time, -nevertheless, a reflection upon the medical profession which has never -shown the interest in psychiatry that the importance of the subject -warrants. It has been suggested that mental diseases did not play a -prominent part in ancient history, owing to the fact that the law of -the survival of the fittest automatically eliminated the insane and -defective. As Tuke[56] says, "They perished in the course of nature, or -were stamped out of existence; many of the perverse and morally insane -were stoned to death; war destroyed a large number of feeble persons; -while the Romans deliberately, and in the interests of the race, threw -down from the Tarpeian Rock the children who were unfit to live." The -papyri of the fifteenth century before Christ show clearly that the -doctrine of demoniacal possession was generally entertained at that -time. - -One of the earliest attempts to explain the origin of mental diseases -perhaps was that of Plato. "There are two kinds of madness, one -arising from human diseases, the other from an inspired deviation from -established custom." Hippocrates[56] had some very clearly defined -views on this subject: "As long as the brain is at rest a man enjoys -his reason; but the depravement of the brain arises from phlegm and -bile, either of which you may recognise in this manner: Those who are -mad from phlegm are quiet, and do not cry out or make a noise, but -those from bile are vociferous, malignant, and will not be quiet, but -are always doing something improper. If the madness be constant, these -are the causes thereof; but if terrors and fears assail, they are -connected with derangement of the brain, and derangement is owing to -its being heated. And it is heated by bile when it is determined to -the brain along the blood-vessels running from the trunk, and fear is -present until it return again to the veins and trunk, when it ceases. -He is grieved and troubled when the brain is unreasonably cooled and -contracted beyond its wont. It suffers this from phlegm, and from -the same affection the patient becomes oblivious." An interesting -theory which he evolved was that the appearance of varicose veins -or hemorrhoids tended to relieve the patient's mental suffering. -Celsus subscribed to the black bile doctrine. Galen's teaching was -that fatuity was due to moisture, while dryness produced sagacity. In -cases where the whole body contained melancholy blood he recommended -venesection. Thick and black wine was to be avoided, "as from it the -melancholy humour is made."[57] This he described as a condition of -the blood "thickened, and more like black bile, which exhaling to the -brain, causes melancholy symptoms to affect the mind." The Roman custom -of appealing to the household gods, sons of the Goddess of Madness, -was quite significant. Horace, in speaking of Orestes, says: "Was he -not driven into frenzy by those wicked Furies, before he pierced his -mother's throat with the reeking point of his sword? Nay, from the time -that Orestes passed for being unsound of mind he did nothing in any -way to be condemned; he never dared wound with his sword either his -friend Pylades or his sister Electra; he merely abused both, calling -one a Fury, the other some other name suggested by his active or bright -bile." In the story of Argive, Horace says that "his relations cured -him with much labour and care, by expelling the disease and the bile by -doses of pure hellebore." - -Little progress was made, if any, by the time of the Christian era. In -fact, as Clouston[58] says, "The mental pathology of the New Testament -and of the early ages of Christianity was founded on the idea that the -disease was a possession of the devil, and the feeling towards this -afflicted class of human beings was naturally that of repulsion and -hatred, their treatment following on those lines. Neglect, the whip, -chains, confinement in stone cells, starvation, unsuitable medical -treatment, speedy death were the natural results." - -Passing to the seventeenth century we find that Sennert, a professor -in Wittenberg, believed that maniacs evacuated stones, iron, living -animals, etc., things not produced in the natural body and therefore -caused by demons. He also believed firmly in witchcraft. Thomas Willis -(1682) is said by some to have been one of the first to suggest a -relation between insanity and pathological changes in the brain. -Prochaska in 1784 went so far as to say, "We think, with Haller, that -no light can be thrown upon it in any other way than by a careful -dissection of the brains of fatuous persons, apoplectics, and such as -have other disorders of the understanding." It would appear to have -been the belief of Pinel that the primary seat of disease in mental -conditions was in the stomach and intestinal tract. Spreading from -these centers it caused a derangement of the mind when the brain became -involved. The influence of the moon, as well as the stars, was spoken -of by Hippocrates and admitted by Galen. To these ideas we owe the -word lunacy which appeared in the laws of England in 1320 and may be -found there today. - -The influence of the moon on the mind was taken quite seriously. Rush -seems to have been somewhat in doubt on this subject and suggested the -probability of there being a kind of sixth sense involved—a perception -of the state of the air, and of light and darkness, as Pritchard -expressed it, to which we are insensible in health. It was thought that -the full moon, by rarefying the air, increased the amount of light, -thus affecting the mind. Dr. Rush noted that during an eclipse of the -sun in 1806 "there was a sudden and total silence in all the cells of -the hospital." He expressed the opinion in his "Medical Inquiries and -Observations" in 1812 that there are few cases in which the insane feel -the influence of the moon and that the excitement resulting in such -cases is to be attributed to the resulting increase of light. It is -interesting to note that von Feuchtersleben, an eminent German writer, -in 1845 was unwilling to go on record as stating positively that the -moon was not a factor in the causation of insanity. Esquirol, in his -"Maladies Mentales," in 1838, branded this belief as a superstition, -but admitted that there were certain facts which could not be -overlooked. "It is true that the insane are more agitated at the full -moon as they are also at the dawn of day; but is it not the bright -light of the moon that excites them, as that of the day every morning? -Nevertheless, an opinion which has existed for ages—which has spread -over all lands, and which is consecrated by popular language—demands -the most careful attention of observers." Dr. Allen of the York Lunatic -Asylum was very firmly of the opinion that the moon had a decided -influence on the time of death in mental diseases. This question was -given very serious consideration by various writers as late as 1856. - -In the meanwhile efforts were being made to ascertain the cause of -mental disease by means of pathological researches. Morgagni,[59] one of -the earlier investigators, came to the conclusion that the more common -lesions were in the pineal gland, although he found some induration -of the brain and various other well-defined changes. Arnold (1782) -thought that insanity was due to an increased density of the cerebral -substance, particularly, according to Tuke, "of those parts of the -brain by means of which the soul is connected with the body." Pinel -finally concluded that pathology had practically nothing to do with the -problem and Esquirol in 1838 wrote very discouragingly on the subject. -Early contributions of considerable importance were made, however, -by Foville, Bayle, Greding, Calmeil, Guislain, Parchappe and others. -These were confined almost entirely to a study of gross or macroscopic -lesions of the brain. Griesinger in 1845 reviewed the pathological -changes in the nervous system quite thoroughly as far as they were -known at that time. It must be admitted that the greater part of our -knowledge of the pathology of mental diseases was acquired at a much -later date. - -A very definite indication of the progress, or lack of progress, made -in determining the etiology of the psychoses is the list of causes -agreed upon at the International Congress of Alienists[60] in 1867:—1. -Physical causes: Artificial deformities of cranium; convulsions of -infancy and dentition; cerebral congestion (primary, not that which -arises in the course of certain forms of insanity); organic affections -of the brain; senility; pellagra; anemia; constitutional syphilis; -intermittent fever; typhoid fever; acute rheumatism; gout and chronic -rheumatism; organic affections of the heart; pulmonary phthisis; -intestinal worms; other acute diseases; other chronic diseases; -suppression of the hemorrhoidal flux; menstrual disorders; metastasis; -alcoholic drinks; abuse of tobacco; other vegetable poisons; mineral -poisons (lead, mercury, coffee, etc.); insolation; intense heat; -intense cold; blows and falls upon the head; other traumatic causes. 2. -Moral causes: Appertain to religion; education; love (love thwarted, -jealousy); family affections; fluctuations of fortune; domestic -troubles; pride; disappointed ambition; fright; irritation; anger; -wounded modesty; political events; nostalgia; ennui; misanthropy; -sudden joy; simple imprisonment; solitary confinement. - -In 1897 the New York State Commission in Lunacy in its eighth annual -report published an analysis of the assigned causes of insanity -given in 39,369 cases admitted from 1888 to 1896. Of these 11,999 -were reported as unascertained. In the remaining 27,370 cases the -important "assigned causes" in the order of their frequency were as -follows: Moral causes (including domestic trouble, loss of friends, -business anxieties, pecuniary difficulties, grief, fright, disappointed -affections, disappointed ambition, political excitement, religious -excitement, etc.) 6,608, intemperance in drink 4,763, hereditary -predisposition 2,095, old age 1,723, general ill health 1,681, -epilepsy 1,605, ill health following overwork 1,092, masturbation -1,063, puerperal (including childbirth and abortion) 773, traumatic -608, climacteric 502, la grippe 442, sunstroke 402, physical diseases -375, syphilis 368, cerebral diseases 312, intemperance in drink and -narcotics 277, congenital defects 223, shock from injury 167, fever -147, uterine and ovarian disease 132, pregnancy 109, privation and -overwork 110, etc. These are given in detail not that they throw any -light on the question of etiology but that they are quite significant -as to the ideas prevalent on this subject only a few years ago. In -justice to the Commission in Lunacy attention should be called to -the fact that this tabulation does not purport to give actual causes -but those officially "assigned" by the examining authorities or -others interested. Clouston[61] in 1911, in making a statistical study -of 11,346 cases admitted to the Royal Edinburgh Mental Hospital in -the course of thirty-five years, enumerated a long list of causes -shown in the hospital reports. It is interesting to note that they -include nursing, disordered menstruation, self abuse, sexual excess, -surgical operations, bronchitis, prostatic disease, lupus, commencing -menstruation, transference of morbid action from other organs to the -brain, excessive tobacco smoking, chloroform inhalation, excessive -number of children, religious excitement, marriage, changes of -residence, sedentary habits, political excitement, bad temper, the -Queen's Jubilee, etc. As he says, "No other disease has anything like -this list of 107 causes. A black and terrible roll it is. Poor humanity -has much to contend with to keep sound in mind." Analyzing these -statistical findings, Clouston concludes that "bad heredity, congenital -defects, and previous attacks are the great predisposing causes, and -that alcohol, the crises of life, epilepsy, the various forms of brain -poisons and the gross brain and nervous diseases constitute the mass of -exciting causes. Together they account for over seventy per cent of the -defects and diseases of the mind that come under my observation." - -A reference to the statistical reports of the past as published by -the hospitals of this and other countries will show nothing radically -different until within the last few years. It will readily be observed -that fundamentals were almost entirely lost sight of and nonessentials -overemphasized. Masturbation, for instance, is often a symptom of -dementia praecox and other forms of mental disease, but is not now -looked upon as an important etiological factor. The immediate -cause, so-called, is usually a mere incident, often not without some -significance, but bearing little if any definite relation to the -fundamental underlying condition responsible for a mental breakdown. -The studies of Meyer, Hoch, Kraepelin, Freud, Jung, Bleuler and -many others have shown that in manic-depressive insanity, dementia -praecox and various other psychoses we are dealing with very definite -constitutional conditions, morbid temperaments, personality defects, -etc., which are responsible for the maladjustments leading to the -development of psychoses. Financial reverses, domestic difficulties, -the death of near relatives, the ordinary hardships and disappointments -of life, even ill health, do not as a rule mean the development -of a psychosis in the normal, properly balanced individual. In -the constitutionally predisposed, the love affair, the loss of a -position, the upsetting factor, whatever it may be, is merely the -"straw that breaks the camel's back" and is nothing more than an -accident of fate, a pure coincidence. Any other comparatively trifling -occurrence out of the ordinary, any difficult situation which the -makeup of the individual could not adequately meet and react to, would -have accomplished the same result. There are, however, of course, -certain psychic traumas to which these inadequate personalities are -particularly susceptible. - -Experience has shown that without any doubt there are conditions for -which defective heredity is largely responsible. It is often difficult -to determine the actual rôle which this plays in a given case. Efforts -have been made to reduce the study of these factors to a definite -scientific basis. In 1865 Gregor Mendel,[62] Abbot of Brünn, published -an account of a series of experiments made by him with the common pea -(pisum sativum) which was destined to revolutionize our views on the - subject of heredity. On crossing a tall with a dwarf plant, -tall hybrids resulted with no intermediate forms. This inheritance is -said to be due to the presence of a definite "determiner" in the germ -plasm. All of his hybrids being of the tall variety, he designated -that character as the "dominant," the dwarf being spoken of as the -"recessive." On the fertilization of these hybrids he obtained another -generation, which averages three tall plants to one dwarf. Further -investigation showed that the dwarfs always bred true, as did about one -out of three of the tall varieties, the remaining two behaving as did -the original hybrids and giving three talls to one dwarf. He therefore -observed that he was dealing with three varieties of inheritance, the -dwarfs which bred true, the talls which bred true and the talls with a -fixed proportion of talls and dwarfs. The phenomenon as noted by Mendel -is not, however, universal in its application. Curiously enough no -attention was given to Mendel's experiments until eighteen years after -his death, when his work was rediscovered by de Vries, Correns and -Tschermak in 1900. - -Davenport[63] has shown that there are six possible matings of germ -cells as illustrated by the pigment of the eye:—1. Both parents, -pigmented iris (brown eyes) and duplex—all offspring with pigmented -iris and duplex; 2. Both parents brown-eyed, one duplex, one -simplex—all children brown-eyed, but half simplex; 3. One parent -brown-eyed and duplex, the other blue-eyed—all children brown-eyed -and simplex; 4. Both parents brown-eyed and simplex—one-fourth of -the children brown-eyed and duplex, one-half brown-eyed and simplex, -and one-fourth blue-eyed; 5. One parent brown-eyed and simplex, and -the other blue-eyed—one-half the children brown-eyed and simplex, -the other half blue-eyed; 6. Both parents blue-eyed—all children -blue-eyed. It should be explained that a duplex origin means the -inheritance of a character from both parents and simplex from only one. -The principles of the Mendelian laws of heredity have been applied -to a study of the color of the eyes and skin, the color and form of -the hair, the stature, body weight and many other family traits such -as musical knowledge, ability along artistic and literary lines, -mechanical skill, etc. They have also been applied to the study of -various diseases, such as Huntington's chorea, hereditary ataxia, -deaf-mutism, feeblemindedness, epilepsy and insanity, etc. - -Rosanoff[64] and Orr have suggested the following hypothesis relative -to the transmission of the neuropathic constitution as based on the -Mendelian theory:—1. Both parents being neuropathic, all children will -be neuropathic; 2. One parent being normal but with the neuropathic -taint from one grandparent, and the other parent being neuropathic, -half the children will be normal but capable of transmitting the -neuropathic constitution to their progeny, and half will themselves be -neuropathic; 3. One parent being normal and of pure normal ancestry, -and the other parent being neuropathic, all the children will be normal -but capable of transmitting the neuropathic makeup to their progeny; 4. -Both parents being normal, but each with the neuropathic taint from one -grandparent, one-fourth of the children will be normal and not capable -of transmitting the neuropathic makeup to their progeny, one-half will -be normal but capable of transmitting the neuropathic makeup, and the -remaining one-fourth will be neuropathic; 5. Both parents being normal, -one of pure normal ancestry and the other with the neuropathic taint -from one grandparent, all the children will be normal; half of them -will be capable and half not capable of transmitting the neuropathic -makeup to their progeny; 6. Both parents being normal and of pure -normal ancestry, all the children will be normal and not capable of -transmitting the neuropathic makeup to their progeny. - -Just how much importance is to be attached to these theories is a -difficult matter to determine. A study of a considerable number of -families by Rosanoff[65] would appear to be very suggestive, although -his conclusions must be looked upon as fairly conservative:—"On the -whole, taking into consideration the limited amount of material as well -as the various sources of possible error, the correspondence between -the actual findings and theoretical expectation, as shown in the table, -must be regarded as strikingly close." On the other hand, as White[66] -says, "In dealing with the subject of heredity, however, it must not -be forgotten that our ideas are of necessity largely founded upon -hypotheses, as biological science has not yet unfolded a sufficient -number of facts to make it possible to tell just how much, in any -individual case, must be attributed to the inherent qualities of the -"germ plasm" and just how much to the influences of environment. The -view which is pretty generally admitted among biologists at present -is that there is little warrant for the belief in the Lamarckian -hypothesis of the inheritance of acquired characters." - -The New York statistical tables on heredity were discontinued in -1907, at which time a total of 104,013 cases had been reported. In -31,290 of these no information was available, leaving a total of -72,622, excluding the not insane. A history of insanity was shown in -the paternal branch of the family in 8.6 per cent of the ascertained -cases, in the maternal branch in 10.1 per cent, in both paternal -and maternal in 1.7 per cent, and in collateral branches in eleven -per cent,—a total of 31.4 per cent in which some form of heredity -was reported. These statistics relate only to insanity in the family -history. There were so many sources of inaccuracy that it was not -thought worth while to continue these studies after 1907. Comparisons -between the heredity of mental cases and that of normal individuals -have been rather surprising. Koller, for instance, as quoted by -Kraepelin,[67] in a comparison of 370 healthy with a similar number -of insane individuals found a history of psychopathic defects in the -immediate families of fifty-nine per cent of the former and 76.8 per -cent of the latter. Diem[68] in 1905 made an analysis of the family -history of 1193 healthy individuals. This was compared with 1850 mental -cases. Neuropathic heredity of some kind was found in 78.2 per cent of -the mental cases and 66.9 per cent of the healthy individuals. There -was, however, a history of mental diseases in the families of 38.3 per -cent of the insane patients as compared with 7.1 per cent of the normal -individuals. Somewhat different results were noted in a study of the -parents. There was a paternal or maternal history of insanity in 18.1 -per cent of the families of the mental cases as compared with 2.2 per -cent in the cases of the normal individuals. In the direct parentage, -Koller found mental diseases in 57.3 per cent of the families of the -insane as compared with 28 per cent in the case of normal individuals. -Kraepelin states that the influence of the father is greater in -heredity than is that of the mother. The father, furthermore, usually -transmits to the son while the mother influences the daughter more. - -Heredity varies with the psychoses, having its greatest influence in -the transmission of manic-depressive attacks, epileptic and hysterical -conditions, nervousness, compulsive and impulsive insanity, sexual -perversions and morbid personalities (Kraepelin). As the result of a -study of two thousand cases, Pilcz[69] (1907) found that in alcoholism -heredity was most likely to manifest itself in the form of alcoholism, -epilepsy and imbecility or manic-depressive psychoses. In the -progenitors of epileptics he found epilepsy and migraine. Apoplectics -showed a family history of paralysis, arteriosclerosis, senile dementia -or melancholia. Senile dementia preceded paralysis, arteriosclerosis, -feeblemindedness and dementia praecox. Tabes and paralysis apparently -frequently precede paralysis and dementia praecox. The various forms of -alcoholic psychoses furthermore show a tendency to repeat themselves -in the offspring of alcoholics. Similar heredity is said to be the -general rule in manic-depressive psychoses, epilepsy and alcoholism, -and to a less extent in arteriosclerosis. Heredity, in so far as it -is related to mental diseases, may be said to be largely a question -of the transmission of a neuropathic or psychopathic constitution or -predisposition. Various psychoses are now held to be the direct result -of constitutional causes or hereditary influences. This is probably -true of manic-depressive insanity, Huntington's chorea, involution -melancholia, dementia praecox, paranoia and paranoid conditions, -epileptic psychoses, the psychoneuroses and neuroses, psychopathic -personality and mental deficiency. It is true that some of these -conditions develop as the immediate results of certain predisposing -factors and that in frequent instances no evidences of heredity can -be found. It is also true that various authorities maintain that -a predisposition to the development of certain psychoses may be -acquired. If, however, we assume that the above mentioned psychoses are -constitutional in their nature and due primarily to heredity, it may -be definitely stated that, based on recent statistical studies, -hereditary influences account for from fifty-five to sixty per cent of -the mental cases admitted to our institutions. It may be pointed out, -as an objection to this suggestion, that although manic-depressive -psychoses often develop in an emotionally unstable or cyclothymic -personality and dementia praecox is associated with certain -peculiarities of makeup, not all of these cases show clear evidences -of constitutional origins. This is unquestionably true. It is equally -true, on the other hand, that heredity is also probably very often a -factor in the production of the senile and arteriosclerotic conditions, -various nervous diseases, alcoholism and drug habits. - -When we leave the subject of heredity we are on much more certain -ground. There is no question whatever as to the rôle played by -traumatism, senility, arteriosclerosis, syphilis, brain and nervous -diseases, alcoholism, exogenous toxins, epilepsy, pellagra and somatic -diseases in the causation of mental disorders. In an analysis of -4,079 cases examined at the Munich Clinic, Kraepelin[70] found the -following factors involved:—1. Physical diseases, infections and gross -brain lesions, 1.3 per cent; 2. Syphilis and metasyphilis, 10.3 per -cent (general paresis 9.4 per cent); 3. Toxins—alcohol, morphine, -cocaine, etc., 22.8 per cent (alcoholic psychoses 22.4 per cent); -4. Traumatic neuroses and prison psychoses, 2.5 per cent; 5. The -presenile and senile psychoses, arteriosclerosis, etc., 5.6 per cent; -6. Dementia praecox, epilepsy, idiocy and imbecility, 27.2 per cent; 7. -Psychopathic and hysterical states, and manic-depressive insanity, 30.3 -per cent. Conditions existing in our hospitals and clinics are somewhat -different. As the result of a study of over seventy thousand first -admissions to forty-eight hospitals in sixteen different states we are -now in a position to speak quite definitely as to the frequency of the -conditions above referred to as etiological factors. Traumatic psychoses -quite uniformly represent a little less than one-half of one per cent -of the admissions to our institutions. The senile psychoses constitute -approximately ten per cent and arteriosclerosis five per cent of the -total. General paresis averages about twelve per cent in the New York -hospitals and from seven to ten per cent in the other states. Cerebral -syphilis amounts to a little less than one per cent of the cases. It -should be said that in the large cities the rate for syphilis is, in -some instances at least, twice as high as that given. Brain tumor, -with all other brain and nervous diseases, only constitutes about one -and one-half per cent of our admissions. Alcoholism, which has been -responsible for as high as ten per cent of all admissions, from time -to time, has been decreasing gradually during the last five years and -in New York in 1920 constituted less than two per cent. Epileptic -psychoses in our state hospitals amount to from one to two and one-half -per cent of the total. As a general rule pellagra is not a factor of -any consequence, amounting to less than one-half of one per cent of -the admissions. In a few of the southern hospitals large numbers of -pellagra are encountered. The psychoses accompanying somatic diseases -are represented by from three to four per cent of the whole number. -In addition to this, there is still a considerable number of cases -reported from the hospitals as being caused by psychic trauma of -various kinds. These represent the acute psychoses usually resulting -from mental and emotional upsets but with nothing which definitely -points to constitutional disorders or hereditary influences. - -If we speak of predisposing causes, some reference should be made -to the influence of the physiological landmarks which are of so -much significance in the life of the individual in more ways than -one—puberty, adolescence, the climacterium and the senium. A no -less noteworthy factor in the female sex is the puerperium. These -periods of life are of tremendous importance in the development of -the psychoses. It is customary to speak of age, sex, race, civil -condition, degree of education, climate, civilization, etc., as factors -in the production of mental diseases. Not much is to be said on these -questions, nor are they closely related to the subject. On January -1, 1920, there were 232,680 patients in the hospitals for mental -diseases in the United States. Fifty-two per cent of these were men and -forty-eight per cent women. This represents about the difference that -has been shown for many years. The reduction in alcoholic psychoses -may affect this ultimately. The striking exceptions to this ratio are -Massachusetts and New York, where the number of women has slightly -exceeded the men for a number of years. The admission rate for men -is, however, slightly higher than that for women in both of those -states. Less than one-half of one per cent of the patients admitted to -the New York hospitals are under fifteen years of age. In that state -approximately five per cent have been between fifteen and nineteen -years old. In Massachusetts the percentage of persons admitted who -were under twenty years of age has averaged 8.5 quite consistently for -some time. The admission rate, for twenty to twenty-five, twenty-five -to thirty, thirty to thirty-five and thirty-five to forty years of age -in Massachusetts and New York has averaged from ten to eleven per cent -for each of those periods for several years. From the age of forty -to fifty the admission rate is about 8.5 per cent, and from fifty to -sixty between five and six per cent. Nine per cent of the admissions in -Massachusetts and eight per cent in New York are seventy years of age -or over. The statistics on race, birthplace and the psychoses of the -various races are shown in detail in the chapter on Immigration. The -admission rate in New York is almost exactly the same for the married -and the unmarried, the former constituting about thirty-nine per cent -and the latter forty. In Massachusetts the single first admissions -amount to about forty-three per cent and the married approximately -forty per cent. Throughout the country generally the unmarried slightly -predominate. The percentage of widowed in Massachusetts and New York -varies from thirteen to fourteen per cent. The divorced constitute -only about one per cent of all admissions. As to education, it may be -said that about nine per cent of all first admissions are illiterate, -from fifteen to twenty per cent can read and write only, about sixty -per cent have had a high school and two per cent a college education. -A study of economic conditions shows that from fifteen to seventeen -per cent are dependent, from sixty to seventy per cent are rated as -marginal, and from eleven to thirteen per cent as being in comfortable -circumstances. In Massachusetts and New York about eighty-five per -cent of the admissions come from a city environment and from twelve -to fifteen per cent from rural communities. It is interesting to note -that in 1919 eighteen per cent of the admissions in Massachusetts and -New York were reported as being intemperate in their habits, with over -fifty per cent abstinent. - -In conclusion, it may be said that the important etiological factors -in the production of mental disease are heredity, senility, syphilis, -arteriosclerosis, somatic diseases, mental deficiency, epilepsy, -diseases of the brain and nervous system, alcoholism, drugs, traumatism -and mental stress and shocks of various kinds. It is hardly necessary -to add that our information on this subject is far from complete. - - - - -CHAPTER IX - -IMMIGRATION AND MENTAL DISEASES - - -A history of the development of our western civilization is very -largely a study of the process of assimilation of the various racial -elements representing a new population. While it must be conceded -that we are indebted to European countries for much that has been -contributory to the welfare and success of American institutions, it -is equally true that the tremendous increase in mental diseases and -defects here is to be attributed in no small degree to immigration. -This constitutes a problem of social and economic importance which is -worthy of serious consideration. Perhaps no better evidence of this -fact can be offered than a study of such statistics as are available -relating to the thirty-three millions of people coming to the United -States from other countries during the last century. This would seem -to be particularly indicated at this time, in view of the fact that -the conclusion of the war has brought about the necessity of a new -adjustment of our relations with other countries. - -Immigration to the United States has varied greatly from time to time. -It is a well known fact that the founders of our government were -practically all of English, Dutch, German or Scotch-Irish extraction. -Unfortunately no information of any consequence is available regarding -the aliens entering the country prior to 1820, when their study -was first undertaken by the federal authorities. As far as can be -determined, during the ensuing ten years about 128,000 were admitted -at the various ports of entry. The history of immigration since that -time has been determined very largely by existing conditions in other -countries. The famines and political disturbances in Ireland between -1840 and 1850 were the occasion of a large influx, concededly of a -highly desirable type. The nature of the tide of incoming immigrants -was changed by the revolutionary troubles in Germany during the decade -following 1848. There was a decrease for a time during the civil war. -This was soon followed by a considerable increase which continued -quite consistently until the outbreak of the world war. There would at -this time seem to be every reason for thinking that an unprecedented -invasion can be expected during the next twenty-five years as a result -of conditions prevailing abroad unless some restrictions are imposed. -In 1850 and 1860 the number of Irish people in the United States -exceeded the German born. The 1890 census showed a predominance of the -latter race and they have exceeded the Irish element in the population -for some time. Nearly a million Germans were admitted between 1880 and -1885. Since 1890, however, the number of Irish and Germans entering -have both decreased markedly. After the Spanish-American war a great -increase in immigration was noted and the rate of admission per year -reached a million in 1905, but the source of supply had entirely -changed. - -Salmon[71] has shown that in spite of the fact that in 1882 only 12.9 -per cent of all incoming aliens admitted were from those countries, -eighty-one per cent of all immigration from Europe in 1907 came from -Austria-Hungary, Bulgaria, Greece, Italy, Montenegro, Poland, Portugal, -Roumania, Russia, Servia, Syria and Turkey. In 1882, 87.1 per cent of -those admitted came from England, Germany, Holland, Norway, Sweden, -Switzerland and Belgium. The races represented by the new tide of -immigration, according to Salmon, were Slavic, thirty per cent, -Italian, twenty-six per cent, and Hebrew, fifteen per cent, the -remainder being made up of various other miscellaneous elements. This -change is shown by the fact that the immigration from Austria-Hungary, -which amounted to only 711,926 from 1820 to 1896, increased to -2,303,323 during the first decade of the present century. Five hundred -and thirty-four thousand three hundred and thirty-six were admitted -from Russia between 1820 and 1896 and 1,756,027 between 1900 and 1911. -The Italian immigration, which amounted to 676,826 between 1820 and -1896, increased to 2,228,759 between 1901 and 1911 (Salmon[72]). The -numerical status of immigration by decades is shown in the following -table: - - From 1831 to 1840 528,721 - 1841 to 1850 1,604,805 - 1851 to 1860 2,648,912 - 1861 to 1870 2,369,878 - 1871 to 1880 2,812,191 - 1881 to 1890 5,246,613 - 1891 to 1900 3,687,564 - 1901 to 1910 8,795,386 - 1911 to 1920 6,747,381 - -A study made by the United States Immigration Commission some years ago -showed that of 68,942 foreign born males employed in various mining -and manufacturing industries, and who had been in the United States -for five years or more, only 33.3 per cent had obtained naturalization -papers. Of 246,673 of this same class representing non-English speaking -races, only 53.2 per cent had learned the language of this country to -any extent. A report made by the Commissioner General of Immigration -showed that of 719,906 immigrants over fourteen years of age and -admitted from 1899 to 1909, 26.6 per cent could neither read nor write -and 29.8 per cent had no occupation. The following table shows the -percentage of foreign born in the population of the United States from -time to time as stated in official reports:— - - 1850 9.7 per cent - 1860 13.3 " " - 1870 14.4 " " - 1880 13.3 " " - 1890 14.7 " " - 1900 13.6 " " - 1910 14.7 " " - 1920 12.96 " " (white only) - -The foreign born population naturally varies more or less in different -parts of the country. In New York state it was twenty-six per cent in -1870, 23.8 in 1880, 26.2 in 1890, 26.1 in 1900, 29.9 in 1910, and 26.8 -per cent in 1920. In Massachusetts it was 30.6 per cent in 1895, 30.2 -in 1900, 30.3 in 1905, 31.5 in 1910, 31.2 in 1915, and 28 per cent in -1920. - -We have little authentic information relative to the institution -population prior to 1903. The United States Census Bureau in its -report of 1904 on the insane in hospitals shows that in 1903 there -were 140,312 patients, of which number 47,078, or 34.3 per cent, were -of foreign birth. The percentage of foreign born in state hospitals in -various parts of the country at that time were as follows:— - - New York 46.9 per cent - Massachusetts 42.0 " " - New Jersey 39.5 " " - Pennsylvania 30.9 " " - District of Columbia 36.7 " " - Connecticut 35.4 " " - Michigan 43.5 " " - Illinois 41.6 " " - Wisconsin 50.9 " " - Minnesota 63.5 " " - North Dakota 68.4 " " - South Dakota 49.9 " " - Montana 57.8 " " - Nevada 63.1 " " - -In 1912 an investigation was made of the foreign born in the New York -state hospitals. As a result of the census taken, it was found that -of 31,624 patients, 13,728, or 43.4 per cent, were foreign born. Of -this number 4,487 had been naturalized and 9,241, or 29.2 per cent -of the total hospital population were aliens. At the Manhattan State -Hospital in New York City, out of a total of 4,570 patients 2,526 were -foreign born and only 708 had been naturalized. The Central Islip State -Hospital at the same time had 4,438 patients. Of this number 2,803 -were foreign born and only 891 were naturalized citizens. Thus, at the -Manhattan State Hospital 39.8 per cent and at the Central Islip State -Hospital 43.1 per cent of the patients were aliens. It was shown that -the average hospital residence of the insane in the state was 9.85 -years. Based on the maintenance expenditures for 1912 it was estimated -that the cost to New York for caring for its 9,241 aliens in the state -hospitals was $2,579,902.78 per year, and for their entire hospital -residence, over twenty-five million dollars.[73] Of the first admissions -to the New York hospitals for the eight years beginning October 1, -1904, and ending September 30, 1910, 46.2 per cent were foreign born. -The citizenship of the first admissions for this same period is shown -by the following table:— - - _Year_ _Aliens_ - - 1905 28.4 per cent - 1906 31.4 " " - 1907 32.6 " " - 1908 33.9 " " - 1909 33.4 " " - 1910 33.0 " " - 1911 32.9 " " - 1912 29.3 " " - -It was also shown that 14.7 per cent of the aliens admitted in 1905 -had been in the United States less than three years, in 1906, 18.7, in -1907, 21.8, in 1908, 20.1, in 1909, 18.1, in 1910, 15.5, in 1911, 14.9 -and in 1912, 18.1 per cent. The birthplace and citizenship of first -admissions to the New York state hospitals since 1912 is shown in the -following table:— - - _Year_ _Foreign born_ _Aliens_ - - 1913 47.0 per cent 22.5 per cent - 1914 46.7 " " 25.2 " " - 1915 47.0 " " 26.4 " " - 1916 48.5 " " 27.8 " " - 1917 47.8 " " 27.1 " " - 1918 46.4 " " 27.5 " " - 1919 46.8 " " 26.4 " " - 1920 45.3 " " 24.8 " " - -The percentage of the foreign born as shown by the first admissions to -the Massachusetts state hospitals during the last eleven years was as -follows:— - - 1910 44.88 per cent - 1911 44.65 " " - 1912 44.40 " " - 1913 45.30 " " - 1914 45.75 " " - 1915 45.59 " " - 1916 43.87 " " - 1917 43.40 " " - 1918 43.07 " " - 1919 43.38 " " - 1920 42.18 " " - -The percentage of aliens as shown by the first admissions to -Massachusetts hospitals was 26.40 per cent in 1918, 27.54 in 1919 and -22.73 per cent in 1920. - -Studies of the population of the New York state hospitals show that the -aliens have for a period of several years constituted nearly thirty per -cent of the entire number. The influence which immigration may have -had in determining the relative frequency of various psychoses in our -institutions is an exceedingly interesting question. In speaking of the -susceptibility of certain races to special types of disease, Salmon[74] -says, "This is particularly true of mental diseases, for if racial -characteristics profoundly affect political, social and religious -ideals we must look for a similar influence upon the individual makeup -which so largely determines trends in mental disease. All those who are -familiar with mental diseases among the Japanese in California testify -to the remarkable tendency to suicide in that race, not only in -depressed conditions but in conditions in which suicidal tendencies, in -other races, are not frequent. This is in accordance with the general -attitude of the Japanese toward self-destruction. The strong tendency -to delusional trends of a persecutory nature in West Indian negroes, -the frequency with which we find hidden sexual complexes among the -Hebrews and the remarkable prevalence of mutism among Poles, even -in psychoses in which mutism is not a common symptom, are familiar -examples of the influence of racial traits upon mental diseases." -As the result of a special study of this subject Salmon has reached -the following conclusions: "1. The psychoses more prevalent among -Hebrews than in the native stock are manic depressive psychosis, -dementia praecox, the psychoneuroses, and psychoses associated with -constitutional inferiority. 2. The absence of alcoholic psychoses -among Hebrews is the most striking clinical fact in connection with -immigration. In 1909 there were but 3 patients with alcoholic psychoses -in 448 Hebrews admitted to all the New York state hospitals. 3. The -very high prevalence of general paresis among Italians bears a direct -relation to the high prevalence of venereal diseases among Italians in -New York.... 4. Italians show a freedom from alcoholic psychoses second -only to Hebrews. 5. Italians exceed the native born in the prevalence -of epileptic psychoses, infective exhaustive psychoses and dementia -praecox.... 7. From the data available, alcoholic psychoses are found -to be more prevalent among Slavs than among any other races of the new -immigration, but not as prevalent as among the native-born. 8. General -paresis is nearly twice as prevalent among Slavs as in the native-born, -but not so prevalent as among the Italians. Dementia praecox is more -prevalent among the Slavs than among the native-born." - -The racial representation as shown by statistics of first admissions -is fairly constant in New York state, at least, as is shown by the -following table of percentages:— - - _Race_ _1916_ _1917_ _1918_ _1919_ _1920_ - - African 3.1 3.3 3.9 3.7 3.8 - English 7.6 5.7 5.1 4.9 5.1 - German 14.3 13.5 12.5 11.7 11.7 - Hebrew 12.2 11.6 12.2 11.7 10.5 - Irish 19.8 19.5 17.3 16.7 16.5 - Italian 6.3 6.9 7.1 8.1 8.5 - Magyar .8 .9 1.0 .7 .8 - Scandinavian 1.9 2.2 2.2 2.1 2.0 - Slavonic 5.7 5.8 5.7 5.4 6.0 - Mixed 12.4 16.0 23.6 23.3 24.1 - Others 5.7 5.6 4.4 4.9 6.2 - Unascertained 10.2 9.0 5.0 6.9 4.8 - -The 1916 report of the Commission on Mental Diseases shows the -following analysis of the nativity of the 34,300 first admissions to -the Massachusetts state hospitals covering a period of thirteen years -(1904-1916):— - - _Birthplace_ _Number_ - - United States 18,757 - Africa 7 - Armenia 68 - Austria 319 - Azores 187 - Canada 3,315 - England 1,359 - Finland 250 - Germany 486 - Greece 129 - Ireland 5,033 - Italy 719 - Nova Scotia 136 - Poland 190 - Russia 1,139 - Scotland 381 - Sweden 539 - Turkey 100 - -It should be borne in mind that these statistics represent birthplace -and not race. An analysis of the above figures shows that 54.68 per -cent were born in the United States and 44.42 per cent in other -countries. Of the other countries represented, 3.96 per cent were born -in England, 3.32 per cent in Russia, 9.63 in Canada and 14.67 per cent -in Ireland. - -A comparison of the more important psychoses represented by the various -races, as reported by the New York State Hospital Commission in 1918, -is shown in the following table[75]:— - - Per Cent of Total First Admissions of Each Race - African German Hebrew Irish Italian Slavonic Mixed - Psychoses - - Senile 5.2 11.6 5.8 13.2 6.2 1.6 10.2 - General paralysis 21.3 17.3 13.3 9.9 19.1 6.7 13.1 - Alcoholic 5.2 4.5 0.2 10.6 2.3 10.3 4.5 - Manic-depressive 12.4 12.2 24.0 9.8 22.0 14.0 12.4 - Dementia praecox 29.6 25.5 35.2 26.7 26.6 47.3 24.0 - -Some variation is shown by a similar analysis of the New York -admissions for the year 1919, as is illustrated by the following -table[76]:— - - Per Cent of Total First Admissions of Each Race - African German Hebrew Irish Italian Slavonic Mixed - Psychoses - - Senile 8.0 12.7 6.9 14.9 4.9 1.6 11.5 - General paralysis 15.7 15.1 11.5 12.0 16.2 9.2 12.3 - Alcoholic 4.0 4.0 0.4 7.9 2.4 7.0 3.0 - Manic-depressive 10.4 13.7 21.6 11.1 20.6 17.6 13.1 - Dementia praecox 31.3 24.2 32.0 25.5 29.7 42.3 23.8 - -For purposes of comparison an analysis of the psychoses shown by -various races in the admissions of the Massachusetts state hospitals -for a period of three years is added (1917-1918-1919):— - - Senile Arterio- General Alco- Manic- Dementia - Race No. Psychoses sclerosis Paresis holic Depressive Praecox - - African 211 5.68% 4.73% 6.16% 7.10% 4.26% 27.96% - English 3281 10.75 9.87 7.46 5.76 9.99 18.65 - French 647 6.64 6.95 12.05 8.19 6.80 24.88 - German 283 6.00 7.77 10.60 9.92 12.01 21.20 - Hebrew 353 .56 2.26 5.66 1.41 10.19 37.11 - Irish 2994 9.01 7.11 7.11 16.13 7.11 23.31 - Italian 522 3.44 2.66 7.66 5.34 10.34 35.44 - Mixed 1244 8.76 12.62 7.70 8.11 7.55 24.35 - Slavonic 635 6.77 7.08 12.28 8.35 6.93 25.20 - -This shows some very interesting results. It will be noted that the -Hebrews and Italians have the highest rate for dementia praecox, the -percentage shown by these races being much higher than any of the -others. The Germans, Italians and Hebrews, in the order mentioned, -have the highest rates for manic-depressive psychoses. The frequency -of alcoholic psychoses as shown by the Irish is nearly double that of -any of the others. The Slavonic race has the highest rate for general -paresis, followed in close succession by the French and Germans. The -highest rate for senile and arteriosclerotic psychoses combined is -shown by the races of mixed origin, the next highest by the English, -closely followed by the Irish. The most common psychosis in every -instance is dementia praecox. In the admissions to the institutions for -the criminal insane in New York the highest percentages are represented -by the Irish, Italian and Hebrew races, as shown in another chapter. -During a period of six years (1912 to 1918) a study of first admissions -to the New York state hospitals shows an incidence of dementia praecox -in the native-born of 75.2 per hundred thousand of the population and -in the foreign born of 161.4. The importance of this is shown by the -fact that over fifty per cent of the entire hospital population is made -up of cases of dementia praecox. - -The necessity of some supervision of immigration for the purpose of -preventing the entrance of undesirable aliens has long been recognized. -As early as 1824 the state of New York tried by legislation to prevent -the admission of the insane and mental defectives. This effort was -a failure, probably owing to the fact that the proposed enactments -would have compelled the companies responsible for the entrance of -undesirable aliens to remove them if they became a public charge. The -introduction of discordant racial elements from abroad at one time -disturbed the equilibrium of the entire country. The agitation for the -restriction of immigration before the civil war led to the formation -of a political organization known as the "Native American" or "Know -Nothing" party, as it was usually called. It at one time had forty -representatives in Congress and nominated a candidate for President -in 1856. These disturbed conditions led to the consideration of this -subject by Congress as early as 1838 and the Judiciary Committee -recommended legislation prohibiting the entrance of idiots, lunatics -and those suffering from incurable diseases or convicted of crime. -The action of several foreign countries in pardoning murderers with -the provision that they should emigrate to the United States led to -a resolution of protest by Congress in 1860 and shortly thereafter -a statute intended to encourage immigration was repealed. An -investigation made by the United States Immigration Commission brought -to light the fact that the great influx of foreigners was largely -caused by the agents of the steamboat companies abroad and that they -had "five or six thousand ticket agents in Galicia alone."[77] - -The activities of those opposed to the indiscriminate entrance of -objectionable aliens led to the federal enactment of August 3, 1882. -The Secretary of the Treasury was charged with the duty of prohibiting -the landing of lunatics, idiots and persons liable to become a -public charge. The provisions for the execution of this law were not -satisfactory and it was amended by an act of 1891. This made it a -misdemeanor to bring in any of the above proscribed classes and imposed -a fine of over one thousand dollars upon anyone guilty of so doing. -Section 11 provided that aliens entering in violation of this law could -be returned at any time within one year thereafter at the expense of -the person or persons, vessel, transportation company or corporation -responsible for their entry, and further, that those becoming public -charges within one year from causes existing prior to landing should -be considered as having entered in violation of law. The provisions -of this statute were unchanged until the act of March 3, 1903. This -excluded persons insane within five years previous to landing, those -having had two or more previous attacks at any time, paupers and all -others liable to become a public charge. Section 17 delegated to -the officers of the United States Public Health Service the duty of -determining the condition of all immigrants. Section 20 provided that -aliens coming to the United States in violation of law, or who were -found to be public charges from causes existing prior to landing, could -be deported at any time within two years. Section 21 authorized the -Secretary of Commerce and Labor to deport any alien within three years -of entering in violation of the act. - -An important step in the legislative restriction of immigration was -the amendment of Feb. 20, 1907. This made mandatory the exclusion -of idiots, imbeciles, the feebleminded, epileptics, insane, all who -had been insane within five years and persons having had two or more -attacks of insanity at any time, or who were likely to become a public -charge, as well as individuals not comprehended in the foregoing -excluded classes but found to be suffering from mental or physical -defects of such a nature as to affect their ability to earn a living. -Section 20 provided that an alien entering in violation of law or -becoming a public charge from causes existing prior to landing should, -upon the warrant of the Secretary of Commerce and Labor, be taken into -custody and deported to the country from whence he came at any time -within three years after the date of his entry into the United States. -The cost of this removal was to be a charge upon the owners of the -vessel or transportation line immediately responsible. When the mental -or physical condition of the alien was such as to require personal -care or attention, the Secretary of Commerce and Labor was authorized -to employ a suitable person for that purpose. This was a great step -in advance. There were, however, some very great difficulties to be -overcome. The force placed at the disposal of the Public Health Service -for the inspection and examination of incoming immigrants was entirely -inadequate and one or two men were sometimes responsible for the -examination of several thousands aliens in a day. This was, of course, -impossible. The burden of proof in showing that the mental condition -was due to causes existing prior to landing, furthermore, devolved upon -the persons requesting deportation. It was impossible in many instances -to submit actual proof even where there could be no reasonable doubt as -to the facts. This led to great difficulties and much dissatisfaction. -Another serious objection to the provisions of this law was the -requirement that only such persons could be deported as were likely to -become a public charge. In many instances such persons were supported -by private funds until they were no longer deportable, after which they -became a burden upon the state in which they resided. - -These conditions were much improved by the action of the Sixty-fourth -Congress in 1917. This definitely excluded "all idiots, imbeciles, -feebleminded persons, epileptics, insane persons; persons who have -had one or more attacks of insanity at any time previously; persons -of constitutional psychopathic inferiority," etc., or "persons not -comprehended within any of the foregoing excluded classes who are found -to be and are certified by the examining surgeons as being mentally -or physically defective" or persons likely to become a public charge. -Section 9 provided that it shall be unlawful for any person, "including -any transportation company," to bring either from a foreign country -or any insular possession of the United States any alien afflicted -with idiocy, insanity, imbecility, feeblemindedness, epilepsy, -constitutional psychopathic inferiority, etc., and subjected to a -fine any person or persons so doing. The Secretary of Labor was also -authorized to detail inspectors and matrons to duty on vessels carrying -immigrants, who shall "report to the immigration authorities in charge -at the port of landing any information of value in determining the -admissibility of such passengers that may have become known to them -during the voyage." It also provided that a mental examination of -all arriving aliens should be made by medical officers of the United -States Public Health Service who shall certify all mental defects or -diseases observed. "Medical officers of the United States Public Health -Service who have had special training in the diagnosis of insanity and -mental defects shall be detailed for duty or employed at all ports -of entry designated by the Secretary of Labor." Section 19 provided, -that any alien "who within five years after entry becomes a public -charge from causes not affirmatively shown to have arisen subsequent to -landing" shall, upon warrant of the Secretary of Labor, be taken into -custody and deported. The act also made provision for the first time -for a literacy test which has been a subject of discussion for years. -These amendments are of far-reaching importance and will eventually -undoubtedly afford the hospitals considerable relief. The fact still -remains, however, that the individual states are expending millions of -dollars annually for the care and maintenance of an alien population -which should have been excluded by the federal government. Under these -circumstances it would seem nothing more than fair that the states -should be reimbursed for the cost of carrying a burden for which they -are in no way responsible. - - - - -CHAPTER X - -MENTAL DISEASES AND CRIMINAL RESPONSIBILITY - - -The question of responsibility for criminal acts, once a legal -problem pure and simple, is now recognized as involving sociological, -psychological and psychiatric considerations of far-reaching -importance. This viewpoint, none too thoroughly established even -now, represents the progress of several centuries, and still lacks -adequate recognition in law. The eloquent protest against the legal -conception of mental diseases written by Isaac Ray[78] in 1838 sounds -like a quotation from a recent medical journal. "In all civilized -communities, ancient or modern, insanity has been regarded as exempting -from the punishment of crime, and vitiating the civil acts of those who -are affected with it. The only difficulty, or diversity of opinion, -consists in determining who are really insane, in the meaning of the -law, which has been content with merely laying down some general -principles, and leaving their application to the discretion of the -judicial authorities.... It is to be feared, that the principles, laid -down on this subject by legal authorities, have received too much of -that reverence which is naturally felt for the opinions and practices -of our ancestors; and that innovations have been too much regarded, -rather as the offspring of new-fangled theories, than of the steady -development of medical science. In their zeal to uphold the wisdom of -the past, from the fancied desecrations of reformers and theorists, -the ministers of the law seem to have forgotten, that, in respect to -this subject, the real dignity and respectability of their profession -is better upheld, by yielding to the improvements of the times, and -thankfully receiving the truth from whatever quarter it may come, than -by turning away with blind obstinacy from everything that conflicts -with long established maxims and decisions." - -A brief reference to the history of the development of the present -legal conceptions of criminal responsibility will justify the comments -made by Ray. The terms idiocy, lunacy and non compos mentis were all -used by Coke in his "Institutes of the Laws of England" written, as -nearly as can be determined, in 1625. A differentiation between the -significance of the word idiot and non compos mentis appeared as -early as 1325 in the English statute "De Praerogativa Regis," which -delegated various responsibilities to the crown that are recognized -to this day. Sir Matthew Hale, about 1670, described a partial and a -total insanity, the former not being accepted as relieving the accused -of responsibility for the commitment of a crime. It is an interesting -fact that we still hear the question of partial insanity seriously -discussed. In 1723 Justice Tracy in a murder trial ruled that "a -prisoner in order to be acquitted on the ground of insanity must be -a man that is totally deprived of his understanding and memory, and -doth not know what he is doing no more than an infant, than a brute -or a wild beast." As a result of this ruling a man was found guilty -of attempting to murder a neighbor who sent devils and imps into his -house at night for the purpose of disturbing his sleep. Fortunately -the sentence was commuted to life imprisonment. In 1812 the Attorney -General of England[79] ruled that "a man may be deranged in his -mind—his intellect may be insufficient for enabling him to conduct -the common affairs of life, such as disposing of his property, or -judging of the claims which his respective relations have upon him; and -if he be so, the administration of the country will take his affairs -into their management, and appoint to him trustees; but, at the same -time, such a man is not discharged from his responsibility for criminal -acts." - -The legal procedure of the present day is based very largely on the -decisions made at the time of the McNaughton trial in 1843. In this -case the Chief Justice, as quoted by Lord Lyndhurst, addressed the -following words to the jury: "The point which at last will be submitted -to you will be whether or not on the whole of the evidence you have -heard you are satisfied that at the time the act was committed, for -the commission of which the prisoner stands charged, he had not that -competent use of his understanding as not to know what he was doing -with respect to the act itself—a wicked and wrong thing—whether he -knew it was a wicked and a wrong thing he had done, or that he was not -sensible at the time he committed this act that it was contrary to the -laws of God and man." This case led to a very serious consideration -of the subject in the House of Lords. As the result of an official -request for an opinion, the majority of the judges of the court, all -concurring but one, expressed the view that "to establish a defense on -the ground of insanity, it must be clearly proved that at the time of -the committing of the act the accused party was labouring under such a -defect of reason, from disease of the mind, as not to know the nature -and quality of the act he was doing; or if he did know it (sic) that he -did not know he was doing what was wrong."[80] - -The importance and significance of these decisions, which one might -very readily assume to be obsolete and too ancient to be worthy of -consideration, will be made clear by a quotation from the penal code in -effect in New York today. "Sec. 1120 (Penal Law). Incompetency of idiot -or lunatic. An act done by a person who is an idiot, imbecile, lunatic -or insane is not a crime. A person cannot be tried, sentenced to any -punishment or punished for a crime while he is in a state of idiocy, -imbecility, lunacy or insanity so as to be incapable of understanding -the proceeding or making his defense. A person is not excused from -criminal liability as an idiot, imbecile, lunatic or insane person -except upon proof that, at the time of committing the alleged insane -act, he was laboring under such a defect of reason as 1, not to know -the nature and quality of the act he was doing; or 2, not to know that -the act was wrong." It will, I think, be conceded that we have, at -least, not lost ground in any way since 1843. - -No less interesting is the legal definition of insanity in -Massachusetts: "The words 'insane person' and 'lunatic' shall include -every idiot, non compos, lunatic and insane and distracted person." -(Chapter 4, Sec. 7, General Laws of Massachusetts.) In New York the -terms lunatic and lunacy include every kind of unsoundness of mind -except idiocy. (Chapter 22, Sec. 28, Consolidated Laws.) This would -presumably include psychopathic personality and imbecility. - -Numerous court decisions have had a material bearing on the subject of -responsibility. It has been held in New York that partial or incipient -insanity is not a sufficient defense if there is still an ability to -form a correct perception of the legal quality of the act and to know -that it was wrong. (People vs. Taylor, 138 N. Y. 398, 407 (1893)). -A weak or disordered mind is not excused from the consequences of -crime. (People vs. Burgess, 153 N. Y. 561, 569 (1897)), etc. Generally -speaking, the legal methods of determining criminal responsibility -do not vary to any material extent with the different states. It is -obvious that the responsibility for crime as defined by the courts is -far from harmonizing with the conception of competency entertained by -the medical profession. To the psychiatrist, if the criminal act is the -result of the mental condition it constitutes a symptom of the disease -process. It is readily apparent from even a very brief reference to -the statutes that a person concededly suffering from paranoia, general -paresis, dementia praecox or any other well-defined psychosis is still -criminally liable for his insane acts within certain limitations. From -a medical point of view the existence of a psychosis, if associated -with a consequent judgment defect, emotional instability, disturbance -of volition, intellectual deterioration, delusional and particularly -persecutory control, hallucinatory trends, ideas of reference, etc., -is of itself quite sufficient to explain criminal acts in the insane. -This, however, as has been shown, is not the legal point of view. -The accused is fully responsible unless it can be shown that he is -suffering from such a defect of reason as not to appreciate the quality -or nature of his act or that the act is wrong. There is no other legal -standard. It is a well-known fact that many persons adjudged insane by -the courts and committed to our institutions are fully competent to -discriminate between right and wrong from an ethical point of view, -although legally held to be incompetent and unsafe to be at large. -These divergent viewpoints presumably are due to the fact that the law -moves only with a degree of dignity which theoretically guarantees -absolute security in avoiding any possible sources of error. It -nevertheless is responsible for many miscarriages of justice. - -Efforts to remedy this state of affairs have been made repeatedly -by the medical profession. The American Psychiatric Association -has devoted a great deal of time and attention to this subject, -unfortunately without any very concrete results. The last -official action taken was the unanimous approval of the following -resolutions:—[81] - -"Resolved: 1. That the proved rarity of wrong acquittals on the ground -of insanity is the strongest evidence that the abuse of the insanity -plea in criminal cases has been unwarrantably exaggerated. - -"2. That the insanity plea is not by any means raised as often as it -should be, to prevent the frequent miscarriage of justice arising from -the conviction and imprisonment of insane persons whose true mental -condition has not been recognized. - -"3. That the abuses which have crept into the method of presenting -medical expert testimony have been largely the result of established -legal tests and procedures, although their correction does not require -radical change in the laws. - -"4. That inaccessibility of the evidence on both sides of the case is -the chief cause of defective medical testimony. - -"5. That whenever possible the medical witness should not testify -unless he has had an opportunity to make both a mental and a physical -examination of the person in whose behalf the plea of insanity is -raised. - -"6. That we consider the hypothetical question as ordinarily presented -to be unscientific, misleading and dangerous to medical repute and -that the evidence on both sides should always be included in its -presentation to medical witnesses. - -"7. That in all criminal cases absolutely equal rights should be -accorded the medical witnesses for both the prosecution and the defence -for the examination of the person alleged to be insane. - -"8. That in our judgment the judiciary should by legal enactment be -allowed more latitude in enlightening the jury and enabling it to -comprehend the nature and meaning of the medical testimony laid before -it. - -"9. That we recommend as advisable the adoption wherever possible of -the so-called Leed's method of preliminary consultation by medical -witnesses on both sides of the case as to its status. - -"10. That we advocate a freer use of appointments of commissions by the -court. - -"11. That a period of hospital observation of all persons committing -crimes in whose defence the plea of insanity has been raised is by -far the best method yet devised for securing impartial and accurate -opinions, silencing popular clamor, avoiding prolonged and sensational -trials and saving expense to the State; also that we advocate the -enactment in every State of laws similar to those of Maine, New -Hampshire, Vermont and Massachusetts, providing that such persons may -be committed by the court to a State hospital for the insane there to -remain for such time as the court may direct pending the determination -of their insanity. - -"12. That it is the sense of the Association that it is subversive of -the dignity of the medical profession for any of its members to occupy -the position of medical advisory counsel in open court and at the same -time to act as expert witness in a medico-legal case. - -"13. That we regard the acceptance by a physician of a fee that -is contingent upon the result of a medico-legal case as not in -accordance with medical ethics and derogatory to the good repute of the -profession, and advocate the regulation of the practice by legislation. - -"14. That we are in favor of any legislation that will secure a -definite standard of qualification for medical men giving expert -testimony." - -An equal amount of consideration has been given to this important -question from time to time by the American Institute of Criminal Law -and Criminology. At a recent meeting of that organization the following -recommendations were submitted by a committee: - -"1. That in all cases of felony or misdemeanor punishable by a prison -sentence the question of responsibility be not submitted to the jury, -which will thus be called upon to determine only that the offense was -committed by the defendant. - -"2. That the disposition and treatment (including punishment) of all -such misdemeanants and felons, i.e., the sentence imposed, be based -upon a study of the individual offender by properly qualified and -impartial experts cooperating with the courts. - -"3. That provisions be made permitting the transfer of such -misdemeanants and felons at any time after conviction from one -institution to another affording a different kind of treatment upon the -presentation of evidence of the needs for such action satisfactory to -the court which passed sentence. - -"4. That no maximum term be set to any sentence. - -"5. That no parole or probation be granted without suitable psychiatric -examination. - -"6. That in considering applications for pardons and commutation -careful attention be given to reports of qualified experts showing -the applicant's mental age and mental stability and that in drafting -statutes determining or defining juvenile delinquency, mental age -and mental stability, within reasonable limits, be regarded as of -importance with the calendar age of the delinquent. - -"In view of the foregoing and as an initial step towards the ends -stated, the committee submits the following resolution and urges its -immediate adoption: - -"Resolved, That the several states be urged to make provision for -the psychiatric examination, under conditions permitting prolonged -observation when necessary, of all persons convicted of a felony, -misdemeanor or other offense by properly qualified experts appointed -to assist the court in reaching a decision as to the proper disposition -and treatment of the offender." - -The courts, the medical profession and the public have shown -indications of a decided dissatisfaction with existing methods of -determining criminal responsibility. This will certainly continue -as long as the sole test of competency is the power of the accused -to discriminate between a knowledge of right and wrong at the time -when the act is committed. The conditions which lead to crime have -been made the subject of scientific study by many. One of the early -investigators in this field was Morel, who saw in the criminal a -personification "of the various degenerations of the species." Much has -been said of "moral insanity," a condition referred to by Abercromby -as one "in which all the upright sentiments are eliminated while the -intelligence presents no disorders." Lombroso advanced the theory -that criminality is a form of atavism—a reversion of man to the -primitive and savage type represented by his early ancestors. This -theory was based on a careful study of the anatomical, physiological -and psychological characteristics of primitive man. His classification -included the occasional, the emotional, the born criminal, the moral -insane, and the masked epileptic. Marro offered an anatomical basis -for the degenerative theory in the form of nutritional defects in the -central nervous system. Ferri distinguished between criminal lunatics -and emotional criminals and held crime to be "a phenomenon of complex -origin and the result of biological, physical and social conditions." -"Habitual criminals," he says, "are the victims of a clear, evident -and common mental alienation which causes the criminal activity," -while the occasional offenders are to be explained by "the impulse -of opportunities more than the innate tendency that determines the -crime." The emotional criminal, according to Ferri, is a sane and -moral individual overcome by momentary emotional paroxysms referred -to as a "psychologic storm." Garofalo, on the other hand, looked upon -crime as "an offense against the fundamental altruistic sentiments -of pity and probity." From his point of view a criminal act was an -indication of the loss of a proper sense of appreciation of the -life or property of another—a moral anomaly. The Italian school of -criminology was responsible also for the theory that criminal acts are -only the expression of epileptic symptoms. Sociological workers have -attributed crime to influences which overcome the natural resistance -of the individual, a variation from which is merely an inability of -the person to conform to the laws of environment. Max Nordau sees -in human failings only an abnormality which he describes as "human -parasitism." Others look upon crime as the natural product of a modern -social and economic system. Colajanni ascribes alcoholism, vagrancy -and prostitution to poverty, but crime, he says, is "due to necessity -and to the degree and kind of education received." In the light of our -present knowledge the conclusion would appear to be warranted that -crime is the result of constitutional defects in the form of hereditary -tendencies and arrested mental development, educational defects, a -deterioration of habits as shown by alcoholism, etc., accidental -influences such as environment and poverty, pathological conditions, -including epilepsy and insanity, and precipitating factors in the form -of emotional disturbances. - -Criminality, alcoholism, poverty, prostitution and mental deficiency -are closely correlated. A special committee appointed by the New York -State Prison Commission has made an exceedingly interesting report[82] -on the relation existing between mental disease and crime. Their -investigation shows that 21.8 per cent of 608 cases at Sing Sing, -thirty-five per cent of 459 men at Auburn, twenty-two per cent of three -hundred men at the Massachusetts State Prison, twenty-eight per cent of -forty-nine women at Joliet, twenty-five per cent of seventy-six women -at Auburn, twenty-three per cent of one hundred cases at the Indiana -State Prison and thirty per cent of 150 examined at San Quentin were -found to be mentally defective. An average of 27.5 per cent has been -found in the prison population as a whole. Thirty-one and four-tenths -per cent of the inmates of reformatories, training schools, workhouses -and penitentiaries were found to be feebleminded. From twenty-seven -to twenty-nine per cent of the inmates of penal and correctional -institutions of the country were said to be defective. About thirty -per cent of the population of the penal institutions for women in New -York were found to be feebleminded. A study of 502 selected cases at -the Psychopathic Laboratory of the Police Department of New York City -in 1917 showed that fifty-eight per cent were suffering from either -nervous or mental abnormalities. Of one thousand offenders examined -by the medical service of the Boston Municipal Court twenty-three per -cent were feebleminded, 10.4 per cent, psychopathic, 3.17 per cent, -epileptic and nine per cent, mentally diseased and deteriorated; -45.6 per cent in all showed abnormal mental conditions. It has been -shown that one of the most important causes of recidivism is mental -deficiency. The importance of this observation may be illustrated by -the fact that of 133,047 persons admitted to the penal and correctional -institutions of New York state sixty per cent had served previous -terms. Of 25,820 persons received at institutions in Massachusetts -during one year, 57.4 per cent were recidivits. Justice Roads is -responsible for the statement that of 180,000 convictions in England in -one year more than ten thousand represented persons convicted upwards -of twenty times previously. - -The mental condition of the cases committed to the Matteawan State -Hospital is of great importance in a consideration of the relation -of crime to the psychoses. Of 2,595 cases admitted between 1875 -and 1907 heredity or congenital defects were shown as etiological -factors in eight per cent of the total number. Of 793 admissions -in which more definite and reliable information was available, -hereditary factors were noted in either the paternal or maternal -branches of the family or both in thirty-five per cent of the cases. -In addition to this, heredity was found in collateral branches in -sixteen per cent. Heredity of some kind was thus shown in 51.3 per -cent of the whole number studied. Of 3,247 admissions, 46.9 per -cent were noted as being intemperate in their habits. An analysis -of 576 unconvicted cases in 1912[83] showed that 41.4 per cent were -diagnosed as dementia praecox, 21.1 per cent as alcoholic psychoses, -6.9 per cent as paranoid conditions, 4.1 per cent as epileptic -psychoses, 7.1 per cent as imbecility with excitements, 2.9 per cent -as manic-depressive psychoses, 2.4 per cent as general paresis, -3.1 per cent as undifferentiated depressions, 6.7 per cent as -constitutional inferiority and 2.2 per cent as not insane. An analysis -of 925 cases committed as insane and charged with criminal offenses -attributable to their mental condition shows the more common crimes -as follows:—assault (all forms), 26.2 per cent, burglary, 7.8, grand -larceny, 8.2, petit larceny, 1, manslaughter, 1.4, murder, 18.9, -homicide (total), 22.4, rape, 3.2, and vagrancy, 4.2 per cent. - -Nolan[84] has made an analysis of 646 first admissions to Matteawan -during a period of six years (1912 to 1918). Forty-eight per cent of -these were found to have been born in foreign countries. A striking -observation was the large proportion of male cases born in Italy (10.8 -per cent) and the female cases born in Ireland (11.7 per cent). Of -the various races represented it was noted that the African, which -was only responsible for 3.9 per cent of the admissions to civil -hospitals, constituted 7.4 per cent of the Matteawan admissions. The -races having the largest representation were the Irish (18.7 per cent), -the Italian (12.4 per cent) and the Hebrew (10.8 per cent). The mixed -races constituted 11.3 per cent of the admissions as compared with -twenty-three per cent of the cases reported from civil institutions. -Among the male cases 11.4 per cent were charged with disorderly conduct -and 26.47 per cent with vagrancy. Of the women, eighteen per cent were -charged with disorderly conduct, 16.4 with public intoxication and 39.8 -per cent with vagrancy and prostitution. These three groups represent -74.2 per cent of all of the female cases admitted. Of the 646 criminal -acts causing commitment, 34.1 per cent were classified from a legal -point of view as felonies and 65.9 per cent as misdemeanors. Only 5.3 -per cent were charged with murder, manslaughter, etc. Of the various -psychoses represented by these cases 26.9 per cent were diagnosed as -dementia praecox, seventeen per cent as alcoholic psychoses, 14.7 -per cent as constitutional psychopathic inferiority, 7.3 as mental -deficiency, 8.3 as manic-depressive psychoses, 11.3 as general paresis, -3.6 as senile psychoses, 2.0 as paranoia or paranoid conditions, 2.2 -as epileptic psychoses, and 1.4 per cent as not insane. The alcoholic, -constitutionally inferior and mentally defective group constituted -thirty-eight per cent of the total. Of the 165 cases diagnosed as -dementia praecox it is interesting to note that eleven were charged -with homicide, ten with assault in the first degree, fifteen with -burglary, thirteen with petit larceny, fourteen with disorderly -conduct, and sixty-six with vagrancy or prostitution. Of the -seventy-four cases of general paresis thirteen were charged with petit -larceny, eleven with disorderly conduct, and twenty-nine with vagrancy -or prostitution. The homicides and assaults were committed principally -by the alcoholic, dementia praecox, constitutionally inferior and the -defective cases. The burglaries and larcenies were committed largely by -patients diagnosed as suffering from general paresis, dementia praecox -and constitutional psychopathic inferiority. - -The type of cases received at an institution exclusively for insane -convicts is naturally quite different, as shown by the admissions to -the Dannemora State Hospital in New York. Of 185 admissions covering a -period of three years the principal psychoses represented were dementia -praecox, forty-one per cent, constitutional psychopathic inferiority, -nineteen per cent, manic-depressive psychoses, eight, mental -deficiency, nine, alcoholic psychoses, five, paranoid conditions, four -per cent, etc. - -Experience has shown that the defective criminal classes are not -suitable cases for either penal institutions or hospitals for the -insane. They are unable to adapt themselves to prison discipline -or hospital routine and prefer to associate only with persons of -their own kind who are given to foolish boasting of their crimes as -their least harmful diversion. They are entirely unappreciative of -any efforts made on their behalf to improve their condition or fit -them in any way for the requirements of society. They are strongly -inclined to unprovoked cruelty to others. Often they manifest an -apparent interest in religious services, thinking it may lead to -some preferment, but not for any moral reason. They are notoriously -untruthful, unreliable and exhibit a low cunning which often deceives -those not familiar with handling individuals of that type. Curiously -enough they are exceedingly critical of others and quick to notice -their shortcomings. Sexual perversions and immoral conduct are only -too common. Prostitution, as has already been shown, is one of the -most common failings of the female delinquent. An interesting but -superficial knowledge of legal matters is noted very frequently and -paraded with a remarkable degree of egotism which is difficult to -understand. It is comparatively an infrequent occurrence for a prisoner -to admit that he is guilty of the crime of which he has already been -convicted by a court. Only a few years since, a prisoner at Sing -Sing wrote the Governor of New York suggesting that his release was -indicated as a moral procedure for the good of the institution, as -he was convinced from information obtained from others that he was -the only guilty man in the establishment. The habitual criminal takes -little, if any, interest in his own relatives or family except when -he is in confinement, and feels no home ties. There is a curious lack -of appreciation for the gravity of his own offense and he always -complains of a "frame up" and asserts that he has not had a square -deal. Homicides even are always explained in an attempt to show that -they were justifiable or unavoidable. The most vicious of assaults -are often committed on their fellow prisoners without any provocation -of consequence. Experience shows that as a rule they are incapable of -any sustained effort and accomplish little or nothing when left to -themselves. Tendencies to crime show not only a marked suggestibility -but a degree of impulsiveness and a lack of self control which is -highly significant. - -Another type of institution for this special group of cases is strongly -indicated. They should be held under an indeterminate sentence and in -some instances committed for life. As a result of hereditary defects, -arrested mental development, ignorance and vicious tendencies this -class furnishes the prisons with our most dangerous criminals. They -should receive separate care, with an opportunity for a special -education adapted to their individual needs. The defective classes -have for centuries been held criminally responsible and have filled our -prisons with incorrigibles and recidivists. Modern civilization should -place at our disposal some means for remedying this situation other -than mere punishment for the possession of an intellectual endowment -for which these individuals are in no way responsible. The ends of -justice can be served and the protection of the public assured at the -same time by a form of medical treatment for the defective delinquent -which will look forward to his ultimate restoration to society rather -than a form of punishment which accomplishes nothing. - - - - -CHAPTER XI - -THE PSYCHIATRY OF THE WAR - - -The psychiatry of the late war is of unusual interest from various -points of view. Never before have mental diseases or defects been -looked upon as military problems worthy of any special attention either -in times of war or peace. It is true that the United States government -has maintained a hospital for the treatment of such conditions at -Washington for many years, and medical officers from the army and navy -have been sent to that institution for instruction, from time to time. -No adequate provision has been made, however, in previous wars for -the special care or observation of the psychoses or neuroses, nor has -any great consideration been given to a determination of the mental -status of recruits. It is, of course, equally true that modern military -methods have brought about different conditions and given rise to new -problems. In 1917 and 1918 definite psychiatric organizations were -established by the United States army for the first time. The services -of specialists in mental diseases were utilized extensively and they -were ultimately assigned to practically all of the large hospitals. -Division consultants were soon found necessary and the active -cooperation of practically every psychiatrist available in the country -was required before the armistice was declared. - -This was directly due to the fact that for the first time in history -one of the most important problems, with which the military authorities -had to deal, was the question of mental diseases and defects. For -purposes of comparison and the intelligent consideration of this -important subject, the incidence of mental diseases in the army in -the past is of considerable interest. The rate in enlisted men, as -shown by the Surgeon General's reports, varied from 1.08 per thousand -in 1898 to 1.73 in 1911, and was 2.72 in 1900, the only year in which -it went above two. In 1912, 1913, 1914 and 1915, when defective mental -development, constitutional psychopathic states, hypochondriasis and -nostalgia were included in the reports the rates per thousand were -respectively 3.45, 3.44, 4.18 and 3.82. The frequency of psychoses was -higher in the men serving in the Philippines—2.07 in 1898, 2.79 in -1900, 1.45 in 1905 and 2.01 in 1911. - -The ratio of mental diseases in the American and English armies has -been higher for many years than in the French, Italian, Russian and -German forces. Universal military service is supposed to have been the -factor producing this difference, the larger establishments naturally -more nearly representing the normal insanity rate of the country. -From May 1, 1861, to June 30, 1866, in other words, during the civil -war period, there were 198,849 discharges for disability from the -United States army.[85] Of this number 819 men were discharged on -account of insanity, 3,872 for epilepsy and 2,838 for various forms -of "paralysis." Based on the mean annual strength of the army, this -represented a rate of .34 per thousand for insanity, 1.6 for epilepsy -and 1.17 for paralysis. Based on the total number of discharges alone, -it represented a rate of 6.0 per thousand for insanity, 20.8 for -paralysis, and 28.3 for epilepsy or a rate for the three combined of -55.1 per thousand. These statistics are for white soldiers only. The -rate for colored troops, based on the total discharges, was seven per -thousand for insanity, 14.3 for paralysis and thirty-six for epilepsy. -No information whatever is available as to what the term paralysis -includes in these reports. The rate per thousand in the United States -army, as has been shown, increased from approximately one in 1898 to -three in 1901, during the Spanish war, Philippine insurrection, etc., -and dropped back to one again in 1903. Weygandt,[86] who made a study -of war neuroses and psychoses in 1904, gives the insanity rate per -thousand of the German army during the Franco-Prussian war as .54, the -American troops during the Spanish war as 2.7, the British army during -the Boer war as 2.6, the Russian army during the Japanese war as 2.0, -and the Bulgarian troops during the Balkan campaign .33. The German -expeditionary corps engaged in Southwestern Africa reported 4.95 per -thousand and a rate of 8.28 including epilepsy and hysteria. - -The first attempt ever made to provide special care for mental diseases -in the field was during the Russo-Japanese war. A hospital set aside -for this purpose by the Russian army at Harbin treated between fifteen -hundred and two thousand men in 1905 and 1906. It has, however, never -been claimed that all of the mental cases reached that place. Of 1,310 -admissions the following conditions were represented[87]:—epileptic -psychoses, 22.5 per cent; alcoholic forms, 19.5 per cent; dementia -praecox, ten per cent; confused states, nine per cent; hysterical -psychoses, 7.7 per cent; general paresis, 5.6 per cent; toxic -conditions, 4.8 per cent; manic-depressive psychoses, four per cent; -degenerative types, 3.5 per cent; traumatic psychoses, 3.2 per cent; -and organic brain diseases, 2.9 per cent. It is interesting to note -that Steida, who analyzed the statistics of the Russo-Japanese war in -1906, reached the conclusion that a psychic trauma alone was not a -sufficient cause for the development of a neurosis. He attached an -equal importance to prolonged physical exertion, deprivation, loss of -sleep, hunger and thirst, etc. The most common disturbances following -battles were found to be hysterical excitements and confused states. - -As soon as the examination of men for military service was undertaken -in this country in 1917 it became apparent that one of the most -frequent causes of rejection was either mental disease or deficiency. -The second report of the Provost Marshal General to the Secretary of -War in 1919[88] showed that of all rejections during the first year of -mobilization, twenty-two per cent were due to physical defects which -would interfere with duty (defects in bones, and joints, flat foot, -hernia, etc.), fifteen per cent were on account of imperfections of the -sense organs, thirteen per cent were for defects in the cardiovascular -system and about twelve per cent were due to nervous or mental -diseases. The inspection at camps following the physical examination -of the first million men mobilized resulted in a rejection of nine -per cent on account of nervous or mental diseases. Of all causes -for rejections from the army up to February 1, 1919, according to -Bailey,[89] mental and nervous diseases ranked fourth numerically. The -"neuropsychiatric" causes were:—psychoses, eleven per cent; neuroses, -fifteen per cent; epilepsy, nine per cent; organic nervous diseases or -injuries, eighteen per cent; mental defects, thirty-two per cent, and -constitutional psychopathic states, nine per cent; a total of 67,417 -cases. - -In the organization of our military forces in 1917, when this country -entered the war, every effort was made to take advantage of the -experience of others. Of the men returned to Canada from European -battlefields on account of disability, the nervous and mental cases -contributed ten per cent of the total at that time, as was shown by -Farrar.[90] These were distributed as follows:—neurotic reactions, -fifty-eight per cent; mental disease and defect, sixteen per cent; head -injuries, fourteen per cent; epilepsy and epileptoid conditions, eight -per cent; and organic diseases of the central nervous system, four per -cent. The first group mentioned consisted of neuroses in general and -included the so-called cases of "shell shock," which brings us to one -of the most interesting problems of the war. Dean A. Worcester, in a -recent letter to the editor of _Science_, has raised the question as -to whether this is a new disease. He calls attention to the following -reference by Herodotus to the Battle of Marathon which occurred in the -year 490 B.C.:—"The following prodigy occurred there: An Athenian, -Epizelius, son of Capliagoras, while fighting in the medley, and -behaving valiantly, was deprived of sight, though wounded in no part of -his body, nor struck from a distance; and he continued to be blind from -that time for the remainder of his life. I have heard that he used to -give the following account of his loss. He thought that a large, heavy -armed man stood before him, whose beard shaded the whole of his shield; -that this specter passed by him, and killed the man that stood by his -side. Such is the account I have been informed Epizelius used to give." - -The nature and cause of shell shock has been the subject of much -controversy. In 1875 Ericksen called attention to the effect of intense -emotional shock on the nervous system. This he explained as "dependent -on molecular changes in the cord itself." Oppenheim's monograph in 1899 -was responsible for the general use of the term "traumatic neurosis." -His conception of these conditions was not accepted by Charcot, who -at the time insisted that they belonged to the domain of hysteria, -and were due solely to psychic traumas. Oppenheim's[91] observation -of cases during the first year of the war confirmed his previous -views. He expressed the opinion in 1915 that "in absolutely healthy -and mentally normal individuals, without any trace of hereditary -taint, war trauma may cause psychoses or neuroses. The causal injury -may be of an objective, psychic or mixed nature. Violent detonations -illustrate the mixed type. Their effect upon the nerve of hearing -is certainly physical, but the psychic effect—terror—is also an -important element in the resulting condition. The enormous air -pressure exerted by the close passage of these missiles is another -influential factor. An element that tends to complicate etiology is -the frequent long duration of the exciting causes (prolonged and -continuous artillery fire, a series of injuries received at brief -intervals, exhaustion from various causes, lack of sleep, insufficient -nourishment, extreme heat or cold, etc.)." He admits that the symptoms -indicate a combination of neurasthenic and hysterical complexes which -may be explained on a psychogenic basis, but maintains that the war -has demonstrated them to be of a different nature. An external shock -causes "a functional disturbance of the delicate mechanism of the -psychic centers shown in 1, faulty distribution of motor impulses, 2, -hypo-innervation, 3, hyper-innervation, causing tremors, tonic and -clonic spasms, etc., instead of single muscle actions." He admits that -a hysterical temperament may be an important factor. Max Nonne[92] in -1915 called attention to the fact that conditions combining symptoms -of hysteria, neurasthenia and hypochondriasis plus vasomotor changes -may occur without any history of injury and should not be called -traumatic neuroses for that reason. He felt that the sudden recoveries -occurring so frequently strongly discredited any theories suggesting -an anatomical basis. He expressed the opinion that the most common -cause was the explosion of hand grenades and that the main factor -involved was an emotional disturbance. Binswanger[93] was of the -opinion that mechanical injuries to the nervous system were responsible -for the clinical pictures in war hysterias. He found that in a few -cases only was there a history of predisposition, and maintained -that in pre-war conditions hysteria was the result of a combination -of psychic traumas with physical disturbances. Exciting causes were -"over-exertion, irregular and insufficient nutrition, loss of sleep -and high mental tension." He concludes that "The theory of a psychic -mechanism as the origin of these motor and sensory symptoms is not -demonstrable." "War neurology has demonstrated that emotional shock, in -conjunction with other injuries, may cause a symptom complex identical -in all its details with the well known clinical picture of hysteria." -Wolfsohn,[94] from a study of one hundred psychoneuroses and one -hundred cases of physical injury received on the firing line, reached -the conclusion that war neuroses are very rarely associated with -external wounds. The vast majority of cases studied had a neuropathic -or psychopathic taint, as shown in the family history in fourteen -per cent of the total. A previous neuropathic constitution in the -patient was found in seventy-two per cent. "A gradual psychic shock -from long-continued fear, together with the sudden change from quiet, -peaceful environment to the extraordinary stress and strain of trench -fighting, is the chief predisposing cause of war psychoneurosis in -soldiers with neuropathic predisposition.... Wounded soldiers do not -suffer from war neuroses except in rare instances." - -When the United States entered the war, Major, afterwards Colonel, -Thomas W. Salmon[95] of the United States army made an exhaustive -study of "The Care and Treatment of Mental Diseases and War Neuroses -("Shell Shock") in the British Army." At that time one-seventh of -all discharges for disability from the British forces were due to -mental and nervous disorders. As a matter of fact, they accounted for -one-third of all discharges for actual diseases (eliminating wounds). -England with the advantage of three years of experience had presumably -completed her organization to its highest efficiency. One and one-tenth -per cent of the cases in the military hospitals were suffering from -mental diseases. The percentage represented by the expeditionary forces -was 1.3. About six thousand "shell shock" cases were being admitted -annually to the English hospitals. Col. Salmon estimated the admission -rate at two per thousand in the troops at home and four per thousand -in the expeditionary forces. The civilian rate during the same period -was about one to one thousand of the population. The confusion which -existed early in the war was shown by the fact that ten per cent -of the cases sent to the Red Cross Military Hospital at Maghull as -war neuroses turned out to be insane and twenty per cent of those -admitted as mental cases at the Royal Victoria Hospital at Netley were -subsequently found to be suffering from neuroses. The first conclusion -reached by Col. Salmon was that "contrary to popular belief and to some -medical reports published early in the war, no new clinical types of -mental disease have been seen in soldiers. There are no war psychoses." -He found that of the cases being admitted to the hospitals for mental -diseases about eighteen per cent were mental defectives, two per cent -syphilitic psychoses, twenty per cent manic-depressive insanity, -fourteen per cent dementia praecox, and seven per cent epilepsy. -Statistics at that time were not available on purely psychopathic -conditions, owing to the classification used. - -In discussing the etiology of shell shock Col. Salmon divides those -conditions into four groups—1. Cases in which death is caused by -exploding shells or mines without external signs of injury; 2. Those -in which severe neurological symptoms follow burial or concussion by -explosions, with characteristic syndromes suggesting the operation -of mechanical factors; 3. Cases in which there may or may not be -damage to the central nervous system, but showing neuroses similar -to those of civil life—"In this group of cases, in which there is -possibility but no proof of damage to the central nervous system, the -symptoms present which might be attributable to such damage are quite -overshadowed by those characteristic of the neuroses;" and 4. Cases in -which even the slightest damage to the central nervous system from the -direct effect of explosions is exceedingly improbable. He also found -that hundreds of men who have not been exposed to battle conditions -at all develop symptoms almost identical with those described as -"shell shock," many occurring in the non-expeditionary forces. The -psychogenic factors involved are very well summarized by Col. Salmon -in the following words:—"The psychological basis of the war neuroses -(like that of the neuroses in civil life) is an elaboration, with -endless variations, of one central theme: escape from an intolerable -situation in real life to one made tolerable by the neurosis. The -conditions which may make intolerable the situation in which a soldier -finds himself hardly need stating. Not only fear, which exists at some -time in nearly all soldiers and in many is constantly present, but -horror, revulsion against the ghastly duties which must be sometimes -performed, intense longing for home, particularly in married men, -emotional situations resulting from the interplay of personal conflicts -and military conditions, all play their part in making an escape of -some sort mandatory. Death provides a means which cannot be sought -consciously. Flight or desertion is rendered impossible by ideals of -duty, patriotism and honor, by the reactions acquired by training or -imposed by discipline and by herd reactions. Malingering is a military -crime and is not at the disposal of those governed by higher ethical -conceptions. Nevertheless, the conflict between a simple and direct -expression in flight of the instinct of self-preservation and such -factors demands some sort of compromise. Wounds solve the problem most -happily for many men and the mild exhilaration so often seen among -the wounded has a sound psychological basis. Others with a sufficient -adaptability find a means of adjustment. The neurosis provides a means -of escape so convenient that the real source of wonder is not that it -should play such an important part in military life but that so many -men should find a satisfactory adjustment without its intervention. The -constitutionally neurotic, having most readily at their disposal the -mechanism of functional nervous diseases, employ it most frequently. -They constitute, therefore, a large proportion of all cases but -a very striking fact in the present war is the number of men of -apparently normal make-up who develop war neuroses in the face of the -unprecedentedly terrible conditions to which they are exposed." - -The symptomatology has been briefly summarized by Col. Salmon in a way -which cannot be improved upon:—"Most of them can be summed up in the -statement that the soldier loses a function that either is necessary -to continued military service or prevents his successful adaptation to -war. The symptoms are found in widely separated fields. Disturbances of -psychic functions include delirium, confusion, amnesia, hallucinations, -terrifying battle dreams, anxiety states. The disturbances of -involuntary functions include functional heart disorders, low blood -pressure, vomiting and diarrhea, enuresis, retention or polyuria, -dyspnoea, sweating. Disturbances of voluntary muscular functions -include paralyses, tics, tremors, gait disturbances, contractures and -convulsive movements. Special senses may be affected producing pains -and anesthesias, mutism, deafness, hyperacusis, blindness and disorders -of speech. It is highly significant that, in this unprecedented -prevalence of functional nervous diseases among soldiers, no symptoms -unfamiliar to those who see the neuroses in civil life present -themselves." - -An analysis of the 170,000 cases discharged for disability in England -showed that twenty per cent were due to war neuroses. In his second -Lettsomian lecture Mott[96] called attention to the interesting -similarity between shell shock following concussion and burial, and -the symptoms resulting from an acute carbon monoxide poisoning. This -was, of course, a very possible complication in trench warfare. -The headache, ringing in the ears, blurred and indistinct vision, -hallucinations of sight, or actual blindness, giddiness, yawning, -weariness, vomiting, cold sensations, palpitation, sense of oppression -on the chest, etc., so common in gas poisoning are often followed, -when consciousness is regained, by confusion and loss of memory, with -retrograde amnesia. Tremors and loss of speech are also frequently -noted. Mott reached the conclusion that shell shock, in some cases -at least, was due to gas poisoning. In his third Lettsomian lecture -he discusses the symptomatology of shell shock. In some instances -there was a partial loss of consciousness, characterized by dazed -states somewhat similar to those of epilepsy. Under speech defects he -includes mutism, aphonia, stammering, stuttering and verbal repetition. -Headache in the occipital region was found to be a very common symptom. -Vasomotor conditions were palpitation, breathlessness, pericardial -pain, rapid weak pulse, low blood pressure, cold extremities, low -temperature, etc. Anesthesia and hyperesthesia or loss of pain -sense also occurred, and deafness was often observed. Smoky vision, -photophobia and functional blindness were frequent eye symptoms. -Tremors, tics, choreiform movements, functional paralysis and gait -disturbances are also mentioned by Mott. In the Chadwick lecture he -later called attention to the presence of insomnia and terrifying -dreams in practically all cases of true shell shock. - -In 1917 Mott[97] reported the examination of the brains from two -cases of pure shell shock. They showed a congestion of the meninges, -scattered subpial hemorrhages, and congested vessels in the internal -capsule, pons and medulla. In one case there was an extravasation of -blood into the substance of the lower surface of the orbital lobe. He -spoke also of a general chromatolysis in the ganglion cells. Eder[98] -in 1917 advanced the theory that the symptoms of neuroses are the -result of mental conflicts and that the mechanisms involved are those -attributed by Freud to hysteria. As a result of an analysis of one -hundred cases he reached the conclusion that mechanical shock, gas -poisoning and other physical traumas were not factors in the production -of these conditions. His cases occurred in persons free from hereditary -or personal psychoneurotic predisposition. Chavigny in a discussion -of the mental diseases in the French army asserted that psychoses and -neuroses were practically unknown until trench warfare began and the -use of heavy artillery became common. From this moment psychiatric -units became necessities. Ballet and de Fursac[99] were very firmly -of the opinion that shell shock was due to purely emotional reactions -in predisposed individuals. "If disturbances from explosion and -from emotional shock, existing with or without traumatism, produce -identical results, it is evident that they have a common factor and -this common factor can be only the emotion itself. Disturbance from -explosion without external injury presupposes an emotional state, and -it is from this state that it derives its causal efficacy; whatever -the etiological complex found as the cause of a condition of shock, -whether the explosion of a shell, bomb or mine, the sight of the dead, -burial in a trench, wound from an explosion or a missile, there is only -one factor of importance, the emotional factor, which is essentially -responsible for all the neuropsychic disorders that together make up -the shock syndrome." - -In 1915 Birnbaum summarized seventy-two articles written on war -psychoneuroses in the German army up to the middle of March of that -year. On analyzing this study Hoch reached the conclusion that the rate -of psychoses was only about two in ten thousand, which would appear to -be entirely too low. Birnbaum compared the statistics of various -observers showing the frequency of psychoses during the first year of -the war as follows:—"Psychopathic constitution, hysteria, traumatic -neuroses, etc., Bonhöffer, fifty-four per cent; Meyer, 37.5 per -cent; and Hahn forty-three per cent. Alcoholism, acute and chronic, -Bonhöffer, ten per cent; Meyer, 21.5 per cent; and Hahn, twenty-one -per cent. Dementia praecox, Bonhöffer, seven per cent; Meyer, 7.5 per -cent; and Hahn, thirteen per cent. Epilepsy, Bonhöffer, fourteen per -cent; Meyer, 11.5 per cent; and Hahn, eight per cent. Manic-depressive -insanity, Bonhöffer, three per cent; Meyer, four per cent; and Hahn, -two per cent. General paralysis, Bonhöffer, six per cent; Meyer, 3.5 -per cent; and Hahn, three per cent." In discussing these findings Hoch -says:—"It is clear from this table that psychopathic constitutions, -various psychogenic reactions, hysterical and anxiety states, also -exhaustive conditions—all of which are included in the first -group—are strikingly frequent; whereas the more serious constitutional -disorders, such as manic-depressive insanity, dementia praecox and -epilepsy are much rarer." Both Birnbaum and Bonhöffer expressed -surprise at the infrequency of manic-depressive conditions. Wollenberg -found that the individuals who broke down during mobilization, and who -had the least resistance, developed manic-depressive insanity, paranoid -schizophrenias, episodic psychopathic excitements and occasional -clouded states. The cases appearing at the front, on the other hand, -were largely hysterias, anxiety states and exhaustive conditions. -Birnbaum described psychoses similar to those reported by Awtokratow -in the Russo-Japanese war and characterized by great weariness with -a tendency to weeping, disturbed sleep and hallucinations related -directly to unpleasant war experiences to which the patients had been -subjected. He attributed these to exhaustion. Lust[100] quotes Mörchen -as finding only five cases of war neuroses in forty thousand prisoners -at Darmstadt and found very few cases in an additional twenty thousand -which he investigated himself. - -Westphal in 1915 expressed the opinion that there were neither war -psychoses nor neuroses and that these conditions did not differ in any -way from those described in times of peace. MacCurdy,[101] who made -an elaborate study of war neuroses in 1917, described them as being -either anxiety conditions or simple conversion hysterias. He looked -upon fatigue as being a very important factor in the development of -a neurosis, with either a physical accident or a mental shock as the -precipitating cause. He defines war neuroses as "Those functional -nervous conditions arising in soldiers which are immediately determined -by modern warfare and have a symptomatology whose content is directly -related to war." MacCurdy found that concussion could be considered as -a possible factor in less than one-fourth of the cases he observed. -He refers to minute cerebral and retinal hemorrhages with blood in -the cerebrospinal fluid as an evidence that concussion is a cause in -some cases. Curschmann, Meyers, Buzzard, Farrar and various others -have noticed that the gross hysterical manifestations were extremely -rare in officers. After an extended discussion of the etiology of -the war neuroses, Farrar in 1918 expressed as one of his conclusions -the opinion that "The drift of opinion is unmistakable towards the -psychogenic basis of war neuroses of all types, including shell shock. -Even in the initial unconsciousness or twilight state of some duration -there is evidence that the psychogenic element may have as great if -not a greater rôle than the item of mechanical shock, although this is -also important." - -Hartung[102] in 1918 reported a study of 780 cases of war neuroses -treated by him at Thal. About ninety-eight per cent were cured by -psychic and mechanical treatments. One hundred and sixty-two cases -showed hysterical paralysis, the lower limbs being affected twice as -often as the upper. Tremors of the head or upper limbs were present -in twenty-eight per cent, hysterical convulsions in eight per cent, -speech disturbances in five per cent, hearing disorders in one per -cent, cardiac and respiratory symptoms in 1.5 per cent, neuroses of the -digestive system in 1.5 per cent, and bladder disturbances in 1.5 per -cent of the cases. Neurasthenia "in the strictest sense of the word" -was present in twenty per cent. Hurst[103] and others have spoken of -endocrine disturbances in war neuroses. He includes hyperadrenalism and -hyperthyroidism due to an over-stimulation of the sympathetic nervous -system, resulting from such emotions as anger and fear. Rapid pulse, -enlargement of the heart, and high blood pressure were common symptoms. -The patients in some cases showed conditions strongly suggesting -Graves' disease. In addition to the circulatory disturbances there was -paroxysmal sweating, the eyes were slightly prominent, sometimes with -von Graefe's sign, and pilomotor reflexes were present. - -An important contribution to the discussion as to the etiology of war -neuroses was the statement made by Major General Ireland[104] to the -Senate Committee on Military Affairs, that of the twenty-five hundred -cases of shell shock awaiting transportation to the United States, -twenty-one hundred recovered within a day or two after the armistice -was declared. He gave the incidence of mental and nervous diseases -in the forces in camps in this country as 2.5 per thousand and ten -per thousand overseas. Another interesting phase of shell shock was -the surprising results which various German observers obtained by the -so-called "Kaufmann" treatment, the sudden application of a strong -faradic current. One of the most significant contributions to the -psychiatric history of the war as far as this country is concerned -is the statement made by Col. Salmon[105] that in the latter part -of December, 1920, of the beneficiaries of the War Risk Insurance -thirty-two per cent were suffering from general diseases; forty-one -per cent from tuberculosis; and twenty-seven per cent from various -neuropsychiatric disorders. "The vague idea that all these men are -suffering from "shell shock" or other mysterious maladies developed -under the stress of modern warfare was replaced by the realization -that more than two-thirds of all neuropsychiatric patients have one or -another type of insanity." Of these cases sixty-six per cent had well -developed psychoses; nineteen per cent psychoneuroses; five per cent -epilepsy; two per cent mental deficiency; and eight per cent organic -nervous diseases or injuries. On December 16, 1920, there were five -thousand five hundred cases receiving hospital treatment. - - - - -CHAPTER XII - -ENDOCRINOLOGY AND PSYCHIATRY - - -The important influence exercised by the glandular structures on the -human organism has long been recognized. Perhaps the earliest evidence -of this is the study of alterations due to the removal of the sexual -glands. Eunuchoidism was described by Larrey as early as 1812 in -his well-known account of the Egyptian campaign. In 1845 Bouchardat -advanced the theory that pancreatic lesions were responsible for the -development of diabetic disorders. Thomas Addison in 1855 showed the -existence of a very definite disease process caused by pathological -conditions in the adrenals. Mongolianism was recognized as a distinct -entity by Langdon-Down in 1866. Gigantism was studied very thoroughly -by von Langer in 1872. The existence of the parathyroids was unknown -until they were described by Sandström in 1880. Weiss in 1881 showed -that the extirpation of the thyroid sometimes caused tetany. After -myxedema had been studied clinically by Charcot and others the fact -that it was clearly related to disturbances of the functions of -the thyroid gland was demonstrated by Kocher and Reverdin in 1882. -Adipositas Dolorosa was described by Dercum as a form of dysthyroidia -in the same year. Acromegaly was originally defined by Pierre Marie -in 1886 and its relation to the hypophysis was pointed out by him. -In 1886 Möbius called attention to the part played by the ductless -glands in Basedow's disease, Grawitz in 1888 showed the significance -of thymic hyperplasia and Paltauf in the following year described the -"lymphato-chlorotic constitution." The pancreatic origin of diabetes -was elaborately outlined by von Mering and Minkowski in 1889. The -influence exerted by glandular secretions on general metabolism was -demonstrated by Brown-Sequard in the same year. Lemoine and Launois -in 1891 reported the existence of sclerosis of the blood and lymph -vessels in the pancreas and Laguerse in 1893 found that the Islands of -Langerhans were often involved in diabetes. Thyroigenic obesity was -reported by von Hertoghe in 1896. The isolation and chemical definition -of adrenalin by Takamine in 1901 was a decided step in advance. -Fröhlich in 1901 suggested that obesity, infantilism of the genitalia -and myxedematous alterations of the skin pointed to tumors of the -hypophysis. In the same year Neumann thoroughly reviewed the subject -of growths in the epiphysis, submitting a study of twenty-two cases. -The various types of dwarfism were first described by von Hansemann in -1902. Thyroplasia and myxedema were exhaustively studied by Pineles -in 1910 and 1912. The literature on the subject of the ductless or -so-called endocrine glands has grown enormously during the last two or -three decades and is shown in full by Falta and Meyers.[106] - -The endocrine syndromes as now understood have been briefly summarized -by Blumgarten[107] in a very graphic form as follows:— - - - THYROID STIGMATA - - _Symptoms of So-called Hyperactivity_ - - Exophthalmus. - Wide palpebral slits. - Tachycardia. - Nervousness. - Tremors. - Stelwag's sign. - Scanty and frequent menstruation. - Emaciation. - Periodic loss of flesh and strength. - Mild hyperthermia. - Increased basal metabolism. - Lymphocytosis. - Von Graefe's sign. - Anginoid attacks. - Hyperidrosis. - Deformities of the nails. - Dryness of the mouth. - Excessive salivation. - Vomiting attacks. - Diarrhea. - Irregular breathing. - Eosinophilia. - Increased coagulation time. - Increased emotional irritability. - Ideas of reference and persecution. - Manic symptoms. - Bluish-white teeth. - High hair line. - Hourglass contraction of the stomach. - - - _Symptoms of So-called Hyposecretion_ - - Precocious graying of the hair. - Drowsiness. - Anorexia. - Small stature. - Puffiness of the face. - Sallow complexion. - Scanty hair. - Deepset eyeballs. - Dull and listless cornea. - Hard, brittle nails. - Scanty eyebrows. - Cold, bluish, moist hands. - Tending to chilblains. - Irregularly developed teeth which decay easily. - Defective development. - Dry, thick, scaly skin. - Acrocyanosis. - Localized transitory edema. - Urticaria. - - - _Parathyroid Stigmata_ - - Intermittent cramps. - Twitching of the hands. - Tetany with associated symptoms. - - - _Pituitary Stigmata_ - - Greatly thickened nose. - Prominence of superciliary ridges. - Tendency to increased tuftings of terminal phalanges. - Coarse, heavy, overhanging eyebrows. - Protruding thick lips. - Prominent hypertrophied lower jaw. - Increased sugar tolerance. - Increased interdental spaces. - Enlarged sella tursica. - Hypertrophied nails. - Hypertrophied, thickened skin. - Short, square hands. - High carbohydrate tolerance. - Amenorrhea. - Visceroptosis. - - - _So-called Deficiency Symptoms_ - - Adiposity. - Fat pads around the malleoli. - Increased development of the mammary glands. - Deposit of fat around the buttocks and the neck. - Alabasterlike skin. - Irregular menstruation. - Subnormal temperature. - Wide intercostal angle. - Fatigability. - Infantile uterus. - Slow pulse. - Sluggish mentality. - Mononucleosis. - Eosinophilia. - Leucocytosis. - Short stature. - Childlike voice. - Bitemporal headache. - Supraorbital headache. - Sterility. - - - _Adrenal Stigmata_ - - Aggressive type of individual. - Increased growth of hair on body. - Masculine type of female and vice versa. - Prominent canine teeth. - - - _So-called Deficiency Symptoms_ - - Asthenia. - Low blood pressure. - Muscular pains. - Fatigability. - Pigmentation. - Sergent's white line. - - - _Thymus Stigmata_ - - Very long stature. - High palatal arch. - Infantile epiglottis. - Lymphocytosis. - General glandular enlargement. - Abnormally long thorax. - Visceroptosis. - Eosinophilia. - - - _Gonadal Stigmata_ - - Hermaphroditism. - Pale, anemic skin. - Flushes in the female. - Scanty growth of lanugolike hair. - Sparse eyebrows. - Dull, lethargic mentality. - Characteristic pyramidal pubic hair in males and flat in females. - - - _Symptoms of So-called Gonadal Hyperactivity_ - - Precocious sexual activity. - Jolly, gay disposition. - Marked fecundity. - Menorrhagia or metrorhagia. - - - _Symptoms of So-called Hyposecretion_ - - Infantilism. - Small, atrophic testes. - Late menstruation. - Menorrhagia. - Dysmenorrhea. - Infantile uterus. - Nervous constipation. - Deficient lateral incisors. - Sterility. - Absent lateral incisors. - - - _Pineal Stigmata_ - - (occur only in children) - - Precocious sexual and mental development. - - -It will be noted that he associates manic symptoms, increased -emotional irritability, ideas of reference and persecution with -thyroid hyperactivity and speaks of a sluggish mentality in pituitary -deficiency and gonadal stigmata. Blumgarten's summary of these -conditions is very interesting: "The study of the various stigmata -shows that many of these are present regularly in certain types of -individuals. Consequently we may group individuals from an endocrine -viewpoint into various types according to the prominent endocrine -stigmata which they show. For example, the nervous, thin individual -with tachycardia, rather prominent eyeballs, fine, delicate hair, -suffering occasionally from gastric symptoms, suggests the thyroid -type, as does also the clean-cut, alert individual, and the young woman -suffering with amenorrhea and a tendency to obesity and lethargic -mentality. On the other hand, the aggressive, energetic individual, -with the history of an ancestry subject to vascular disease, with -high blood pressure, with abundant, unusual distribution of hair and -a tendency to pigmentation, suggests the adrenal type. And so does -the tired, asthenic individual with low blood pressure and Sergent's -white line, who may have had influenza or diphtheria and even may be -suffering from tuberculosis. On the other hand, however, the heavily -built individual with broad, large frame, wide intercostal angle, broad -nose, prominent supra-orbital ridges, prominent lips, large, square -fingers, suggests the pituitary type. These individuals are very fond -of meats, are heavy eaters, and are constantly subject to diseases of a -gouty nature, may have a history of syphilis, are often musical and, as -a rule, are usually successful in their particular community." - -According to Kaplan[108] "such states as lack of courage, melancholy, -suicidal tendencies, dementia praecox, precocious adolescence, and -immature senility, sadism and masochism; all of these are possible -manifestations in a gonadotrop individual." Garretson[109] is of the -opinion that the "large group of patients generally misunderstood and -frequently classed in civil life as neurasthenics, psychasthenics, -hysterics, cyclothymics, and hypochondriacs, is now capable of an -intelligent analysis and rational therapy, if one will concede that -these are the victims of an endocrinic asthenia." - -As an evidence of the influence of the endocrine glands on psychical -functions, Falta[110] refers to "the alteration in character that is -almost always associated with the development of Basedow's disease; -to the psychical irritability, the inclination to irascibility, the -manic-euphoristic attitude of patients with Basedow's disease; to the -apathy and lack of interest of the myxedematous; to the characteristic -quiet mental attitude in hypophysial dystrophy, and the feeling of -mental want of strength in those suffering with Addison's disease; -to the depressive attitude of the tetany patient, and finally to the -profound influence that the ripening of the sexual glands at the time -of puberty or the loss of function of the sexual glands in castrates -exercises on the psyche." Going into this subject more in detail Falta -gives the following mental symptoms as associated with Basedow's -disease: abnormal irritability, "immotivated" gaiety, hasty speech, -rapid flow of thoughts, a suggestion of flight of ideas, changeable -moods and terrifying dreams. He also finds an alteration in the -personality as shown by suspiciousness, capriciousness, irritability -and either euphoric or depressed tendencies. Möbius compares this with -a condition of mild intoxication associated with maniacal periods -alternating with depression. Occasional attacks of delirium with -confusion and hallucinations terminating in coma have been described. -Sattler, who has analyzed 150 of these cases as reported in current -literature, classifies over seventy as cases of manic-depressive -insanity. Boinet, Parhan and others have shown that depression with -suicidal inclinations may follow the ingestion of large amounts -of thyroidin. Conditions of excitement have also been reported in -thyroidism, and, according to Falta, are not uncommon. Brunet has -expressed the opinion that in such cases Basedow's disease acts only as -a precipitating factor in an individual predisposed to a psychosis. - -The English Myxedema Commission found the apathy characteristic of that -disease present in all but three of 109 cases. This condition develops -early and may manifest itself in the form of a mild mental dulness. -Intellectual activities are often markedly diminished and there is a -slow, monotonous form of speech. Deterioration may be well developed -and memory seriously impaired. The commission in its investigations -found illusions in eighteen cases, hallucinations in sixteen and -psychoses in sixteen. These took the form usually of a depression -with occasional excitements. The symptoms, in some cases at least, -disappeared after thyroid treatment was instituted. - -The psychic changes in cretinism have been made the subject of -considerable study. The usual mental state is, of course, one of -feeblemindedness. Perception has been shown to be disturbed, memory is -impaired and there is a marked emotional deterioration and instability. - -In the parathyroid form of tetany von Frankl-Hochwart found depressions -and confused states with hallucinations. Depressions were reported by -him in fourteen of thirty-seven cases examined. Excitements were also -noted in some instances. Falta refers to "a characteristic apathy, a -want of initiative, and a slowing of speech" in acromegaly. In rare -cases he has also noted mental exaltation. Oppenheim (1914) has called -attention to cases of acromegaly presenting the picture of general -paresis but due to an alteration of glandular functions and not -syphilitic in origin. - -Falta includes the following in his description of the symptomatology -of Addison's disease: "Almost always the disease manifests itself -in ready fatigability, disinclination for work, and apathy; to -these symptoms are sometimes added headaches, poor sleep, sometimes -obstinate insomnia, psychical ill humor and depression, often too, -abnormal irritability; further, diminution in memory, noises in -the ears, vertigo and commonly fainting attacks, singultus, and -rheumatoid pains in the back and in the extremities, sometimes, also -epileptiform convulsions. Extremely stormy manifestations on the part -of the nervous system may, especially in the later stages, make their -appearance—violent delirium, acute confusion, convulsions, deep -stupor, and coma." - -Raeder[111] has made an analysis of glandular involvements found in -the study of one hundred cases of feeblemindedness at autopsy. He -classifies these as 1, extreme changes—in which three or four glands -were involved and where there were marked anomalies of growth, -underdevelopment, disproportion of the body parts, etc.; 2, marked -changes—in which at least two glands were involved and where there -were distinct changes in growth and anomalous development; 3, moderate -changes—in which one or two glands were involved; and 4, cases where -no glandular involvement was found. He noted extreme changes in ten per -cent of the series, marked changes in eleven per cent, moderate changes -in fifty-three per cent and none at all in twenty-six per cent. Sixty -per cent of these individuals showed deviation from the normal in size, -fifty-one per cent were undersized and nine per cent were above the -average height, while thirty-eight per cent were normal. The pituitary -was found to be involved in forty per cent of the one hundred cases, -the thyroid in nineteen per cent, the suprarenal in twenty-seven per -cent, the sex glands in thirty-eight per cent, the thymus in twelve -per cent and other glands in six per cent. He frequently found several -involved: "Pituitary with gonads in nine cases, was the most common -dual adenosis, though there were combinations of sex and thyroid in -four instances, sex and suprarenal in four cases, and in three cases -the thyroids, pituitary and gonads were affected in triple involvement. -Furthermore, there were six cases in which the gonads were combined -with three other glands; two included the gonads, thyroid, pituitary -and suprarenal; two, gonads, thyroid, pituitary and thymus." Further -investigation only can accurately determine the exact relation which -exists between disturbance of these glands and the presence of mental -deficiency. - -Attention was called some time since to the fact that the injection -of adrenalin leads to an increase in blood pressure. This has been -discussed by Falta, Newburgh, Nobel and others. Neubürger[112] made a -study of thirty-nine cases, seven of which were normal, the others -including alcoholism, neurasthenia, manic-depressive, etc., but not -dementia praecox. A fairly well marked rise of blood pressure followed -adrenalin injection very quickly, reaching its maximum in from six -to twelve minutes. He found the reaction diminished or absent in -eighty per cent of the sixty-three cases of dementia praecox which he -examined, but does not advance the claim that this can be utilized -for diagnostic purposes. Walter and Krumbach[113] found an increased -pressure in sixty per cent of normal control cases and obtained similar -reactions in dementia praecox. Schmidt, on the other hand, confirmed -the findings of Neubürger. Emerson[114] found status lymphaticus in over -twenty-nine per cent of his cases of dementia praecox and Davis[115] -found the same condition in twenty-four per cent of war neuroses in -a series of over one hundred cases. These findings, however, lack -confirmation by other observers. Straus[116] includes as mental -symptoms in thyroidal disbalance: sluggish mental reactions alternating -with sparkling wit, irritability, general moodiness and depression, -difficulty in thought with inability to concentrate, forgetfulness, -fatigability and somnolence. - -Turro[117] has shown that all of the physical evidences of -fright—pallor, dilatation of the pupils, rapid pulse, cutis anserinus, -perspiration, etc., can be produced experimentally by the injection of -epinephrin in certain cases. Knauer and Billigheimer[118] have called -attention to the striking similarity between the functional changes -to be found in disturbances of the vegetative (sympathetic) nervous -system and certain manifestations associated with fear neuroses. They -attribute these disturbances to congenital inferiority, toxic sources, -emotional shock or fatigue. - -A uniform defective development of the physical and mental personality -of the individual has been designated by Lasègue as infantilismus. -As described by Di Gaspero and de Sanctis the mental status of these -cases belongs to the domain of feeblemindedness and in some instances -to imbecility. According to Kraepelin[119] the attention is easily -attracted and as easily distracted. These individuals are inquisitive -and flighty. Apprehension is defective. What they hear and see can only -be related in a fragmentary and unreliable manner. They often learn -readily and forget as quickly. Pende described the mental development -as only one-third of the normal. Memory gaps are supplied by -exaggeration and fabrication, as influenced by emotion or suggestion. -Di Gaspero found falsification of memory in twenty per cent of -his cases. Imagination is very active with a tendency to dreamlike -unrealities, wonderful tales of adventure, etc. Mental processes are -inadequate, vague and uncertain. The real and the unreal are not -clearly differentiated. Explanations and descriptions are inaccurate -and indefinite. Standards of value, size or time are vague. The store -of ideas is impoverished and associations are poor. Calculations -are slow and faulty. These persons are illogical, impractical and -credulous. They are swayed by prejudices, catchwords and hasty -judgment. Their range of thought is narrow and their viewpoint of life -childish. The emotional and volitional content is immature. They are -cheerful but lack earnestness, and are often ambitious and boastful. At -other times they are likely to be despondent, timid, anxious, fearful -and lacking in self-confidence. The mood is exceedingly variable. They -are not industrious, cannot apply themselves constantly to any line of -work, and tire easily. Their conduct is very uncertain and unreliable. -Some have criminal tendencies. Occasionally hysterical symptoms appear. -Evidences of an absence of physical development manifest themselves -in all varieties of immaturity. These defects, according to Falta, -are shown especially in the genitalia and the lymphatic apparatus, -with a delay in the closure of the epiphysis and the retention of a -childish physique generally. The skeletal framework shows a failure of -development, the lower length of the body exceeds the upper slightly, -if at all, the head is relatively large, the bones slender and the -pelvis infantile in type. The sexual organs and the "vita sexualis" -are those of a child. The blood shows a large lymphocyte count and a -definite status lymphaticus is sometimes found to be present. The hairy -development of the pubis and axillary surface is slight. The internal -organs are normal. True infantilism, according to Falta, is not due to -a glandular disturbance. He also maintains that the mind, while that of -a child, is normal otherwise and shows no defects. Juvenile myxedema, -hypophysial dystrophy and eunuchoidism, Falta would not include with -the infantilismus group. Infantilism has been ascribed to syphilis, -tuberculosis, alcoholism, etc., of the parents. Brissaud in 1907 -advanced the theory that it was a hypothyroid symptom. His views have -been supported by various other writers, although not shared by either -Falta or Kraepelin. The latter has also described mental conditions -more or less suggesting feeblemindedness and associated with lesions of -the hypophysis, the pineal gland, the adrenals, the sexual glands and -the thymus. - -Lesions in the anterior lobe of the pituitary result in gigantism or -acromegaly, with a childish mentality most marked in the emotional -sphere. These persons are usually indifferent, good-natured and -boastful, and at the same time clumsy and inactive. A diminished -activity of the glandular portion of the hypophysis means dwarfism. -Lesions of the posterior or "nervous" lobe may cause "dystrophia -adiposo genitalis," the "adipositas dolorosa" of Dercum. The mental -status in this condition Kraepelin compares to that described in -acromegaly—apathy and indifference, with occasional restless or -excited types. The intellectual capacity may be normal, mediocre or -somewhat deficient. - -The pineal gland is spoken of as having a very definite relation to -sexual development. Extirpation is said to lead to rapid development -of the body, the accumulation of fat and early sexual development,—a -condition described by Pellizzi as "makro-genitosomia praecoce." -Schüller in fifty-one cases with pineal involvements found ten -occurring during the first decade of life. Death usually takes -place within a few months or years. Similar conditions result from -hyperactivity of the adrenal cortex,—rapid development of the body, -and particularly of the sexual organs, obesity and overgrowth of the -hair and beard. Wiesel described as a "suprarenal genital symptom -complex" cases of pseudo-hermaphrodism in women. - -Lesions of the adrenal, as studies of Addison's disease show, have, -according to Kraepelin,[120] the following symptoms: weakness of memory, -apathy, dulness, inactivity and inhibition of growth. He also calls -attention to the fact that in anencephaly, hemicephaly and microcephaly -defective development of the adrenals is very common. "Eunuchoidismus" -and "viriginität" with mental symptoms due to defective development of -the sex glands are also described. The physical manifestations include -defective secondary sexual characteristics, in men in the growth of -the beard and change of the voice, and in women in the development -of the mammary glands, the fat deposits and the curve of the hips. -There is a failure of sexual development and absence of menses, as -well as defective physical growth. Eunuchoidismus may manifest itself -in a giantism somewhat suggesting that resulting from lesions of the -pituitary or in a dwarflike physical development. The former variety -is characterized by an unusual height with long arms and legs. The -forehead is receding, with a low hair line. The external genitals are -very small and there is little pubic or axillary hair. Ossification is -delayed. In the second form (dwarfs) the body, arms and legs are short -and thick. The head is large and the neck short. The genitals are small -and the penis is short and button-shaped. Hair formation is slight. The -mental condition in either case is characterized by an intellectual -defect with timidity, emotional instability, helplessness and weakness -of will, sometimes with an active imagination. Kraepelin also describes -endocrine conditions resulting from thymic lesions—thymic idiocy, -status thymolymphaticus—and mentions the pancreatic infantilismus -referred to by Brownell, Basedow's disease, acromegaly, pluriglandular -insufficiency and other conditions already mentioned. Kraepelin has -encountered only seven "dysadenoid" forms in a study of 244 cases. -Bourneville has reported 104 cases of persistent thymus. - -One of the most interesting contributions to the literature of -endocrinology is Mott's[121] suggestion that dementia praecox is due -to a combination of degenerative changes in the cortical neurones and -the generative organs. As a result of the study of twenty-two cases of -dementia praecox he found that more marked pathological changes were -found in the testes than were observed in cases of manic-depressive -insanity, alcoholic psychoses, epilepsy or paranoia. The characteristic -findings consisted in regressive changes in the seminal tubules and -abnormal staining reactions in the spermatozoa. He found more evidences -of virility in a senile individual of eighty than in any of his cases -of dementia praecox. His theory as to the pathogenesis of the disease -is based on the fact that the changes in the neurones are of the same -character—a degeneration of the nuclear elements. These findings have -not at this time been confirmed by other observers. - -Timme[122] has described a psychic makeup due to subinvolution of the -thymus. "The mental picture presented by these subinvoluted thymic -states is also of great importance, for analogous to their structural -lack of differentiation is their psychic makeup. They remain child-like -in their character, so that they are self-centered; simple in their -mental processes and imitative; looking for protection and care, and -more or less unfitted for the active struggles of life. They are -obstinate and negativistic; if, however, an efficient compensation -takes place, then, although the mental development may have been -delayed, it nevertheless seems finally to reach complete maturity; and -these individuals are among the brightest and most intelligent of their -community." In cases of precocious involution of the thymus he finds -the mental condition to be of chief interest. "They are precocious, -with much initiative, are easily aroused to anger and are resentful. -They have cruel instincts and show little inhibition. Although they -seem far advanced for their years while still young, yet they never -seem thoroughly to mature, and become blocked in early adolescence. -They seem to retain their impulsive, unreasoning characteristics, brook -no restraint and remain constantly a prey to their easily aroused -anger." Of thyroid insufficiency he says: "Mentally, the patient is -dull, sluggish and with little initiative. He moves slowly and thinks -slowly, is extremely forgetful and his lethargy is occasionally -disturbed by outbursts of anger due probably to his maladjustment -to the more quickly moving world about him." In his summary of the -hyperthyroid makeup, Timme says: "Both mind and body are everlastingly -busy. And not only with present problems, but anticipatory of -tomorrow's as well. The patient shows no rest or relaxation. His mind, -filled with echoes of the day's troubles, prevents his falling to sleep -until long after he retires, and he is again awake and immediately on -the "qui vive" as soon as daylight comes." Statistics on endocrine -conditions are unfortunately not available as yet. - - - - -CHAPTER XIII - -THE MODERN PROGRESS OF PSYCHIATRY - - -The remarkable accomplishments of medical science during the last -few decades may be looked upon as a fairly accurate index of modern -progress in general. Nor have these advances been confined to any -limited field. Standards of education have changed with almost -startling rapidity. The most extended course of instruction open -to medical students fifty or sixty years ago covered a period of -two years. Qualifications for entrance consisted in little more -than a demonstration of the candidate's ability to pay the required -matriculation fee. The three year course, only recently established -and generally recognized, was lengthened to four years during the -latter part of the nineteenth century. The number of medical colleges -has been materially reduced and the size of the graduating classes has -decreased fifty per cent or more during the last twenty-five years -as a result of the higher standards. Several of our medical schools -admit college graduates only and two years of college work is now a -minimum entrance requirement in institutions of the highest type. -Very few men feel properly equipped for taking up the practice of -medicine today until they have had an experience of at least a year in -a general hospital. The profession is tending more and more towards -specialization and the old-fashioned general practitioner is now at a -considerable disadvantage. Ophthalmology has become almost an exact -science. Gynecologists, obstetricians, pediatrists, orthopedists, -laryngologists, neurologists and internists are looked upon as almost -indispensable in a community of any size. All of these specialists are -more or less dependent on the cooperation of a pathologist, who can do -nothing without a well equipped laboratory at his disposal. Surgery has -long been regarded as a specialty which required an extended training -as well as years of experience. - -The progress of modern medical science has been almost bewildering. It -has been a comparatively short time since the principles of antisepsis -and asepsis were established by Lister. The plasmodium of malaria was -described in 1880. It was not until 1882 that the tubercle bacillus was -discovered by Koch. Diphtheria was rendered an almost harmless disease -by the discovery of a specific antitoxin. The uncertainties relating -to the diagnosis of typhoid fever were entirely removed when the Widal -reaction came into general use. The Roentgen ray has revolutionized -surgery. The diagnostic and therapeutic use of tuberculin has been of -inestimable value to internal medicine. Schaudinn's discovery of the -treponema pallidum in 1905 cleared up one of the greatest scientific -mysteries of modern times. The introduction of salvarsan has added -a new and important chapter to our history of therapeutics. The -Wassermann reaction represents probably the most important diagnostic -discovery of the century. The recent studies of the so-called ductless -glands have opened up new and important fields of research which -promise to be far-reaching in their results. Social service, unknown -only a few years ago, is now an indispensable adjunct of the modern -hospital organization. Training schools for nurses have become highly -specialized educational institutions. - -What is to be said of the progress made in our knowledge of mental -diseases? Certainly much has been accomplished during the last -century. The earliest American contributor to this branch of medicine -was Benjamin Rush (1745-1813), professor in the Medical Department -of the University of Pennsylvania, member of the Continental -Congress, a signer of the Declaration of Independence and one time -physician-in-chief to the American armies. His "Medical Inquiries and -Observations into Diseases of the Mind," which appeared in 1812 was the -first publication of the kind in this country. It is interesting to -note that he condemned the misuse of mechanical restraint, advocated -hydrotherapy and recommended the appointment of instructors to -direct the employment and amusement of patients. Incidentally he was -the chairman of a committee appointed by the College of Physicians -of Philadelphia to memorialize Congress and the legislature of -Pennsylvania on the evils of alcoholism. Reference should also be made -to the fact that he opposed capital punishment, advocated the abolition -of slavery and objected to the study of the classics as a required -part of the college curriculum. He even favored woman suffrage. In -addition to his other activities this remarkable man was treasurer at -one time of the United States Mint, vice-president of the American -Bible Society, one of the founders of Dickinson College and associated -for many years with Franklin in the work of the American Philosophical -Society. Certainly he was many years in advance of his time. When -his work on "Diseases of the Mind" appeared, the word psychiatry was -unknown in this country. The term lunatic, which first appeared in -the English statutes in 1320, during the reign of Edward the Second, -was still in quite general use. The only state hospital for mental -diseases was the one at Williamsburg, Virginia. Such institutions were -universally known as asylums for many years. - -Insanity was generally discussed in the terminology of Pinel and -Esquirol as including mania, melancholia, dementia and idiocy. Those -not thoroughly familiar with the psychiatry of the past may not -understand the sense in which the word dementia was employed. It was -defined by Esquirol in the following terms: "There exists, therefore, -a form of mental alienation which is very distinct—in which the -disorder of the ideas, affections and determinations is characterized -by feebleness and by the abolition, more or less marked, of all the -sensitive, intellectual, and voluntary faculties. This is dementia." It -was looked upon usually as a terminal state following excitements or -depressions and in some rare instances as being primary in origin. - -There have been many important developments in psychiatry since the -days of Benjamin Rush. The mania, melancholia and dementia of the -eighteenth century have apparently gone for all time. The events of -the last hundred years include more particularly the delimitation and -complete differentiation of general paresis, the rise and fall of the -paranoia concept, the description of the traumatic psychoses, the -establishment of the alcoholic insanities as clinical entities, a study -of the mental diseases due to endogenous and exogenous toxins, the -recognition of the neuroses and psychoneuroses in their modern sense, -the addition of the psychopathic personalities to our classification -and the definition of manic-depressive insanity, dementia praecox and -involutional melancholia. The mental states due to somatic conditions -have been exhaustively studied and the psychoses associated with -epilepsy and pellagra have been fully investigated. Psychology and -psychiatry have been definitely correlated and pathological research -placed upon a firm foundation. The psychiatric phraseology of today -would have been practically meaningless to the students of Pinel. -Curiously enough the word psychiatry, which goes back to nearly 1800 in -the literature of Germany and Italy has only been used for a few years -in this country and England. The word psychosis is of even more recent -origin. - -This modern era may be said to have been ushered in by the preliminary -studies made of general paresis by Haslam in 1798. These were -followed by the researches of Bayle, Delaye and finally Calmeil, -which definitely established the integrity of that disease as a -clinical entity. Even then its specific origin was only a matter of -conjecture. When Esmarch and Jessen suggested that general paresis -was a syphilitic disease in 1857, their views were rejected by men as -prominent as Charcot and Déjerine. Although paranoia is a term which -has appeared in the literature of medicine for centuries, it has only -had the significance now attached to it since the latter part of the -nineteenth century. Its description was foreshadowed perhaps by the -monomania of Esquirol and Pritchard and the partial insanity of Rush -and others. Heinroth, Griesinger, Magnan, Lasègue, Régis, Falret, -Mendel, Krafft-Ebing, Herz, Snell, Werner, Schüle, Ziehen, Kraepelin -and many other well-known psychiatrists have played a part in the -evolution of paranoia which only definitely displaced the wahnsinn, -verrüchtheit, and various other designations of the earlier writers, -in the neighborhood of 1890. Paranoia is a term which has only been -infrequently used since the general acceptance of Kraepelin's paranoid -forms of dementia praecox. Its territory has been still further invaded -by paraphrenia, the fate of which, however, is somewhat uncertain as -yet. The forerunners of the psychopathic personalities were the moral -insanity of Pritchard, the insanity of degeneracy of Morel, Magnan, -Régis, Lombroso, etc., and the "demifous et demiresponsables" of -Grasset, Trélat and others. The introduction of the "constitutional -inferiority" idea into the psychiatry of this country was directly -attributable to Adolf Meyer following the work of Koch in Germany. -After the elaborate study of alcoholism made by Magnus Huss in 1852 the -psychoses due to that condition were described by Bonhöffer, Magnan, -Korsakow, Kraepelin and various other writers. The psychoneuroses -represent the developments of Brachet, who wrote on hysteria in 1847, -Briquet, Oppenheim, Lasègue, Möbius, Charcot, Janet, Babinski, Beard, -Kraepelin and many others. To Meyer again we are indebted for the -first exhaustive study and classification of the traumatic psychoses. -The description of amentia by Meynert in 1881 was of considerable -significance. The first comprehensive study of mental disorders -associated with the use of cocaine was made by Erlenmeyer in 1886. The -same writer was responsible for the first elaborate investigation of -morphinism in the year following. Circular insanity was described by -Falret in 1851 and again as "folie à double forme" by Baillarger in -1854. Hecker was responsible for an event of great importance in the -history of psychiatry when he published his description of hebephrenia -in 1871. Kahlbaum in his "Katatonia" made a contribution which was -destined to influence the future of medicine in 1874. - -In the meanwhile what is to be said as to the progress of pathological -research? The earliest contribution to psychiatry from that point of -view was made by Morgagni in 1761, his opinions being based on the -autopsy reports in some thirteen cases. Greding in 1790 published the -results of autopsies in a series of thirty-seven cases. The findings -at that time included variations in the thickness of the skull, -adhesions and thickenings of the dura, changes in the consistency of -the cerebrum and cerebellum, effusions into the ventricles and various -gross defects. The early writers attached a great deal of importance -to the pineal gland changes. These pathological conditions were so -generally reported, that Portal in the eighteenth century went so far -as to say that "Morbid alteration in the brain or spinal marrow has -been so constantly observed, that I should greatly prefer to doubt the -sufficiency of my senses, if I should not at any time discover any -morbid change in the brain, than to believe that mental disease could -exist without any physical disorder in this viscus, or in one or other -of its appurtenances." Pinel spoke very discouragingly, however, of the -results and Esquirol finally reached the conclusion that nothing really -important had been accomplished after all. In his Charenton reports -(1835) he expressed himself on this subject as follows:—"However -important may have been the researches of anatomists made during our -days into diseases which affect the mind, we may venture to repeat -that pathological anatomy is yet silent as to the seat of madness, -and that it has not yet demonstrated what is the precise alteration -in the encephalon which gives rise to this disease. What shall we, -then, think of the rash pretensions of those who assume that they can -fix upon the diseased portion of the brain, judging merely from the -character of the disease?" In 1836 Guislain summarized the various -lesions found in insanity at autopsy under nine headings—congestion of -the brain or meninges or both, serous congestion of the same, cerebral -softening, adhesions of the membranes to each other or to the brain, -cerebral induration, cerebral hypertrophy, and abnormalities of the -brain or skull. The appointment of a pathologist at the Utica State -Hospital in 1868 as a result of the remarkable interest taken in this -subject by Dr. John P. Gray must be looked upon as one of the important -events in the history of American psychiatry. The later developments of -the nineteenth century included studies of general paresis, cerebral -syphilis, arteriosclerosis, senility, epilepsy, mental deficiency, -pellagra and various other somatic conditions. It may fairly be said, -at least, that pathology has kept fully abreast of the progress made by -clinical psychiatry during the nineteenth century. - -Notwithstanding all of these advances, the generally recognized mental -diseases, as late as 1895, included the following types:—mania, -melancholia, dementia, imbecility, idiocy, general paresis, chronic -delusional insanity or paranoia and senile insanity. This was in -substance the psychiatry of Savage, Maudsley, Clouston, Blandfield, -Régis, Chapin, Kellogg, Spitzka, Kirchoff, Berkley and many other -well-known writers of a comparatively recent date. A new era in the -history of mental medicine was ushered in by Kraepelin when the sixth -edition of his "Psychiatrie" appeared in 1899. This established -manic-depressive insanity and dementia praecox as clinical entities. -Kraepelin called attention to the fact that excitements and depressions -frequently recur in the same individual, often with frequent attacks -but with no marked tendency towards mental enfeeblement. This class of -cases he grouped together as manic-depressive psychoses and pointed -out certain characteristics common to the excitements and depressions -included. He showed that certain other forms of depression marked -by anxiety, fear, restlessness, self-accusation, marked suicidal -tendencies, etc., were common to the involutional period of life. -To this anxious depression the name involution melancholia has been -applied, although Kraepelin is now somewhat in doubt as to its -differentiation from the manic-depressive group. To certain other -cases characterized by emotional dulness, apathy, hallucinations with -phantastic delusions, and in some types, mannerisms, negativism, -stereotypy, verbigeration, etc., tending sooner or later towards -deterioration, he attached the name dementia praecox. This included the -hebephrenia of Hecker and the katatonia of Kahlbaum. - -Wernicke in 1906 advanced the hypothesis that psychical symptoms may -be attributed to disturbances of various association mechanisms. These -interruptions were to be found in various parts of the psychical -reflex arcs. This included the psychosensory tracts or receptive -mechanisms, the intrapsychical tracts or elaboration mechanisms and the -psychomotor mechanisms. Manic-depressive psychoses were looked upon as -representing a disorder of the intrapsychic mechanism, while dementia -praecox was considered to be an illustration of a disturbance of the -psychomotor mechanisms. This was an exceedingly interesting but purely -theoretical scheme for putting psychiatry on a definite anatomical and -pathological basis. - -The progress made by Kraepelin, Stransky, Wernicke, Bleuler, Ziehen -and other modern psychiaters led to renewed interest in pathological -research. This was to a considerable extent due to the suggestion -of Kraepelin that dementia praecox was autotoxic and endogenous in -origin. The neurons were exhaustively studied by Alzheimer and changes -in metabolism thoroughly investigated by Folin and many others. To -the researches of Nissl and Alzheimer in 1904 we are largely indebted -for an accurate knowledge of general paresis. Studies of the cortex -in dementia praecox by Alzheimer and many others have been extremely -interesting if not conclusive. The introduction of lumbar puncture -by Quincke and the studies of the cerebrospinal fluid made by Widal, -Plaut, Nonne, Mott and others were of great aid in diagnostic -procedure. These have been supplemented by the Wassermann reaction, the -colloidal gold test, etc. The isolation of the treponema pallidum in -the cortex settled the question of the identity of general paresis and -cerebral syphilis for all time. - -Another line of research responsible in no small measure for the -remarkable progress of psychiatry during the last few decades was -that instituted by Freud, Jung and others in their studies of -psychological mechanisms. It is a rather remarkable fact that it is -only in comparatively recent years that a study of the psychological -processes of the normal mind has been looked upon as essential to an -understanding of the mental reactions involved in the development of a -psychoneurosis or psychosis. This is really the basis of Freud's work. - -Psychiatry may be said to be practically the only branch of medical -science in which a study of pathological processes has not been based -largely upon physiological and anatomical foundations. Our textbooks -for many years have insisted that "insanity" was a disease of the -brain but have not given much consideration to a correlation of the -physiology with the pathology of that organ. The application of -psychological methods to psychiatric research was largely a result -of the studies of hysteria by Janet. This was supplemented by the -important contribution of Breuer and Freud in 1895 calling attention -to their theories in regard to the production of the psychoneuroses -by psychic traumas, usually of a sexual nature. Freud's views -were outlined more fully in his "Selected Papers on Hysteria," -"Three Contributions to the Sexual Theory," and his studies of the -"Psychopathology of Everyday Life," etc. The psychological processes of -dementia praecox and paranoia were subjected to elaborate studies by -Freud, Jung and various other authors. - -The relation existing between psychology and psychiatry has been placed -on a very practical basis by the studies of shell shock and other -hysterical conditions so important during the recent war. Probably -nothing will contribute more towards a recognition of the importance -of psychiatry than the discovery made early in the war that mental -diseases and defects were responsible for more disabilities than were -attributable to almost any other single cause. Certainly the inactivity -of many years has been followed by an awakening which has placed modern -psychiatry on a dignified plane and its progress will now compare -favorably with the accomplishments of any other branch of medicine. -The statement is, I think, justified, that psychiatry has been -established on a thoroughly scientific basis as the result of the work -of comparatively few years. We have, however, reached a stage where -careful analyses should be made of the clinical data upon which future -progress entirely depends. - -A brief consideration of existing conditions should be sufficient to -show this conclusively. Psychiatric literature is, and for many years -has been, characterized largely by an unfortunate absence of accurate -scientific information which would warrant the conclusions reached in -many instances by the authors of our textbooks. We have been subjected -to an avalanche of theories and a remarkable paucity of facts. In the -discussion of abstract propositions where concrete evidence is not -obtainable this is of course unavoidable. There has, however, been a -very noticeable oversight of many facts which the wealth of clinical -material in our hospitals has placed at our disposal. Our literature -has been filled with too many unsubstantiated statements. There is -no reason why many of the views entertained by various authorities -should be matters of personal opinion or based entirely on individual -observation. The fact that there are over two hundred thousand cases -of mental disease in the state hospitals of this country, with an -admission rate of sixty thousand annually, is sufficient evidence to -justify the statement that there is no lack of material for accurate -studies. - -A brief reference to some of the discrepancies shown in a consideration -of the various psychoses will serve to illustrate the need of more -accurate information on many of these subjects. In discussing the -predisposing causes of mental diseases, for instance, White[123] made -the following statement, which is perfectly correct: "An inherited -predisposition to mental disorder is found in from 30 to 90 per cent -of cases according to different authorities, while the average for all -conditions has been estimated at from 60 to 70 per cent." Information -on this subject is certainly far from being complete or satisfactory. -The Thirty-first annual report of the State Hospital Commission shows -that of 4,492 first admissions to the New York hospitals during the -year ending June 30, 1919, 2,003, or 44.6 per cent, were reported as -having a family history of insanity, nervous diseases, alcoholism or -other neuropathic taint. As far as could be determined 55.4 per cent -showed no evidence of heredity in their family history. The necessity -of further information on this important subject would appear to be -obvious. The question as to the relation between syphilis and general -paresis may be said to have been definitely settled for all time. The -origin of this disease has, however, been the subject of controversy -since 1857. Paton[124] in a review of this discussion in 1905 states -that Gudden found a history of syphilis in 35.7 per cent of his cases, -Hirsch, in fifty-six per cent, Jolly, in sixty-nine, Mendel, in -seventy-five, and Alzheimer, in ninety per cent. In the light of our -present knowledge this difference of opinion and experience is quite -interesting and illuminating. - -The most extravagant and misleading statements made about etiological -factors, perhaps, are those which relate to the alcoholic psychoses. -This was due largely to the statements of enthusiastic propagandists -who were advocating prohibitory legislation. The facts of the matter -are that when the use of liquor was unrestricted, the admission rate of -alcoholic psychoses, as shown by the New York state hospital reports, -had averaged ten per cent for a number of years (1908 to 1913). - -Frequent contributions have been made from time to time to the -literature of psychiatry on the subject of dementia praecox. Voluminous -articles have been written on its pathology, psychological mechanisms, -etiology, etc. Many of the theories advanced are not in harmony with -what little definite information we possess. Many of the theses on -this subject have been based on the study of a surprisingly small -number of cases. The statement has been made[125] that attacks either -of a syncopal or epileptic nature are among the most important -physical symptoms of dementia praecox, and "occur in about eighteen -per cent of the cases." In his eighth edition Kraepelin speaks of -convulsive attacks of various sorts in sixteen per cent of all cases -of dementia praecox, and says that they also occur in a few cases of -manic-depressive insanity. These findings are certainly not consistent -with those of other observers. In a review of eight hundred cases, five -hundred of dementia praecox, one hundred and eighty of manic-depressive -insanity and sixty in each of the "allied to" groups, Simon[126] found -convulsions in less than one per cent of the total number of cases in -which epilepsy or organic conditions could be definitely excluded. In -a study of 367 cases of dementia praecox Ullman[127] found convulsive -manifestations in 2.7 per cent of the total. He also reported seizures -in 1.4 per cent of 340 cases of manic-depressive insanity. Kraepelin -formerly held that recovery was to be expected in about eight per cent -of the cases of hebephrenic dementia praecox and thirteen per cent of -the cases of katatonia (seventh edition). Notwithstanding this, he says -in his eighth edition in one place:[128] "Further investigations of a -series of observations carried on extensively and carefully for decades -must show how far the view, which is gaining in probability for myself, -is correct, that permanent and complete recoveries of dementia praecox, -though they may perhaps occur, still in any event belong to the -rarities." As Kraepelin himself suggests, the widely varying views on -this subject are due to different conceptions as to what constitutes -dementia praecox and what is to be considered a cure. Certainly we -are in need of further information. On June 30, 1918, there were -37,352 patients in the state hospitals of New York.[129] Twenty-one -thousand nine hundred and two cases were diagnosed as dementia -praecox. Fifty-four of these were discharged as recovered during the -year. This represents 3.2 per cent of the 1,687 cases discharged as -recovered, 2.8 per cent of the 1,883 cases of dementia praecox admitted -during that period (first admissions) and .2 per cent of the 21,902 -cases of dementia praecox in the hospitals. The reports of the State -Psychopathic Hospital at the University of Michigan show 1.19 per cent -of recoveries in the cases of dementia praecox discharged during a -period of eleven years. Reference is made to these discrepancies not -in any spirit of criticism but for the purpose of pointing out the -necessity of utilizing such facts as may be available. - -There is nothing new about this suggestion. It was strenuously -advocated by Louis, the founder of one of the greatest French schools -of medicine many years ago. This was referred to by his pupil and -admirer, Oliver Wendell Holmes, in his farewell address to the Harvard -Medical School in 1882 in the following words: "The 'numerical -system,' of which Louis was the greatest advocate, if not the absolute -originator, was an attempt to substitute series of carefully recorded -facts, rigidly counted and closely compared, for those never-ending -records of vague, unverifiable conclusions with which the classics of -the healing art were overloaded. The history of practical medicine had -been like the story of Danaides. 'Experience' had been, from time -immemorial, pouring its flowing treasures into buckets full of holes." - -A determined effort has been made by the American Psychiatric -Association to correlate the activities of the various state hospitals -for mental diseases and utilize the great wealth of clinical material -within the walls of these institutions for such studies as may promote -the advancement of psychiatry. With this end in view a committee was -appointed at the annual meeting at Niagara Falls in 1913 to formulate -a plan for the compilation of statistical data relating to mental -diseases. The conclusions reached by this committee are illustrated -by the following quotation from their report in 1917: "That the -statistical data annually compiled by the various institutions for -the insane throughout the country should be uniform in plan and scope -is no longer open to question. The lack of such uniformity makes it -absolutely impossible at the present time to collect comparative -statistics concerning mental diseases in different states and -countries, and extremely difficult to secure comparative data relative -to movement of patients, administration and cost of maintenance and -additions. The importance and need of some system whereby uniformity in -reports would be secured have been repeatedly emphasized by officers -and members of this Association, by statisticians of the United -States Census Bureau, by editors of psychiatric journals, and by -administrative officials in various states. We should know accurately -the forms of mental disease occurring in all parts of the country; we -should know the movement of patients in every hospital for the insane; -we should know the cost of maintenance of patients and the amounts -spent for additions and improvements in every state hospital; we should -be able to compile annually complete data concerning these and other -matters, and compute rates and draw comparisons therefrom. Such data -would serve as the basis for constructive work in raising the standard -of care of the insane, as a guide for preventive effort, and as an aid -to the progress of psychiatry." - -A permanent committee on statistics has been maintained by the -Association since 1913. The following statistical tables were -officially adopted some years ago and are now in general use: 1. -General information; 2. Financial statement; 3. Movement of patients; -4. Nativity and parentage of first admissions; 5. Citizenship of -first admissions; 6. Psychoses of first admissions, types as well as -principal psychoses to be designated; 7. Race of first admissions -classified with reference to principal psychoses; 8. Age of first -admissions classified with reference to principal psychoses; 9. -Degree of education of first admissions classified with reference to -principal psychoses; 10. Environment of first admissions classified -with reference to principal psychoses; 11. Economic condition of first -admissions classified with reference to principal psychoses; 12. Use -of alcohol by first admissions classified with reference to principal -psychoses; 13. Marital condition of first admissions classified with -reference to principal psychoses; 14. Psychoses of readmissions, types -as well as principal psychoses to be designated; 15. Discharges of -patients classified with reference to principal psychoses and condition -on discharge; 16. Causes of death of patients classified with reference -to principal psychoses; 17. Age of patients at time of death classified -with reference to principal psychoses; 18. Duration of hospital life -of patients dying in hospital, classified with reference to principal -psychoses. - -An elaborate statistical manual fully explaining the use of these -tables has been furnished to the psychiatric hospitals of the country -by the Association. Since this work has been undertaken the full -cooperation of the institutions of the following states has been -assured: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, -Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, -Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, -Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New -Hampshire, New Jersey, New Mexico, New York, North Carolina, North -Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South -Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, -Washington, West Virginia, Wisconsin and Wyoming, and the District of -Columbia. Practically every state hospital in the United States is -now officially represented in this important movement. The success of -this undertaking has been largely due to the active cooperation of the -National Committee for Mental Hygiene through its Bureau of Statistics. -It should receive the enthusiastic support of all who are interested in -the future progress of modern psychiatry. - - - - -CHAPTER XIV - -THE CLASSIFICATION OF MENTAL DISEASES - - -When the American Psychiatric Association first approached the problem -of formulating a definite scheme for the collection of statistical -data relating to mental diseases it was immediately confronted with -the necessity of adopting an official classification of psychoses -purely for purposes of uniformity. This undertaking, which suggested -no difficulties at the outset, led to all kinds of unexpected -complications and embarrassments. Classifications of "insanity" are -almost as old as the terms mania and melancholia and have been given a -grossly exaggerated importance by the space which for so many years has -been devoted to a consideration of this subject in textbooks. This, if -nothing else, appears to have been demonstrated quite clearly by the -discussions of the last few years. - -A review of the literature of psychiatry shows that attempts to -classify the psychoses date back almost to the beginning of medical -history. Hippocrates is said to have recognized three forms of mental -disorders—mania, melancholia and dementia, although there is some -question as to his having used those terms in accordance with their -present significance. Celsus[130] also described three forms of -insanity. The first, which was accompanied by febrile symptoms, he -termed phrenitis. The second was characterized by sadness and caused by -black bile. The third was accompanied in some cases by false images, -while in others the whole mind or judgment was impaired. The Roman law -divided the dementes or mad into two classes, the excited or violent -(furiosi) and those deficient in intellect (menti capti). Aretaeus[131] -discussed mania, melancholia and dementia, apparently regarding them -as all manifestations of some one disease process. Melancholia, he -said, "does not affect all the faculties of the mind; the patients are -sad and dismayed; they are without fever." He described it as only -an initial stage of mania. Caelius Aurelianus[132] did not regard -melancholia as a form of insanity, "from which disease it differs in -that the stomach chiefly suffers, while in Madness it is the head." -Galen in his writings referred to amentia or dementia, imbecility, -mania and melancholia. - -In the sixteenth century Felix Plater[133] devised the following -classification: 1. Mentis imbecillitas: Hebetudo, tarditus, oblivio, -imprudentia. 2. Mentis consternatio: Somnus immodicus, carus, -lethargus, apoplexia, epilepsia, convulsio, catalepsis, ecstasis. -3. Mentis alienatio: Stultitas, temulentia, amor, melancholia, -hypochondriacus morbus, mania, hydrophobia, phrenitis, saltus viti. -4. Mentis defatigatio: Vigiles, insomnia. Linnaeus[134] in 1763 called -his fifth class of diseases Mentales, divided into three orders: -Ideales, Imaginarii and Pathetici. Sauvages in the same year included -Hallucinationes, Morositates and Deliria under the heading of Vesaniae -in his "Nosologia Methodica." Vogel[134] in 1764 divided Paranoiae -into mania, melancholia, and amentia. Cullen in 1772 included insanity -or the Vesaniae in the neuroses, divided into four groups—Amentia, -Melancholia, Mania and Oneirodinia. He described eight varieties of -melancholia and three of mania. Oneirodinia included somnambulism and -nightmare. According to Jelliffe, Plocquet described six varieties of -delirium in his treatise on paranoia in 1772. Pinel in 1791 limited -himself to four classes of insanity—mania, melancholia, dementia -and idiotism. He looked upon melancholia as a delirium exclusively -directed upon one object or series of objects and accompanied by -sadness. Idiotism was an advanced form of dementia. Esquirol in 1838 -modified Pinel's scheme somewhat and described Lypemania, Monomania, -Mania, Dementia and Imbecility or Idiocy. The active discussion of -classifications of various kinds led Pritchard[135] to make the -following interesting comment in 1822: "I cannot conceive anything -more preposterously absurd than the attempt to classify diseases with -all the divisions and technology of a botanical or zoological system, -and to force what is essentially disorder and confusion to assume the -appearance of that order and symmetry which nature displays in the -arrangement of the organized world. An aetiological classification -is the only mode of terminology and arrangement that can be of any -practical advantage, and that is all that we have to consult." -He nevertheless published a classification of his own which was -essentially psychological in principle, although containing nothing new. - -The German school of this time was exceedingly prolific in the -production of classifications, as will be shown by the following -interesting and elaborate scheme of Flemming's[136] published in 1844:— - - - FAMILY-AMENTIA—MENTAL DISEASES - - - _First Group_—Infirmitas (Feeblemindedness). - - Varieties: - - A. According to etiology: - 1. Inf. primaria, or congenita (Idiocy) - 2. Inf. secundaria, or acquisita (Imbecility) - a. Inf. e. morbo (Brain injuries, encephalitis, epilepsy, etc.) - b. Inf. senilis - - B. According to degree: - 1. Inf. adstricta, or partial feeblemindedness (Weakness of a single - mental faculty) - a. Dysmnesia (weakness of memory) - b. Inf. adstr. surdo-mutorum (feeblemindedness of the deaf and - dumb) - c. Inf. adstr. coecorum (feeblemindedness of the blind) - 2. Inf. sparsa—General (absolute or relative weakness of general - mental faculties) - - _Second Group_—Vesania. - _First Order_:—Dysthymodes or Dysthymia. - - Varieties: - - A. According to types: - 1. Dys. transitoria or subita (acute) - 2. Dys. continua (chronic) - 3. Dys. remittens (remittent) - - B. According to degree: - 1. Dys. adstricta (limited or partial) - a. Dys. atra (melancholia or lypemania) - 1. Homesickness. - 2. Ferocitas et morositas ebriosorum (Alcoholic excitement - and ill humor) - b. Dys. candida (cheerful dysthymia or melancholia hilaris) - c. Dys. mutabilis (changeable or alternating) - 2. Dys. sparsa (apathica)—General dysthymia (melancholia attonita). - - _Second Order_:—Vesania anoëtos or Anoësia—Deliria of various forms. - - Varieties: - - A. According to types: - 1. Anoësia transitoria or subita (acute) - Species: - a. A. e febre—fever delirium - b. A. e potu—alcoholism - c. A. ex affectu—affective - d. A. semisomnis—confusion of drunken sleep - e. A. Somnambula—somnambulism - 2. Anoësia continua—chronic - 3. Anoësia remittens—remittent. - - B. According to degree: - 1. Anoësia adstricta—partial or limited - a. A. ad sensationes—hallucinatory delirium - b. A. ad cogitationes—delusional delirium - 2. Anoësia sparsa—general - a. Delirium tremens - - _Third Order_:—Vesania Maniaca (Mania). - - Varieties: - - A. According to types: - 1. Mania transitoria or subita—acute - a. M. s. a febre—encephalitic delirium - b. M. s. a potu—alcoholic mania - c. M. s. ex affectu—affective mania - d. M. s. e partu—puerperal mania - e. M. s. e mordo occulto—amentia occulta, which includes the - above forms. - 2. Mania continua—chronic mania - 3. Mania remittens—remittent mania - - B. According to degree: - 1. Mania adstricta seu instinctiva—partial or limited mania. (Mania - sine delirio of Pinel.) (Moral insanity, monomania.) - 2. Mania sparsa—general mania. - - -This is said to have been based on Jacobi's somato-aetiological -theory (1830) that "there is no disease of the mind existing as -such, but that insanity exists solely as the consequence of disease, -either functional or organic, in some parts of the body system." -Heinroth[137] saw in the various mental disorders a disturbance of one -or the other of the normal functions of the mind which he divided into -three classes. "If the cause of derangement is in relation to one of -these manifestations of mental existence—and to one or another it -must belong, since the mind is ever occupied with phenomena related -to one out of the three classes—we have only to inquire to which -modification the disorder actually refers itself, or whether it affects -the feelings, the understanding, or the will. Since one of these has -possession of our consciousness, or is at least predominant at every -point of time, whichever function of the mind happens to be that which -is falling into disorder, by it the form of insanity is determined." -Griesinger[138] in 1845, on the other hand, was of the opinion that -all classifications must in the end return to the principal forms -previously described—mania, melancholia and dementia. In 1860 Morel -announced his well-known classification: Hereditary Insanity, which -included imbecility and idiocy; Toxic Insanity (alcohol, lead, mercury, -etc., as well as cretinism); Insanity produced by the transformation -of other diseases (hysterical, epileptic, hypochondriacal); Idiopathic -Insanity (general paresis, etc.); Sympathetic Insanity, and Dementia, -"a terminative state." - -Maudsley spoke of Affective or Pathetic, and Ideational Insanity. -The former was divided into maniacal perversion, melancholic -depression and moral alienation. The latter included general forms -(mania or melancholia), partial forms (monomania or melancholia), -dementia (primary and secondary), general paralysis and imbecility. -Régis described five forms of mania, five of melancholia, two of -insanity of double form, and a systematized progressive insanity. -In addition to these, he divided constitutional insanity into two -groups—the degeneracy of evolution and the degeneracy of involution. -Krafft-Ebing[139] included melancholia, mania, primary dementia, -exhaustion psychoses and terminal conditions in his group of -psychoneuroses. Under the heading of degenerative forms he described -constitutional affective insanity, paranoia and periodical insanity. -Neurasthenic, epileptic, hysterical and hypochondriacal psychoses were -grouped together under the constitutional neuroses. In addition to -this he described chronic intoxications, organic brain diseases and -arrested development. At a meeting of the International Congress of -Alienists in 1889 the following classification was adopted: 1. Mania; -2. Melancholia; 3. Periodical Insanity; 4. Progressive Systematical -Insanity; 5. Dementia; 6. Organic and Senile Dementia; 7. General -Paralysis; 8. Insane Neurosis (hysteria, epilepsy, hypochondriasis, -etc.); 9. Toxic Insanity; 10. Moral and Impulsive Insanity; and 11. -Idiocy. Ziehen[140] had a classification scheme which represented an -advance in some respects. Mania and melancholia were described as -affective psychoses, and paranoia as an intellectual disorder. He also -referred to mixed or combined forms. Imbecility, general paresis, -terminal deteriorations, etc., were grouped together under the general -heading of psychoses with intellectual defects. - -The British Medico-Psychological Association has had an official -classification for many years. This was quoted by Savage[141] in 1907 as -follows:— - - 1. Congenital or infantile mental deficiency (idiocy or imbecility) - occurring as early in life as it can be observed: - (1) Intellectual - a. Without epilepsy - b. With epilepsy - (2) Moral - 2. Insanity arising later in life: - (1) Insanity with epilepsy - (2) General paralysis of the insane - (3) Insanity with the grosser brain lesions - (4) Acute delirium (acute delirious mania) - (5) Confusional insanity - (6) Stupor - (7) Primary dementia - (8) Mania - a. Recent - b. Chronic - c. Recurrent - (9) Melancholia - a. Recent - b. Chronic - c. Recurrent - (10) Alternating Insanity - (11) Delusional Insanity - a. Systematized - b. Non-systematized - (12) Volitional Insanity - a. Impulse - b. Obsession - c. Doubt - (13) Moral Insanity - (14) Dementia - a. Secondary or terminal - b. Senile - -An elaborate classification was also officially adopted by the Royal -College of Physicians of England[142] about the same time. This -recognized seven varieties of mania, seven of melancholia and six of -dementia. The subject of classifications would not be complete without -a reference to Kraepelin. His eighth edition (1910-1915) showed the -following:— - - 1. Psychoses accompanying Injuries to the Brain: - Concussion - Traumatic delirium - Traumatic epilepsy - Traumatic enfeeblement - - 2. Psychoses accompanying Diseases of the Brain: - Meningitis - Brain tumors - Abscesses - Hemorrhages - Thrombosis - Embolism - Encephalitis - Multiple sclerosis - Lobar sclerosis - Huntington's chorea - Amaurotic idiocy - - 3. The Intoxication Psychoses: - Acute: - Endogenous—Uraemia, Eclampsia, Acute yellow atrophy of the liver. - Exogenous—Ether, Santonin, Hashish, Nitrous Oxide Gas, Atropin, - Hyoscin, Carbonic Oxide Gas, etc. - Chronic: - Alcohol: - Delusional (jealousy) - Delirium Tremens - Korsakow's Psychosis - Acute Hallucinosis (paranoid) - Alcoholic paralysis and pseudo-paralysis - Morphine - Cocaine - - 4. The Infectious Psychoses: - Fever delirium - Infection delirium - Acute confusion (amentia) - Infective exhaustive conditions - - 5. The Psychoses of Syphilis: - Syphilitic neurasthenia - Gummatous growths - Syphilitic pseudo-paralysis - Syphilitic apoplexy - Syphilitic epilepsy - Paranoid forms - Tabetic psychoses - Hereditary syphilis - - 6. Dementia Paralytica: - Paralytic, Depressive, Expansive and Agitated forms - - 7. The Senile and Presenile Psychoses: - Presenile psychoses - Arteriosclerotic psychoses - Senile deterioration - - 8. The Thyroigenous Psychoses: - Basedow's Disease - Myxoedema - Cretinism - - 9. The Endogenous Dementias: - Dementia praecox: - Dementia simplex - Hebephrenia - Depressive dementia - Circular form - Agitated form - Periodical form - Katatonia - Paranoid form - Schizophasia - Paraphrenia: - Systematica - Expansiva - Confabulans - Phantastica - - 10. The Epileptic Psychoses. - - 11. The Manic Depressive Psychoses: - Manic form - Depressive form - Mixed form - - 12. The Psychogenic Disorders: - Nervous exhaustion - Dread neurosis - The Induced psychoses - The psychoses of the Deaf - The Accident or Traumatic neuroses - The Psychogenic disorders of Prisoners - The Querulants - - 13. Hysteria - - 14. Paranoia - - 15. The Constitutional Disorders: - Nervousness - The Compulsion neuroses - The Impulsion neuroses - Sexual perversions - - 16. The Psychopathic Personalities: - The Excitable - The Unstable - The Impulsive - The Eccentric - The Liar and Swindler - The Antisocial - The Quarrelsome - - 17. Defective Mental Development (oligophrenia) - -At the annual meeting of the American Medico-Psychological Association -in 1869 Nichols called attention to the statistical studies proposed -by the International Congress of Alienists in 1867. As a result of -his efforts a series of twenty-one statistical tables was prepared -and used unofficially for several years, although never formally -adopted. A committee reported again on this subject in 1896, but -without any definite action being taken. The Italian psychiatrists have -had a classification which has been in general use by them for some -time. Interest in this subject has been stimulated by the frequent -publications of Kraepelin during the last thirty years. Meyer and Hoch -have been largely responsible for bringing his work to the attention -of the profession in this country, and Kraepelin's classification with -some modifications has come into very general use here. It was not -until the publication of its twenty-first annual report in 1909 that -the New York State Commission in Lunacy adopted a modern classification -of psychoses. - -At that time there were practically as many different forms of -statistical reports in the United States as there were hospitals. In -the meanwhile almost every textbook published during the last fifty -years has announced a new classification of mental diseases. They have -been based on etiology, pathology, symptomatology and psychology. -English, French, German, Italian and American classifications -have appeared, each representing, as a rule, different schools of -psychiatry. Kempf[143] would discard the term psychosis altogether -and speak only of neuroses as "more consistent with the integrative -functions of the nervous system." For diagnostic purposes he proposes -to separate the benign from the pernicious processes and classify them -according to their psychological mechanisms as suppression, repression, -compensatory, regression and dissociation neuroses. The easiest way -out of all these difficulties, as Southard[144] has said, would be "to -deny the existence of entities in mental disease. There are two forms -of this contention; first, that mental disease is nothing more or less -than insanity, an entity itself, a genus with but one species, or -secondly, that all victims of mental disease are individually to be -provided with entities, that is, all examples of mental disease are sui -generis. The development of psychiatry has killed the former contention -stone dead, but the latter contention still flourishes to an extent -among those who overstress the individual factor. And this latter -contention is bolstered up by the existence of so many psychopathic -patients of whom a diagnosis cannot be rendered for practical or -theoretical reasons. However, there are no really consistent advocates -of the sui generis plan of classification." It is interesting to -note that he concedes ... "that the American Medico-Psychological -Association's classification, adopted as it has been by a great number -of American institutions and by the United States Government for war -purposes, is a reasonably good classification and aware that its -constituent elements fairly well correspond with what all American -psychiatrists agree upon." - -Southard[145] raises the question as to how this classification can -be used for diagnostic purposes. He answers this query by suggesting -"A key to the practical grouping of mental diseases"[146] ... "to be -followed, when necessary, like a botanical key in the search for -the classification of a plant."... "It is a key to study and not an -analytical classification with any pretence to finality."... "The plan -is not so much an excursion into nosology as an essay in the technique -of psychiatric diagnosis for the tyro." - -The problem presenting itself in the adoption of a classification -purely for statistical purposes was not a question of a scientific -grouping of the psychoses based on either etiological, anatomical, -pathological, clinical or prognostic considerations. It was a question -of compiling a tabulation or list of clinical entities recognized -generally by American psychiatrists, subject to such changes and -modifications as may be necessary to make it conform to accepted -standards. As a matter of fact, no adequate reason for a classification -of mental diseases for any other than statistical purposes has even -been advanced by the authors of our textbooks on psychiatry. They -do not contribute anything of value whatever to our knowledge of -symptomatology, diagnosis or treatment. Practically the only point -on which the writers of our textbooks agree is that there is no one -fundamental principle upon which a satisfactory classification can be -based. It is unfortunate that tradition seems to demand the serious -consideration of a problem which many believe admits of no solution and -which would mean little or nothing to the future of psychiatry if it -were solved. The views of the Committee on Statistics are shown by a -quotation from the report made to the Association at its meeting in -New York in 1917:—"Your Committee feels that the first essential -of a uniform system of statistics in hospitals for the insane is a -generally recognized nomenclature of mental diseases. The present -condition with respect to the classification of mental diseases is -chaotic. Some states use no well-defined classification. In others the -classifications used are similar in many respects but differ enough -to prevent accurate comparisons. Some states have adopted a uniform -system, while others leave the matter entirely to the individual -hospitals. This condition of affairs discredits the science of -psychiatry and reflects unfavorably upon our Association, which should -serve as a correlating and standardizing agency for the whole country. -The large task of your Committee therefore has been the formulation of -a classification which it could unanimously recommend for adoption by -the Association. The task was accomplished only after several prolonged -conferences at which classifications now in use in various states -and countries, and the recommendations of leading psychiatrists were -considered. The classification finally adopted is simple, comprehensive -and complete; it copies no other classification but includes the strong -features of many others; it meets the demands of the best modern -psychiatry but does not slavishly follow any single system. In short, -your Committee has endeavored to formulate a classification that could -be easily used in every hospital for the insane in this country and -that would meet the scientific demands of the present day." - -Since the compilation of statistical data relating to the various -activities of the hospitals for mental diseases in this country was -definitely decided upon by the Association at its meeting in 1913, -the membership of the Committee on Statistics has from time to time -included the following:—Dr. Thomas W. Salmon, Medical Director, -National Committee for Mental Hygiene; Dr. Owen Copp, Physician in -Chief and Superintendent, Pennsylvania Hospital, Department for -Nervous and Mental Diseases; Dr. E. Stanley Abbot, Medical Director, -Public Charities Association of Pennsylvania; Dr. Henry A. Cotton, -Medical Director, New Jersey State Hospital, Trenton; Dr. L. Vernon -Briggs, Boston, former member of the Massachusetts State Board of -Insanity; Dr. Adolf Meyer, Professor of Psychiatry, Johns Hopkins -University; Dr. Albert M. Barrett, Professor of Psychiatry and -Neurology, University of Michigan; Dr. George H. Kirby, Director -of the Psychiatric Institute, New York City; Dr. Samuel T. Orton, -Professor of Psychiatry and Director of the Psychopathic Hospital, -University of Iowa; Dr. Frankwood E. Williams, Associate Medical -Director, National Committee for Mental Hygiene; Dr. Elmer E. Southard, -Director of the Massachusetts State Psychiatric Institute; Dr. C. -Macfie Campbell, Director of the Boston Psychopathic Hospital, and the -writer. Associated with the committee officially were: Dr. August Hoch, -formerly Director of the Psychiatric Institute, New York; Dr. H. M. -Pollock, Statistician of the New York State Hospital Commission; Miss -Edith M. Furbush, Statistician of the National Committee for Mental -Hygiene, and various others. - -The Association's classification of mental diseases at this time (1921) -is as follows: - - 1. Traumatic psychoses: - (a) Traumatic delirium - (b) Traumatic constitution - (c) Post-traumatic mental enfeeblement (dementia) - (d) Other types - 2. Senile psychoses: - (a) Simple deterioration - (b) Presbyophrenic type - (c) Delirious and confused types - (d) Depressed and agitated type - (e) Paranoid types (f) Pre-senile type (g) Other types - 3. Psychoses with cerebral arteriosclerosis - 4. General paralysis - 5. Psychoses with cerebral syphilis - 6. Psychoses with Huntington's chorea - 7. Psychoses with brain tumor - 8. Psychoses with other brain or nervous diseases: - (a) Cerebral embolism - (b) Paralysis agitans - (c) Meningitis, tubercular or other forms (to be specified) - (d) Multiple sclerosis - (e) Tabes dorsalis - (f) Acute chorea - (g) Other diseases (to be specified) - 9. Alcoholic psychoses: - (a) Pathological intoxication - (b) Delirium tremens - (c) Korsakow's psychosis - (d) Acute hallucinosis - (e) Chronic hallucinosis - (f) Acute paranoid type - (g) Chronic paranoid type - (h) Alcoholic deterioration - (i) Other types, acute or chronic - 10. Psychoses due to drugs and other exogenous toxins: - (a) Opium (and derivatives), cocaine, bromides, chloral, etc., alone - or combined (to be specified) - (b) Metals, as lead, arsenic, etc. (to be specified) - (c) Gases (to be specified) - (d) Other exogenous toxins (to be specified) - 11. Psychoses with pellagra - 12. Psychoses with other somatic diseases: - (a) Delirium with infectious diseases - (b) Post-infectious psychosis - (c) Exhaustion delirium - (d) Delirium of unknown origin - (e) Cardio-renal diseases - (f) Diseases of the ductless glands - (g) Other diseases or conditions (to be specified) - 13. Manic-depressive psychoses: - (a) Manic type - (b) Depressive type - (c) Stuporous type - (d) Mixed type - (e) Circular type - (f) Other types - 14. Involution melancholia - 15. Dementia praecox: - (a) Paranoid type - (b) Catatonic type - (c) Hebephrenic type - (d) Simple type - (e) Other types - 16. Paranoia or paranoid conditions - 17. Epileptic psychoses: - (a) Epileptic deterioration - (b) Epileptic clouded states - (c) Other epileptic types (to be specified) - 18. Psychoneuroses and neuroses: - (a) Hysterical type - (b) Psychasthenic type - (c) Neurasthenic type - (d) Anxiety neuroses - (e) Other types - 19. Psychoses with psychopathic personality - 20. Psychoses with mental deficiency - 21. Undiagnosed psychosis - 22. Without psychosis - (a) Epilepsy without psychosis - (b) Alcoholism without psychosis - (c) Drug addiction without psychosis - (d) Psychopathic personality without psychosis - (e) Mental deficiency without psychosis - (f) Others (to be specified) - - - - - PART II - - THE PSYCHOSES - - - - -CHAPTER I - -THE TRAUMATIC PSYCHOSES - - -Traumatic affections of the nervous system have been recognized in a -general way for centuries, although the psychoses resulting directly -from injuries have been given very little consideration or attention -in the past. Concussion of the brain, referred to in the writings of -Hippocrates, Galen and Celsus, was first studied postmortem in 1705 by -Littré. It is now discussed in all textbooks on surgery. Usually milder -forms are described with evidences of shock or collapse—a brief period -of unconsciousness, partial or complete, with visual and auditory -disturbances, dizziness, muscular relaxation or temporary paralysis, -respiratory symptoms, dilated pupils, weakness of the pulse, lowered -temperature, etc. Delirium and stupor or coma are associated with more -severe injuries. If the cortex is lacerated, twitchings or convulsions -often occur. Returning consciousness shows various reactions—headache, -vomiting, amnesia, etc., and may be succeeded by convulsions, -encephalitis or mental disturbances. DaCosta[147] says that some cases -are followed by a complete change in the personality, forgetfulness, -headache, insomnia, attacks of depression, lassitude and vertigo with -increased susceptibility to alcohol, heat and physical exertion. -Acute surgical injuries, and compression due to growths, hemorrhages, -fractures, etc., have been exhaustively studied. Compression has been -differentiated surgically[148] by the later appearance of a gradual -unconsciousness, more definite paralysis, usually on the side opposite the -injury, slow pulse and stertorous respirations, unequal immobile -pupils, choked disc, convulsive movements, etc. Traumatic encephalitis -and meningitis have long been recognized but present no definitely -characteristic symptoms which distinguish them from simple inflammatory -reactions. - -One of the earliest accurate descriptions of brain injury associated -with mental symptoms was that of the well-known "crowbar" case. It will -be recalled that while blasting in Vermont in 1848 a man by the name of -Gage had an iron bar driven through the frontal region of his skull, -making a complete recovery and living for over twelve years after -the accident. An autopsy showed that only the prefrontal cortex was -involved. A very interesting report on his mental condition was made by -Dr. John M. Harlow:[149] "His contractors, who regarded him as the most -efficient and capable foreman in their employ previous to his injury, -considered the change in his mind so marked that they could not give -him his place again. The equilibrium, or balance, so to speak, between -his intellectual faculties and animal propensities seems to have been -destroyed. He is fitful, irreverent, indulging at times in the grossest -profanity (which was not previously his custom), manifesting but little -deference for his fellows, impatient of restraint or advice when it -conflicts with his desires, at times pertinaciously obstinate yet -capricious and vacillating, devising many plans of future operations, -which are no sooner arranged than they are abandoned in turn for others -appearing more feasible. A child in his intellectual capacity and -manifestations, he had the animal passions of a strong man. Previous -to his injury, though untrained in the schools, he possessed a well -balanced mind, and was looked upon by those who knew him as a shrewd, -smart business man, very energetic and persistent in executing all his -plans of operation. In this regard his mind was radically changed, so -decidedly that his friends and acquaintances said he was 'no longer -Gage.'" - -Various other cases reported have established the fact that mental -deterioration usually follows extensive injuries to the frontal lobes. -Witmer[150] summarizes this as consisting of "slight intellectual -degradation, moral and emotional perversion, deficiency of attention, -and volitional inefficiency." - -A work by Ericksen in 1866 on "Railway Injuries to the Nervous -System" and Page's book in 1882 on "Injuries of the Spine" pointed -the way to an extensive study of the so-called traumatic neuroses. -This characterization of the functional disturbances of the nervous -system following injuries was apparently the result of a monograph by -Oppenheim on that subject in 1889. They had previously been considered -as purely organic in origin. Traumatic hysteria was discussed very -fully at various times by Charcot, whose work is so well known as to -require no comment. In 1892 Friedmann described a vasomotor complex -due to concussion. This is accompanied by such symptoms as headache, -dizziness, loss of capacity for both physical and mental work with -an increased fatigability, irritability, memory defects, and changes -in personality, such as sensitiveness and eccentricity with a marked -intolerance to alcohol. This condition appears some time after the -symptoms of concussion and shock have subsided and may last for some -months. Friedmann looked upon this as purely a vasomotor disturbance. -It is probably an important factor, in some cases at least, of -"shell shock". Traumatic epilepsy may result from foci of softening -or other local areas of injury to the brain. Neurasthenia, hysteria -and other neuroses are now generally looked upon as being essentially -functional and not organic in origin, although they may follow a -trauma. The simulation of these conditions has led to a great deal of -discussion, notwithstanding the fact that Oppenheim found them in only -about four per cent of his cases. Köppen (1897) made a very elaborate -study of the postmortem lesions in the "traumatic neuroses". He found -that violence to the skull often resulted in small injuries at the -base of the frontal area, at the apices of the parietal lobes or in -the occipital region. The pathological changes involved represented -localized encephalitis with hemorrhagic infiltration. Foci of softening -were often found in the cerebral cortex. He noted coma and convulsions -with only minute areas of destruction of the basal cortex at autopsy. -This would indicate a severe irritation, probably due to circulatory -disturbances. The resulting symptoms he thought were very likely to be -confused with general paresis. In cases of extreme dementia following -traumatism he often found no pathological lesion other than a cicatrix -in the cerebral cortex. - -One of the most important contributions to the literature of traumatism -as associated with psychoses was made by Adolf Meyer[151] in 1903. -Notwithstanding the statements of such observers as Savage, appearing -as late as 1905, he expressed the opinion that traumatism and general -paresis are not directly related except that injuries may rarely act as -precipitating factors. He does not expect to find psychoses resulting -from small lacerations or other similar lesions in the cortex. As a -result of his observations Meyer[152] described the following forms of -traumatic disorders:— - - 1. The direct post-traumatic deliria with the following subdivisions: - a. Preeminently febrile reactions; - b. The delirium nervosum of Dupuytren, not differing from deliria - after operations, injuries, etc.; - c. The delirium of slow evolution of coma, with or without alcoholic - basis; - d. Forms of protracted deliria, usually with numerous tabulations, - etc. (with or without alcoholic or senile basis). - - 2. The post-traumatic constitution: - a. Types with mere facilitation of reaction to alcohol, grippe, etc.; - b. Types with vasomotor neurosis; - c. Types with explosive diathesis; - d. Types with hysteroid or epileptoid episodes, with or without - convulsions (such as most reflex psychoses); - e. Types of paranoic development. - - 3. The traumatic defect conditions: - a. Primary defects allied to aphasia; - b. Secondary deterioration in connection with epilepsy; - c. Terminal deterioration due to progressive alterations of the - primarily injured parts, with or without arteriosclerosis. - - 4. Psychoses in which trauma is merely a contributing factor: - a. General paralysis, with or without traumatic stigmata; - b. Manic-depressive and other transitory psychoses, catatonic - deterioration and paranoic conditions, with or without traumatic - stigmata. - - 5. Traumatic psychoses from injury not directly affecting the head. - -The most interesting feature perhaps of this classification is the -post-traumatic constitution. Meyer[153] quotes Köppen's excellent -description of this condition as follows:—"Men who have suffered from -a cranial lesion in which there has been a severe damage of the brain, -with or without an injury to the cranial bones, on their recovery from -the immediate results complain especially of all kinds of sensations -in the head, which they describe either as pain or as pressure with -feeling of crawling or dullness of the head, more or less definitely -located at the point where they were hit. They frequently become -dizzy, and at times even faint for a short time without any epileptic -attack. Although slight attacks of dizziness may recur frequently, -epilepsy with typical attacks need not develop. There is further in our -patients a great irritability and nervosity. The formerly good-natured -or even-tempered persons become irascible, hard to get along with; -formerly conscientious fathers cease to care for their family. The -irritability at times increases to excessive violence in which actions -occur of which they have no remembrance; the nervous system is not only -under the influence of psychic irritation but especially susceptible -to the influence of alcohol or tobacco, in even small quantities. The -working capacity of our patients is very poor. It suffers variously, -although such individuals often give an impression of perfect capacity; -and since the morbid symptoms are essentially subjective, they always -arouse doubts whether they could not do something at least, even if -they are unable to work in a noisy shop or on a high scaffolding. It -is, however, certain that the patients are very forgetful; in giving -orders or doing errands they make the most incredible blunders; -frequently everything must be written down. Their capacity for thought -has suffered, as is sometimes shown, especially in the great slowness -of thought. These patients are unable to concentrate their attention, -not even in occupations which serve for mere entertainment, such as -reading or playing cards. They like best to brood unoccupied; even -conversation is rather obnoxious. This point is so characteristic that -it gives a certain means of distinction from simulation, which as a -rule does not interfere with taking part in the conversations and -pleasures of the ward and playing at cards, which means as a rule too -much of an effort for the brain of actual sufferers. The patients are -usually advised to take light physical work, but even there they are -perfectly useless. Excessive sensitiveness of their head obliges them -to avoid all work which is connected with sudden jerks, bending over is -especially troublesome; and there is hardly any physical work in which -this can be avoided; the blood rushes to the head, headache increases, -dizziness sets in and the work stops. Patients feel best when in the -open air, inactive and undisturbed. There are but few objective signs, -such as increase of pulse, flushing of the face, dermatographia, -trembling and uncertainty in the Romberg position, such as is shown -in all general nervosity. But the complaints are so exceedingly -uniform that the uniformity of the subjective complaints justifies the -conclusion that they are well founded. The picture thus is briefly -that of a mental weakness shown by easy fatigue, slowness of thought, -inability to keep impressions, irritability, and a great number of -unpleasant sensations, before all headaches and dizziness." - -It is exceedingly interesting to note that Schläger in discussing -disorders resulting from concussion of the brain, in 1857, as quoted by -Griesinger,[154] makes the following comment on these cases:—"Very often -the character and disposition changes; in 20 cases great irascibility, -an angry, passionate manner even to the most violent outbursts -of temper was remarked—less frequently over-estimation of self, -prodigality, restlessness, disquietude; in 14 cases there were attempts -at suicide, frequently weakness of memory, confusion." Meyer found, -furthermore, in his analysis "all the possible degrees of episodes -of more or less dazing and dream states; from a temporary dazed -feeling to episodes of hysteriform or epileptoid absences. Apart from -the subjective feeling of haziness, the characteristic trait is the -occurrence of complete dream interpretations and peculiar fabrications, -which color the primary traumatic insanity as well as the subacute and -episodic types, and even the paranoic type." - -Kraepelin[155] describes concussion and compression, traumatic -delirium, traumatic epilepsy and traumatic mental enfeeblement. He -finds these conditions due to concussion, compression or injury to -the brain substance either at the site of traumatism or at some -point opposite. There may be contusions, lacerations of the brain -tissue or hemorrhages, usually in the frontal, occipital or parietal -regions. Injuries to the cortex are not demonstrable in all cases. The -circulatory disturbances he considers an important factor and thinks -that they account for smaller lesions of the cerebral tissue in many -instances where no gross changes are apparent. More or less disturbance -of consciousness is to be expected in these conditions. The patient is -somewhat dull, drowsy, clumsy, forgetful and absentminded. Memory is -sometimes much affected. In more severe cases there is a complete loss -of consciousness which may last a few minutes only or be a matter of -hours or days. On waking, the patient is bewildered and confused, with -a marked disturbance of apprehension. Perception is involved as in the -recognition of complicated pictures or the understanding of long and -detailed statements. A clear comprehension of events and surroundings -is lacking. The patients may know that they are in a hospital without -knowing what hospital it is or why they are there and are unable to -recognize persons around them. Occasionally hallucinations of sight -or of hearing occur. At times delusional ideas are expressed, usually -of a depressive type. They have no realization whatever of their own -condition. The memory disturbance may take the form of a Korsakow's -complex. Memory gaps appear sometimes for events just before the -accident and in other cases cover long periods of time. While as a rule -events of the remote past are retained, recent impressions are quickly -lost. They cannot repeat what is read to them, do not remember -the names of persons about them, and sometimes show evidence of -falsification of memory with fabrication. All idea as to time is -usually lost. Mental reactions become noticeably difficult. The patient -is distractible, cannot count accurately, has difficulty in repeating -dates and numbers and forms no correct judgment as to his own personal -affairs. Many express themselves, however, on the other hand, with -great facility and readiness. Some show considerable fatigability. -The mood is often elated with a tendency to facetiousness, although -frequently tearful and anxious, particularly at night. Irritable, -faultfinding trends usually appear later. As a rule they are talkative, -restless, sensitive, abusive or even insolent. Bonhöffer has reported -stereotypies as well as stuporous and other catatonic types. In speech -the patients often become incoherent, make mistakes, forget words -or coin new ones. Similar mistakes appear in reading and writing. -Asymbolism and parapraxia are observed. Residual symptoms of the brain -injury are headaches, dizziness, fainting attacks and convulsions. The -pupils are contracted and do not react properly to light. The pulse is -frequently very slow. - -In fractures at the base of the brain there is likely to be a -hemorrhage from the ears and deafness from injuries to the labyrinth. -Involvement of the pyramidal tracts may cause unilateral weakness or -even paralysis, with increased knee-jerks and occasionally a Babinski -reflex. Usually the mental symptoms appear promptly after the injury. -Sometimes, however, there is for a while only a slight dulness. -The patients are unable to go about the house unassisted, and act -peculiarly, becoming clouded or delirious after a few hours or days. -Improvement begins to show itself in a few weeks as a rule unless -some intercurrent affection intervenes, but the symptoms may persist -for several months. Meningitis or abscess formation often causes -death. These developments are usually indicated by a marked delirium -or coma. There may also be paralysis, convulsions, disturbances of -speech, rise of temperature, etc. The subsidence of active delirious -symptoms is sometimes succeeded by Kraepelin's traumatic neurosis. -Following the traumatic delirium or concussion psychosis described, -mental enfeeblement sometimes appears. Clouding of consciousness is -not a factor in this condition. There is usually a complete change -in the psychic personality. The patients tire easily, are incapable -of sustained mental efforts, forgetful, absentminded, complain -of dizziness, dulness, noises in the ears, pressure in the head, -migraine, palpitation, etc. Or they may be irritable, with outbursts -of anger often alternating with apathy. Some are depressed, anxious or -hypochondriacal. There is a greatly increased susceptibility to alcohol -and intoxication often induces excitements, epileptiform attacks, -stupors or rarely actual dreamstates. - -Wildermuth found a history of traumatism in 3.8 per cent of his cases -of epilepsy. The statistics of the German Army show 4.2 per cent. When -the convulsive manifestations are in the foreground and the picture -is one of traumatic epilepsy, advanced mental deterioration may be -exhibited, with impairment of mental capacity and disturbance of -memory. These cases remain apathetic, forgetful, dull, irritable and -childish. At autopsy there are often no evidences of any great injury -to the brain. Occasionally extensive areas of softening may, however, -be found. Usually there is a widespread destruction of the nerve cells -and their associated fibres. There is often a proliferation of the -glia, with changes in the vessel walls which may be thickened and -dilated, with capillary hemorrhages and softenings. Extensive areas -of the cortex may be involved. Bleuler's description of the traumatic -psychoses is not essentially different from that of Kraepelin. - -The differentiation of these conditions as suggested in the statistical -manual of the American Psychiatric Association is as follows:— - -"The diagnosis should be restricted to mental disorders arising as a -direct or obvious consequence of a brain (or head) injury producing -psychotic symptoms of a fairly characteristic kind. The amount of -damage to the brain may vary from an extensive destruction of tissue -to simple concussion or physical shock with or without fracture of the -skull. - -"Manic-depressive psychoses, general paralysis, dementia praecox, and -other mental disorders in which trauma may act as a contributory or -precipitating cause, should not be included in this group. - -"The following are the most common clinical types of traumatic -psychosis and should be specified in the statistical record of the -hospital:— - -"(a) Traumatic delirium: This may take the form of an acute delirium -(concussion delirium), or a more protracted delirium resembling the -Korsakow mental complex. - -"(b) Traumatic constitution: Characterized by a gradual post-traumatic -change in disposition with vasomotor instability, headaches, -fatigability, irritability or explosive emotional reactions; usually -hyper-sensitiveness to alcohol, and in some cases development of -paranoid, hysteroid, or epileptoid symptoms. - -"(c) Post-traumatic mental enfeeblement (dementia): Varying degrees of -mental reduction with or without aphasic symptoms, epileptiform attacks -or development of a cerebral arteriosclerosis. - -"(d) Other types." - -We have not as yet, unfortunately, sufficient data at our disposal to -warrant intelligent conclusions as to the frequency of the various -forms of traumatic psychoses. One hundred and twenty-seven cases -reported from the New York state hospitals during a period of six years -were classified as follows:— - - _Form_ _Number_ _Per cent_ - - Traumatic delirium 38 29.32 - Traumatic constitution 32 25.19 - Post traumatic mental enfeeblement 32 25.19 - Others, not specified 25 19.70 - -Undoubtedly with a more definite understanding as to the delimitation -of these different conditions more complete information will be -available later. We are nevertheless justified in feeling that the -frequency of the traumatic psychoses considered as a group can be -determined with a fair degree of accuracy. Of 49,640 first admissions -to the New York hospitals during a period of eight years, 161, or .32 -per cent, were definitely ascribed to traumatism. Twenty-one other -hospitals in fourteen different states reported forty-five cases of -traumatic psychoses (.24 per cent) in 18,336 admissions. Two hundred -and seventeen cases (.3 per cent) have therefore been reported in a -total of 70,987 first admissions to forty-eight state hospitals for -mental diseases in this country. - - - - -CHAPTER II - -THE SENILE PSYCHOSES - - -Never until very recently has any great importance been attached to the -psychoses due solely to age or much interest manifested in them. These -forms of insanity in the majority of our textbooks have appeared only -under the designation of senile dementia. This is true of the earlier -editions of Krafft-Ebing and many other writers. Clouston referred to -senile dementia as one of four varieties of mental enfeeblement. "Most -cases,"[156] he says, "fall under three varieties. The first has as its -chief characteristics depression and lethargy. The second consists -chiefly of excitement, sometimes with a certain exaltation, but always -with irritability, restlessness, unreason, suspicion, and change of -affection. The third variety consists chiefly of the abolition of -mind in all its forms, or senile dementia, and of complete dotage. In -some cases those three varieties form three different stages in the -same case. In others they do not change." Régis, in a work on mental -medicine covering 668 pages in all, devoted two and one-half pages to -a consideration of the insanity of old age. Ziehen[157] in 1894 included -"dementia senilis" with general paralysis, epileptic, alcoholic and -terminal deteriorations in his group of "acquired defect psychoses" and -characterized it as "a chronic organic psychosis of advanced years, -the principal symptom of which is a progressive intelligence defect." -Excitements, depressions, confusional states, deliria, deteriorations, -mental mechanisms of any and all kinds, occurring late in life, -were usually disposed of without any effort at differentiation by -the very convenient method of relegating them to the obscure domain -of senile dementia. This is a field which on exploration has been -found to be one of considerable interest. It has been pointed out -that manic-depressive insanity not infrequently occurs in persons of -advanced age. Uncomplicated alcoholic psychoses are not at all rare. -Bleuler has advanced the theory that dementia praecox and certain of -the senile conditions are similar if not identical processes. General -paresis has been demonstrated in the later periods of life by modern -laboratory methods and the diagnosis confirmed at autopsy. Cerebral -syphilis certainly cannot be left out of consideration. Toxic deliria -are encountered now and then. Even the psychoneuroses are possibilities. - -Kraepelin first established the importance of involution melancholia -as a form of depression warranting separate consideration. The anxiety -psychoses occurring late in life have since been made the subject of -exhaustive study by various observers. It was discovered that many of -the mental disturbances of the aged could be attributed directly to -arteriosclerosis alone. Korsakow's syndrome has been found to be as -frequently due to senility as it is to alcoholism. Some of our more -modern works on psychiatry have included very elaborate chapters on -purely "presenile" conditions. Kraepelin[158] in his last edition devotes -twenty pages to a review of this subject. - -He divides the presenile psychoses into melancholia, anxieties, late -katatonia, depressive delusional conditions, anxious delusional -types terminating in advanced deterioration, depressive states with -deterioration, excitements and paranoid forms. The development of -Kraepelin's conception of melancholia has been fully discussed in -another chapter. He speaks also of the occasional occurrence of anxious -conditions in late life with excitements or an exalted mood with -grandiose ideas or even paranoid manifestations. These may present a -catatonic picture with more or less inaccessibility, stereotypies, -peculiar attitudes and movements, absurd resistance, impulsiveness, -desultoriness and disconnected speech. Our knowledge as to the exact -causation and nature of katatonia still being far from complete, he -knows of no reason why a process of that kind should not be recognized -as one of the presenile conditions. Thalbitzer suggested the name, -depressive delusional insanity (depressiven Wahnsinn), for the -conditions exhibiting numerous delusions and active hallucinations -with an emotional reaction "determined by the course of the disease." -Rehm also described a similar form associated with arteriosclerotic -changes and characterized by hallucinations of hearing, together with -mannerisms and sterotypies. - -Kraepelin[159] describes first a group of presenile cases showing the -development of depressive ideas and anxious states with a progressive -mental enfeeblement. Delusions of self-accusation and persecution -present themselves early in the course of the disease. Symptoms of a -more decidedly hypochondriacal type may occur later. Hallucinations and -somatic delusions also develop, often with nihilistic trends. Everyone -is dead, the patient is the only one left in the world, has no legs, -cannot go out of the house, has entirely disappeared, does not exist -any more, etc. The consciousness is usually fairly clear, orientation -is well preserved and there is no marked disturbance of thought. -Anxious excitement is often an important feature. The termination -is in mental enfeeblement invariably. This condition manifests -itself usually at about the fortieth year. He is of the opinion that -this symptom complex cannot be considered either as belonging to -manic-depressive insanity or attributable to arteriosclerosis, nor is -it catatonic in its origin. - -He finds another group of cases occurring in women between forty-five -and fifty years of age, characterized pathologically by striking -anatomical changes and clinically by a very unfavorable course. A -depression first appears, followed by anxiety with thoughts of suicide. -Hallucinations do not occur as a rule. Restless and agitated excitement -is a prominent symptom leading finally to confusion, clouding of -consciousness, and disorientation. This is followed by a condition of -mental enfeeblement terminating in early death. Well-defined postmortem -changes have been found, such as the "grave alteration" described by -Nissl, proliferation of the glia, swelling of the protoplasmic bodies -with cell enclosures, etc., but no fibril formation. Large quantities -of lipoid material are found in the surrounding vessels and in the -vascular sheaths. This condition, also observed by Nitsche and Döblin, -Kraepelin looks upon as probably a presenile process of autotoxic -origin, there being no other cause demonstrable. He does not consider -this disease process as being related to "late katatonia," genuine -katatonia or manic-depressive insanity. - -He would also separate out another smaller group as probably belonging -to the presenile forms—cases with excitements of long duration, -terminating in a marked deterioration. This condition is likely to -be of sudden onset, with depressive ideas of self-accusation, later -showing an active restlessness. These patients soon become clouded -and confused, often with grandiose ideas suggesting general paresis. -They may show memory falsifications. Stuporous states occasionally -intervene, followed by an active excitement. Echolalia is common. - -The excitement may last for months or even for a year or more and -often stops suddenly, always with deterioration later. In the -cases which have come to autopsy Alzheimer has reported severe and -widespread cell alterations, fibre loss, glia reactions, and changes -in the vessel walls, somewhat suggesting the pathological findings -in general paresis. The cases in this group usually have been of the -male sex between sixty and seventy years of age. Kraepelin speaks of -the clinical picture as a mixture of the symptoms of general paresis, -katatonia and manic-depressive psychoses and it is usually diagnosed as -one or the other of these conditions. - -The paranoid presenile forms occur usually in women. Consciousness is -clear, although there may be a mild anxiety or hypochondriasis. The -persecutory ideas are variable and changeable. Delusions of jealousy -are common although hallucinations are infrequent. Memory is often -somewhat impaired and retrospective falsifications are occasionally -observed. The mood is as a rule anxious and suspicious. Suicidal -tendencies often appear. Restlessness, excitement, impulsive actions -and outbursts of anger are noted at times. Rarely a more cheerful mood -develops. The disease may become stationary and show no marked changes -for years. - -Kraepelin himself seems to be very uncertain as to the significance and -the delimitation of these various presenile forms. It must be confessed -that some of the types described very strongly suggest the condition -formerly looked upon by him as involutional melancholia. It will be -noted that he considers as possible etiological factors the disturbance -of metabolism which may result from regressive or involutional -processes. The differentiation from manic-depressive forms, from -arteriosclerotic disorders and from senile psychoses must also be -looked upon as presenting some difficulties which cannot be entirely -disregarded. Many possibilities suggest themselves. - -In the senile deteriorations Kraepelin notes particularly a loss in -the capacity of apprehension and perception, with a sluggishness of -the train of thought, a dulling of the emotions, a reduction of energy -and the development of conduct disorders. Ranschburg in psychological -tests noticed a lengthening of the reaction time, with a delay in the -choice of action, the reading of words, the performance of addition, -and the formation of judgment. The retardation was shown particularly -in psychic processes and the association time. The reactions were, -moreover, much more monotonous, irregular and unreliable than in the -young. Memory tests also showed poor associations. - -The most advanced form Kraepelin describes as senile dementia, a -progressive mental enfeeblement in which the loss of apprehension -and memory becomes a conspicuous feature. The perception of external -impressions is diminished and delayed and there is a profound disorder -of attention. Memory of the remote past is much better than it is for -current events. Retrospective falsification is a common symptom. The -patient is, moreover, unable to change old viewpoints or acquire new -ones. Delusional manifestations such as childish egotism, foolish -suspicions or notions of impending illness develop. Grandiose ideas -often occur, delusions of great wealth being common. These symptoms -are transitory and come and go without apparent reason. In some cases -the hallucinations resemble those found in the alcoholic psychoses. -Sooner or later there is a disturbance of consciousness leading to -a dreamlike existence suggesting a delirium. There is a noticeable -dulling of the emotional feelings. The patients become indifferent -and apathetic, losing interest in their surroundings, and are often -irritable and excitable. In a certain number of cases depressive -states develop, sometimes with suicidal tendencies. The delusions -may be hypochondriacal or nihilistic in character. Complaints of -persecution are common. Some of the patients show a simple, childish -deterioration with seclusive tendencies. Stuporous or cataleptic states -may develop. Others become uneasy, wander in the streets, remove their -clothes, collect rubbish, or show sexual excitement. Restlessness at -night is especially suggestive. - -Delirious excited states ("Senile Delirium") characterized a certain -number of Kraepelin's cases. In these, clouding of consciousness is -marked. The presbyophrenic complex described by Kahlbaum often occurs. -These cases are fairly clear mentally at first, as far as their -surroundings are concerned, but show memory disturbances, particularly -for recent events. Orientation is lost very soon and they fail to -recognize old friends and relatives. Fabrications are resorted to for -the purpose of remedying these defects of memory and delusions are very -common. Nevertheless, judgment about many things is well retained. In -some instances, however, orientation for time, place and person is -completely lost. Kraepelin is in doubt as to whether presbyophrenia -should be looked upon as constituting a definite entity or only a form -of senile insanity. It may last for years or terminate in a marked -deterioration. In some of the senile cases arteriosclerotic changes -in the cortex are very pronounced. This is more noticeable in the -depressive and anxious forms and in the incoherent varieties. These -individuals become clouded, incoherent, and deteriorate rapidly. - -There is also a characteristic paranoid form of senile psychosis. -Delusions of suspicion and jealousy are common in these cases. They -usually develop persecutory trends and often exhibit hallucinations -of hearing. They sometimes show partial disorientation and gaps in -the memory. The mood is usually irritable and often anxious. There is -very likely to be a disturbance of sleep and often signs of physical -enfeeblement. There may be neurological symptoms caused by the -arteriosclerotic complications, such as headache, pupillary changes, -tremors of the tongue and disturbance of the reflexes. Tremors are -also shown in the writing. Paraphasia occurs and there may be sensory -aphasia or apraxia. - -In severe cases of senile dementia Kraepelin expects to find definite -lesions at autopsy. The brain weight is always decreased, sometimes -to a very striking degree. The volume of the brain is reduced and the -ventricles enlarged. The cortex is diminished in thickness, the frontal -region being most affected. The parietal region may be involved, but -not to any such extent as in general paresis. There may be localized -areas of atrophy. Pachymeningitis and hemorrhagic membranes are often -found. The microscope shows a proliferation of the glia cells and -there is often some disturbance of the layering of the cortex. Cell -alterations appear, with fatty degeneration, some neurones showing -little more than a darkly colored nucleus. The glia cells are enlarged. -There should be no marked changes in the vessels. Fatty changes in the -ganglion cells are very noticeable. There is also some loss in the -tangential fibres. - -Quite characteristic of the senile brain is the occurrence of -the miliary plaques or "drusen" described by Redlich in 1898. -Fischer in 1907 reached the conclusion that these "drusen" were -pathognomonic of presbyophrenia, as he did not find them in senile -dementia, in other psychoses or in normal brains. Hübner, however, -noted them in alcoholics and "circular" cases as well as in normal -individuals. Oppenheim also found them in the brains of the aged -when no psychoses were observed. The interior of the plaque is a -homogeneous, dark-staining, structureless mass. Sometimes there is a -clear space around this center, with club- or spindle-shaped bodies -in the periphery, representing remnants probably of neurones, glia -cells or axis cylinders. The whole structure is encapsulated in glia -fibres. These so-called plaques were spoken of by Fischer as "miliare -Nekrosen" and by Redlich as "miliare Sclerosen." Kraepelin is of the -opinion that they are associated either with senile cases showing -arteriosclerotic changes or presbyophrenia. Alzheimer has described a -senile atrophy of the brain with wedgeshaped areas showing cell loss. -This is due to a gradual occlusion of the smaller vessels extending -down from the meninges into the cortex, and may result in a hemorrhage, -a softening or merely an atrophic area characterized by an absence of -ganglion cells. He has also described another group of cases showing -characteristic cell changes. - -This condition has been given the name "Alzheimer's disease" by -Kraepelin.[160] It is marked clinically by a gradual senile deterioration -with organic brain changes. These eases show some thought defect, -loss of memory, confusion, and clouding. Later they become restless, -talkative, sing and laugh, etc. Aphasic disturbances develop early, -with paraphasia or apraxia. There are speech disturbances ending -in a senseless jargon and writing becomes impossible. An advanced -deterioration ensues. Physically there is a general weakness and -uncertain gait, sometimes with epileptiform attacks. The pupillary -reaction may be lost and evidences of arteriosclerosis usually appear. -The disease may last for many years. At autopsy "drusen" are common -in the cortex and almost a third of the nerve cells are found to be -destroyed. These are replaced by darkly-staining fibril bundles. There -is marked neuroglia reaction, particularly around the "drusen" and -retrogressive changes are found in the vessel walls. This disease -usually appears about the fortieth year and may be looked upon, -Kraepelin says, as a "senium praecox," although its significance is not -clear. - -He finds the senile psychoses occurring usually between the ages of -sixty-five and eighty, although they occasionally appear before sixty. -Seven and sixty-seven hundredths per cent of his cases were between -sixty and sixty-five years of age; ten per cent between sixty-five -and seventy; thirty-five per cent between seventy and seventy-five; -27.8 per cent between seventy-five and eighty; 22.2 per cent between -eighty and eighty-five; 10.5 per cent between eighty-five and ninety; -and 2.78 per cent were over ninety years of age. Of 183 cases studied, -twenty-three per cent were cases of presbyophrenia; sixty-three per -cent of simple deterioration; eight per cent of arteriosclerotic -origin; and the remainder, of delusional forms. More than half of the -cases of presbyophrenia occurred in persons over seventy-five. The -paranoid and arteriosclerotic forms occurred in younger individuals. In -the alcoholic cases the Korsakow complex was common. The analysis of -presenile psychoses made by Kraepelin is, to say the least, exceedingly -interesting. Such clear-cut differentiations as he describes are, -however, not always possible or necessary. Very few other writers have -gone into the question so exhaustively, nor is his classification of -these conditions generally accepted. Bleuler[161] in 1918 in discussing -the presenile psychoses quotes Kraepelin's classification and -also refers to Gaupp's anxious depressive forms. Under the senile -deteriorations he describes "dementia senilis" and presbyophrenia. He -also calls attention to the fact that Binswanger spoke of a "pre-senile -dementia" occurring between the fortieth and fiftieth years of age and -characterized by an emotional dulness and a diminished capacity for -work. Bleuler speaks of the affective disturbances in advanced years -as senile mania and melancholia, which he says may recover, the former -frequently, the latter more rarely. - -The American Psychiatric Association has only attempted to cover -the principal groupings of the characteristic senile forms. The -differentiation of these conditions as suggested in the statistical -manual is as follows:— - -"A well defined type of psychosis which as a rule develops gradually -and is characterized by the following symptoms: Impairment of retention -(forgetfulness) and general failure of memory more marked for recent -experiences; defects in orientation and a general reduction of -mental capacity; the attention, concentration and thinking processes -are interfered with; there is self-centering of interests, often -irritability and stubborn opposition; a tendency to reminiscences and -fabrications. Accompanying this deterioration there may occur paranoid -trends, depressions, confused states, etc. Certain clinical types -should therefore be specified, but these often overlap: - -"(a) Simple deterioration: Retention and memory defects, reduction -in intellectual capacity and narrowing of interests; usually also -suspiciousness, irritability and restlessness, the latter particularly -at night. - -"(b) Presbyophrenic type: Severe memory and retention defects with -complete disorientation; but at the same time preservation of -mental alertness and attentiveness with ability to grasp immediate -impressions and conversation quite well. Forgetfulness leads to absurd -contradictions and repetitions; suggestibility and free fabrication are -prominent symptoms. (The general picture resembles the Korsakow mental -complex.) - -"(c) Delirious and confused types: Often in the early stages of the -psychoses and for a long period the picture is one of deep confusion -or of a delirious condition. - -"(d) Depressed and agitated types: In addition to the underlying -deterioration there may be a pronounced depression and persistent -agitation. - -"(e) Paranoid types: Well marked delusional trends, chiefly persecutory -or expansive ideas, often accompany the deterioration and in the early -stages may make the diagnosis difficult if the defect symptoms are mild. - -"(f) Pre-senile types: The so-called 'Alzheimer's disease.' An early -senile deterioration which usually leads rapidly to a deep dementia. -Reported to occur as early as the fortieth year. Most cases show an -irritable or anxious depressive mood with aphasic or apractic symptoms. -There is apt to be general resistiveness and sometimes spasticity. - -"(g) Other types." - -The frequency of senile cases is shown by the fact that of 84,143 -admissions to the New York hospitals during a period of sixteen years, -12,017, or 14.2 per cent, were over sixty years of age, while 8.4 -per cent were between sixty and seventy years old, and 4.5 per cent -between seventy and eighty. Of 49,640 first admissions to the New York -state hospitals during eight years 4,724 cases, or 9.52 per cent, -were diagnosed as senile psychoses. They constituted 9.63 per cent of -the admissions in Massachusetts during 1919 and 10.61 per cent of the -18,336 admissions to twenty-one hospitals in fourteen other states. Of -70,987 admissions to all of the institutions referred to, 6,961, or 9.8 -per cent, were senile psychoses. - -During a period of eight years in the New York state hospitals, when -the present classification was not adhered to absolutely, 4,724 senile -psychoses were divided into types as follows:—Simple deterioration, -52.01 per cent; presbyophrenia, 5.75 per cent; delirious and confused -states, 12.99 per cent; depressed and agitated forms, 8.25 per cent; -and paranoid varieties, 16.23 per cent. During the same period less -than one per cent of presenile psychoses were reported. Since the -Association's classification has been in use the same institutions -show the following distribution of 1,351 senile psychoses during 1918 -and 1919:—Simple deterioration, 56.24 per cent; presbyophrenia, 4.14 -per cent; delirious and confused states, 13.53 per cent; depressed -and agitated forms, 18.65 per cent; and paranoid varieties and -presenile forms, less than one per cent. The senile psychoses in the -Massachusetts hospitals during 1919 were divided as follows:—Simple -deterioration, 56.94 per cent; presbyophrenia, 7.79 per cent; delirious -and confused states, 7.45 per cent; depressed and agitated forms, 7.11 -per cent; paranoid conditions, 18.64 per cent; and presenile forms, -2.03 per cent. In nineteen hospitals in other states 1,823 cases -were classified as follows:—Simple deterioration, 64.39 per cent; -presbyophrenia, 11.62 per cent; delirious and confused states, 9.59 per -cent; depressed and agitated forms, 4.71 per cent; paranoid conditions, -6.91 per cent; and presenile forms, .27 per cent. The total of 6,842 -cases referred to above were, therefore, distributed as to type as -follows: - - _Type_ _Per Cent_ - - Simple deterioration 55.52 - Presbyophrenia 7.40 - Delirious and confused states 11.83 - Depressed and agitated forms 7.26 - Paranoid conditions 13.85 - -Four hundred and nineteen cases reported by the Ohio state hospitals in -1920 and not included in the above summary were shown as follows:— - - _Type_ _Per Cent_ - - Simple deterioration 49.88 - Presbyophrenic types 6.20 - Delirious and confused forms 18.61 - Depressed and agitated conditions 7.39 - Paranoid states 15.75 - Presenile types 2.14 - -These constituted in all 14.4 per cent of the 2,895 first admissions -during the year, a much higher rate than that shown in other states. In -analyzing these findings it should be borne in mind that the American -classifications do not take into consideration presenile conditions -as such, they being all reported with the senile psychoses, with the -exception of involutional melancholia, which is, of course, shown -separately. - -Southard[162] has called attention to the margin of error in the -diagnosis of senile psychoses. Forty-two cases unanimously diagnosed -as "senile dementia" were "reviewed clinically and anatomically, with -a surprisingly low general percentage of accuracy (sixty-six per cent) -where either cerebral atrophy or cortical arteriosclerosis or both were -regarded as confirmatory, and with still lower percentages: (48 per -cent) where cortical arteriosclerosis was considered essential and (38 -per cent) where cerebral atrophy was considered essential for a correct -diagnosis." It is significant that exactly one-third of the cases -studied were found by Southard to more properly "belong in a group of -acute psychoses or other mental diseases occurring in old age but not -dependent on recognizable senile changes." - - - - -CHAPTER III - -THE PSYCHOSES WITH CEREBRAL ARTERIOSCLEROSIS - - -Sufficient weight has not been attached heretofore to the important -influence of cerebral arteriosclerosis in the production of mental -diseases. Unquestionably it has been a complicating factor in many of -the generally recognized psychoses which has not been given adequate -consideration. Its relation to involution melancholia as well as -the presenile and senile disorders has been given a great deal of -attention, but cannot as yet be clearly defined. Only in its syphilitic -forms can it be looked upon as contributing to the clinical picture in -general paresis. It is, however, productive of late deterioration in -the chronic alcoholic conditions and in the manic-depressive psychoses -occurring in advanced years. It plays a part frequently in the terminal -stages of dementia praecox. In paranoia and the paranoid conditions of -long standing it often becomes a factor to be reckoned with. Certainly -in the differentiation of the epilepsies of the aged it must be taken -into definite account. - -The importance of arteriosclerosis, a term used first by Lobstein some -seventy-five years ago, has long been recognized. Osler in referring to -this subject made the following interesting comment:—"To a majority of -men death comes primarily or secondarily through this portal. The onset -of what may be called physiological arteriosclerosis depends, in the -first place, upon the quality of arterial tissue (vital rubber) which -the individual has inherited and secondarily upon the amount of wear -and tear to which he has subjected it. That the former plays the most -important rôle is shown in the cases in which arteriosclerosis sets in -early in life in individuals in whom none of the recognized etiological -factors can be found. Entire families sometimes show this tendency to -early arteriosclerosis, a tendency which cannot be explained in any -other way than that in the make-up of the machine bad material was used -for the tubing." - -Our present knowledge as to the relation of syphilis to this disease -has not changed the significance of the observations made by Osler in -any way. Heredity more than any other one factor undoubtedly determines -the development of both senility and arteriosclerosis. "When," as -Lambert[163] expresses it, "physiological involution anticipates in time -or exceeds in direction, extent and severity normal senescence, the -various senile and arteriosclerotic disorders are the result." It is -as a rule only in the later stages of the disease when focal symptoms -occur or a psychosis develops that hospital care becomes necessary. -Practically any of the vessels of the brain may be involved and it -frequently happens that more than one is affected either directly or -indirectly. The neurological symptoms resulting depend entirely on the -location and extent of the lesion. Lambert[164] has made the following -excellent anatomical classification of the more common arteriosclerotic -processes:— - - I. Incipient type. - II. Focal types. - (a) Trunk disorders. - 1. Basilar-carotids. - (b) Branch disorders. - 1. Inferior cerebellar. - 2. Superior cerebellar. - 3. Posterior cerebral. - 4. Middle cerebral. - 5. Anterior cerebral. - (c) Twig disorders. - 1. Medullary. - 2. Cortical. - -Some reference should be made, perhaps, to the focal symptoms resulting -from more or less sharply circumscribed lesions which are productive of -certain fairly well known complexes, whether due to arteriosclerotic -softenings, hemorrhages, or growths. These have been concisely -summarized by Barker[165] somewhat as follows:— - -Frontal Lobes—Lesions of the left inferior frontal in righthanded -persons cause motor aphasia. Subcortical involvements cause word -dumbness. Disturbances in the anterior part of the frontal region are -sometimes associated with the Witzelsucht of the German writers—a -tendency towards joking and witticisms. - -Central and Paracentral Lobules—Contralateral sensory, motor symptoms -or a combination of the two. Monoplegias, anesthesias and Jacksonian -epilepsies are characteristic. Contralateral tactile agnosia and -apraxia occur, especially in lesions of the left hemisphere. An -involvement of the left side may also cause a homolateral apraxia, -dyspraxia or a tactile agnosia. - -Parietal Lobes—Lesions in the anterior part cause contralateral -somesthetic disturbances, tactile agnosia or apraxia. Involvement of -the left angular gyrus may cause optic aphasia or alexia; if deep -enough, hemianopsia results. The voluntary movement of the eye may be -interfered with. - -Temporal Lobe—Lesions in the posterior half of the first temporal may -cause Wernicke's sensory aphasia and a subcortical involvement, word -deafness. Bilateral destruction of the first and transverse temporals -causes cortical deafness. Extensive bilateral lesions in the lower -part of these lobes result in mind deafness. Irritative lesions in the -uncinate gyrus lead to hallucinations of taste and smell, with smacking -of the lips and tongue movements. - -Island of Reil—Lesions of the anterior part cause symptoms resembling -Broca's motor aphasia. Lesions of the posterior part result in symptoms -suggesting Wernicke's sensory aphasia. Transcortical motor and sensory -aphasia may result. - -Occipital Lobes—Lesions of the calcarine area give rise to -hemianopsia, and bicortical involvements lead to cortical blindness. -Bilateral lesions of the lateral surface may cause mind blindness. - -Disturbances in the centrum ovale may cause monoplegias or -monoanesthesias, and lesions in the corpus callosum, apraxic symptoms. -Characteristic of cerebellar lesions are ataxias and disturbances of -equilibrium, often with vertigo and paroxysmal vomiting. - -An involvement of the corpora quadrigemina may cause pupillary changes, -unilateral or bilateral paralysis of eye muscles, nystagmus, visual -disturbances, deafness and ataxia or anesthesia. - -Lesions of the cerebral peduncles may give rise to very characteristic -syndromes. If the tegmentum and pes pedunculi (basis pedunculi) are -both involved, there may be a complete hemiplegia of the opposite side -with an oculomotor paralysis on the same side (Weber-Gubler syndrome). -Or there may be in addition to this a marked tremor in the limbs of the -paralyzed side (Benedikt's syndrome). A unilateral oculomotor paralysis -may be combined with a cerebellar ataxia (Nothnagel's syndrome). -The thalmic syndrome of Déjerine and Roussy shows a contralateral -hemianesthesia, violent and persistent pains on the anesthetic side, -hemiataxia, hemichorea or hemiathetosis, slight temporary hemiparesis -and sometimes hyperesthesia. Lesions further back, possibly involving -the internal capsule, may cause hemianesthesia of touch, pain and -temperature senses. - -S. A. K. Wilson in 1912 called attention to a particularly important -syndrome, designated by him as "progressive lenticular degeneration" -and characterized by dysarthria, dysphagia, general tremors of the -extremities, forced laughing and crying, muscular rigidities and -contractures, with a slight intellectual impairment. Interesting -features of this disease complex are that it is familial in type, but -not hereditary, comes on early in life, usually progressing to a fatal -termination, and is associated with a cirrhosis of the liver which -is not alcoholic in origin. At autopsy degenerations of the nucleus -lentiformis have been found. J. Ramsey Hunt in 1916 called attention to -the association of both paralysis agitans and Huntington's chorea with -lesions in the globus pallidus. Oppenheim has recently differentiated -a striatum syndrome to which he gave the name "dystonia musculorum." -Difficulties in writing, tremors, disturbance of the gait, rigidities, -tonic and clonic movements of the muscles and other neurological -symptoms are present. Several cases reported by Abrahamson in 1920 -showed definite emotional disturbances. Cecile and Oskar Vogt have -recently (1919) studied the striatum lesions from a standpoint of both -pathology and symptomatology. As summarized by Lhermitte[166] their work -shows that athetosis, paralysis agitans, Huntington's chorea, dystonia -musculorum, probably paralysis agitans and various other neurological -syndromes are to be attributed directly to conditions involving the -striate bodies. Prominent among these are softenings and hemorrhages -which may result from arteriosclerosis. In view of these facts a -careful study of the focal lesions associated with the arteriosclerotic -disorders is exceedingly important. - -The pathological processes involved have been carefully studied by -Heubner and others. He was originally of the opinion that cerebral -arteriosclerosis was always of specific origin. Baumgarten, however, -subsequently showed that this was not the case. The more characteristic -changes in the larger vessels manifest themselves in the form of -patches of atheromatous thickening so common at autopsy. As a result -of degenerative changes in the elastica and media, and a consequent -weakening of the vessel wall, intimal thickening takes place. This is -not the circular, uniform, concentric involvement found in syphilitic -processes but a localized proliferation of the intima at some one -point. There may be an infiltration of colloid and calcareous material -in the media. This leads to further intimal thickening. In the smaller -vessels arteriocapillary fibrosis has been described—a uniform -thickening of the vessel walls with a connective tissue formation. -Endarteritis obliterans, first described by Friedländer in 1876, is -probably always of syphilitic origin. - -In addition to the vascular changes in the cerebral vessels -Kraepelin[167] finds usually atheromatous changes in the aorta and its -branches, particularly the coronaries, with ulcerations or calcareous -plates, hypertrophy and dilatation of the heart, myocarditis, -interstitial nephritis and infarctions of various organs. At autopsy -the dura and pia are usually thickened and adherent, with a general -atrophy of the cerebral convolutions. There are often fresh -hemorrhages under the membranes as well as cyst formations and -dilatation of the brain ventricles. He particularly emphasizes a -splitting of the elastica in the larger cerebral vessels with a -thickening and tortuosity, fatty infiltration and calcareous deposits. -Hyaline degeneration is common in the elastica and muscularis with -fatty granular cells in the adventitia. Capillary aneurysms are often -found. Glia proliferation is to be expected in the surrounding area. A -condition described by Alzheimer as perivascular gliosis often occurs. -There is a disappearance of the perivascular nervous elements with -consequent proliferation of the neuroglia. In a general way Kraepelin -differentiates several distinct pathological groups—a diffuse cortical -involvement, circumscribed processes in the neighborhood of vessels, -hemorrhages and softenings. There is also a loss of nerve fibres -which are replaced by neuroglia. Binswanger has described a "chronic -subcortical encephalitis" due to arteriosclerosis. This consists of an -atrophy of the white matter due to an involvement of the deeper marrow -vessels. Large gaps and lacunae are found in the course of the vessels. -There is an extensive atrophy of the fibres and there may be occasional -foci of softening. As a general rule involvement of the large vessels -is liable to affect the medullary substance while sclerosis of the -smaller vessels leads to cortical disturbances. It is also possible -to have extensive lesions without mental symptoms and well developed -psychoses with only a slight physical basis. The site of the damage to -the vessels determines this. On the other hand, the mental condition -may be due to cardiovascular complications resulting usually in -anxiety psychoses. The symptomatology may be complicated by senility, -alcoholism or syphilis. - -Clinically Kraepelin[168] divides the arteriosclerotic psychoses into -deteriorations, or milder forms of mental enfeeblement, dementias, -depressions, excitements, late epilepsies, and apoplectic dementia. -In the milder forms there is a gradual change in the entire psychic -personality, with a later development of more marked changes, either -physical, mental or both. The early symptoms are a general reduction -of the mental capacity and an impairment of memory. The patient tires -easily and loses all evidences of energy, with no inclination to -undertake anything new. Familiar names and dates are forgotten. Recent -occurrences are particularly lost to memory. The real is confused with -the false. In business the patient becomes careless and unreliable, -overlooks important transactions and forgets appointments. There are -often subjective feelings of impending illness. The mood becomes -depressed, whining and tearful. Irritability and outbursts of anger -occasionally appear, characterized by a marked emotional instability, -varying rapidly from tears to laughter. Suicidal tendencies are -sometimes noted. Mild confusional states may be induced by alcoholic -indulgences. Early physical symptoms are headache, sensations of -fulness and pressure in the head, followed by a feeling of dizziness, -fatigue, exhaustion, debility, etc. Sooner or later, following a -seizure of some kind, neurological signs appear—drooping of the -mouth, lateral deviation of the tongue, weakness of an arm, dragging -of one leg, loss of sensation on one side, ankle clonus, an increase, -decrease or inequality of the patellar reflexes, and sometimes a -Babinski reflex. The pupils are very likely to be unequal and sluggish -in reaction. The features present a tired, sleepy expression and -speech becomes tremulous and monotonous. There may be a difficulty -in finding words, or the misuse of words. There are usually tremors -of the fingers and movements are uncertain, the gait being unsteady. -Romberg's symptom may be present. Dizzy spells and fainting attacks -also occur, sometimes followed by genuine convulsions. Apoplectiform -seizures may be observed, with unconsciousness for hours or days. These -may be followed by sensory or motor aphasia, unilateral paralysis with -or without disturbances of sensation, hemianopsia, alexia, agraphia, -asymbolism or apraxia. Cardiac disturbances with anxieties are often -complications. These apoplectiform and other severe attacks sometimes -occur a long time after mental symptoms have appeared. They are likely -to recur, mental deterioration progressing rapidly with the repetition -of the seizures. - -Apprehension is much disturbed and memory weakened, in the advanced -cases of deterioration. The patients cannot remember anything for -more than a short time. They become disoriented as to time, place and -person and forget their own names. Genuine "confabulation" sometimes -appears. There are often confusional and delirious states. The mood is -frequently depressed or anxious, sometimes irritable or quarrelsome -and at times humorous. There is a group of cases showing genuine -depressions, usually with hypochondriacal delusions, sometimes with -delusions of persecution, self-accusation, and ideas of sinfulness. -Even delusions of grandeur are observed. Hallucinations are not -infrequent in these cases. States of excitement may intervene with -occasional delusions and confused attacks. These excitements are -usually of the agitated, restless type, sometimes with suicidal -inclinations. Stuporous or even cataleptic states may follow. In the -highest forms of excitement sensory or motor aphasia may develop, -often with speech disturbances, sometimes of a genuine scanning -type. Paraphasias are common. The writing is ataxic or paragraphic. -Ideational or motor apraxia often is a symptom. Cyanoses and other -evidences of general arteriosclerotic involvement appear. There may be -an albuminuric retinitis. Albumen and sometimes sugar appear in the -urine. The radials and temporals are thickened or hardened and cardiac -murmurs are often found. Blood pressure is greatly increased in many -instances, although Romberg found it in only ten per cent of his cases. -Sleep is usually interfered with to a marked degree. - -In a certain number of the more advanced cases of arteriosclerosis late -epilepsies appear. The attacks usually begin between the forty-fifth -and sixty-fifth years. There may be fainting spells or genuine -convulsions recurring at frequent intervals. These may be associated -with brief periods of delirium or may even occur without loss of -consciousness. Forgetfulness and mental enfeeblement soon appear in -such cases. They also show physical changes with tremors, disturbed -reflexes, paralyses, increased blood pressure, etc. Alcoholism seems -to be a strongly predisposing factor in this form of arteriosclerotic -disorder. Kraepelin found that the epileptic attacks almost invariably -appeared in cases which showed a previous history of alcoholic excesses. - -In nearly half of his cases Kraepelin found apoplectiform attacks -appearing without any marked psychosis preceding them. In some -instances no mental symptoms appeared for many years. The attacks -were, however, immediately followed, usually, by periods of confusion -and clouding, sometimes of excitement and violence. The acute -disturbance as a rule subsides rather quickly and clears up partially -or completely. Usually there remains a memory defect, an increased -fatigability and a depressed or irritable mood. These he refers to as -cases of apoplectic deterioration or mental enfeeblement. Recurrent -apoplectiform seizures may result in excitement, depressions or -deliria. Gradual progressive deterioration is the usual picture. As a -general rule the cases with marked excitements, depressions and deliria -are of short duration and have a bad prognosis. - -Kraepelin finds that the arteriosclerotic psychoses appear a decade -earlier than the senile psychoses. Less than one per cent developed at -the age of forty; 2.7 per cent at forty-five; 3.7 per cent at fifty; -7.4 per cent at fifty-five; twenty-two per cent at sixty; twenty-two -per cent at sixty-five; 18.57 per cent at seventy; twelve per cent at -seventy-five, etc. In the cases observed at a particularly early age -he believes heredity to be a very important factor. Seventy-one and -five-tenths per cent of his cases were men. Sixty-two per cent of the -men and fifty-three per cent of the women were less than sixty-five -years of age. The epileptic and demented forms appear earlier than the -apoplectiform variety. Arteriosclerotic involvement of the smaller -vessels occurs earlier than that of the larger arteries. Kraepelin -found alcoholism more common in the history of his cases than syphilis. -He is uncertain whether specific infections can produce a genuine -arteriosclerosis or not. - -Erb has shown that by the experimental injection of adrenalin into -the blood stream artificial arteriosclerosis can be produced, with -an increase of blood pressure, splitting of the elastica, thickening -of the vessel walls and aneurysm formation. Thoma considers alcohol, -tobacco, coffee, tea, and infectious poisons important causes. Cramer -found the disease more common in innkeepers, actors, directors, -officers, bankers and parliamentarians. Alcohol, syphilis, overwork -and high living are important etiological factors. Kraepelin assumes -the existence of certain metabolic products in the blood, possibly the -result of infections which affect blood pressure and the structure of -the vessel walls during a period of lowered resistance. - -The pathological changes associated with the arteriosclerotic psychoses -are quite clearly demarcated. Clinical differentiations, however, are -not so well established. There is some question as to the justification -of the separate entities into which Kraepelin would divide the -arteriosclerotic processes. For statistical purposes the Association's -committee felt that a determination of the frequency of occurrence of -the arteriosclerotic group as a whole is all that should be attempted -at this time. The following suggestions were offered in the manual as -to the delimitations of these conditions:— - -"The clinical symptoms, both mental and physical, are varied depending -in the first place on the distribution and severity of the vascular -cerebral disease and probably to some extent on the mental make-up of -the person. - -"Cerebral physical symptoms, headaches, dizziness, fainting attacks, -etc., are nearly always present, and usually signs of focal brain -disease appear sooner or later (aphasia, paralysis, etc.). - -"The most important mental symptoms (particularly if the -arteriosclerotic disease is diffuse) are impairment of mental tension, -_i.e._, interference with the capacity to think quickly and accurately, -to concentrate and to fix the attention; fatigability and lack of -emotional control (alternate weeping and laughing), often a tendency -to irritability is marked; the retention is impaired and with it there -is more or less general defect of memory, especially in the advanced -stages of the disease, or after some large destructive lesion occurs. - -"Pronounced psychotic symptoms may appear in the form of depression -(often of the anxious type), suspicions or paranoid ideas, or episodes -of marked confusion. - -"To be included in this group are the psychoses following cerebral -softening or hemorrhage, if due to arterial disease. (Autopsies in -state hospitals show that in arteriosclerotic cases softening is -relatively much more frequent than hemorrhage.) - -"Differentiation from senile psychosis is sometimes difficult -particularly if the arteriosclerotic disease manifests itself in -the senile period. The two conditions may be associated; when this -happens preference should be given in the statistical report to the -arteriosclerotic disorder. - -"High blood pressure, although usually present, is not essential for -the diagnosis of cerebral arteriosclerosis." - -In the 49,640 admissions to the New York state hospitals during a -period of eight years the 2,318 cases diagnosed as psychoses with -arteriosclerosis constituted 4.67 per cent of the total number. In -twenty-one hospitals in other states there were 18,336 admissions, of -which 492, or 2.68 per cent, were cases of arteriosclerosis. On the -other hand, the Massachusetts hospitals show 9.63 per cent of their -first admissions during 1919 as arteriosclerotic psychoses. There would -appear to be no way to harmonize these dissimilar findings unless it -is merely a question of differentiation between the senile psychoses -and those due to arteriosclerosis. In a total of 70,987 admissions to -all institutions, there were 3,100 cases of arteriosclerotic psychoses, -a percentage of 4.36. It is worthy of note that in all of the various -groups of institutions the percentage of senile and arteriosclerotic -cases combined is practically the same. This would strongly suggest -varying standards of diagnosis which will undoubtedly be reconciled in -time. It is only recently that any great amount of attention has been -given to the psychoses due to arteriosclerosis and it must be confessed -that there has been entirely too great a tendency to dismiss without -further interest as senile psychoses all mental disturbances occurring -in persons of advanced years. On the other hand, the custom of basing -a diagnosis of arteriosclerotic psychosis on the mere presence of an -increased blood pressure without the existence of any of the other -symptoms which characterize that condition indicates, if nothing else, -the necessity of a greater uniformity in our methods of diagnostic -procedure. - - - - -CHAPTER IV - -GENERAL PARALYSIS - - -General paralysis of the insane, general paresis, or dementia -paralytica, as it is variously known, from the standpoint of etiology, -symptomatology and pathology, is unquestionably the most clearly -differentiated and sharply circumscribed of the psychoses at this -time. Its history, like its pathology, is inseparable from that of -syphilis—a subject of never failing interest and importance, from the -time of the first appearance of that word in a poem (Syphilidis, sive -morbi Gallici) written by the Italian physician and poet Fracastoro -in 1530. Guarinoni referred to epilepsies due to syphilis in the -seventeenth century. Frequent allusions are made in the literature of -that period to manifestations of the disease in the nervous system. -Thomas Willis called attention to the association of paralysis with -mental disorders as early as 1672. A form of mania due to syphilis was -described by Sanché in 1777. Jelliffe found references in literature -to a specific leptomeningitis in 1766 and paraplegias in 1771. Haslam, -a pharmacist at the Bethlem Hospital, is said to have given a fairly -accurate description of general paresis in 1798. A French writer, A. -L. Bayle, is usually spoken of as having clearly differentiated the -disease in 1822. The work of Calmeil, "De la Paralysie Consididérée -chez les aliénés," in 1826, was, however, the first elaborate -monograph ever written on this important psychosis and established its -recognition as an entity. Griesinger looked upon it as a combination of -different mental conditions. Esquirol is credited with having been the -first to describe the speech defect now considered such an important -symptom. Baillarger is said to have introduced the term dementia -paralytica in 1846. - -The etiology of the disease was a subject of controversy for many -years. The early writers ascribed it to sexual excesses, masturbation, -alcoholism, heredity, overwork, and various other causes. It was looked -upon by some as one of the sequelae of syphilis and was described as a -"meta syphilitic" disease by Möbius and a "para syphilitic" disorder -by Fournier. It was noted by many as occurring only in the more -intellectual and highly developed races and was therefore referred -to by Krafft-Ebing as a disease of "syphilization and civilization." -Both Bayle and Esquirol mentioned syphilis very casually in their -writings. Sandras in 1852 spoke of it as one of the principal causes -of general paresis. Its etiological importance was, however, first -given serious consideration by Esmarch and Jessen, prominent Danish -writers, in 1857. Their views were corroborated by Steenberg in 1860 -and by Kjellberg in 1863. The theory of an exclusively specific origin -was not generally accepted, however, for many years. Rieger published -elaborate statistics in 1886 showing that the incidence of general -paresis was sixteen or seventeen times as great in syphilitics as it -was in healthy persons. The fact that a definite history of infection -was not available in many cases led to considerable doubt. Such eminent -authorities as Charcot, Binswanger and Déjerine went so far as to -deny that there was any relation between the two diseases. That some -uncertainty was warranted by the information at hand is shown by the -fact that Kraepelin[169] found a history of syphilis in seventy-eight -per cent of his cases, while Sprengeler reported 41.5 per cent, Räcke -57.3 per cent, Torkel fifty-one per cent, Marcus seventy-six per cent, -Houghberg 86.9 per cent, and Alzheimer over ninety per cent. This is -not at all surprising in view of the statement made by Kraepelin[170] -that Hirschl could find a definite history of an initial lesion in -only thirty-six per cent of his cases of tertiary syphilis. Hudovernig -found that 42.3 per cent of the women suffering from syphilis did -not know when they were infected. In discussing this subject in 1897 -Krafft-Ebing reported the inoculation of nine paretics with syphilitic -virus without the appearance of luetic symptoms in any instance, -although reinfections have been mentioned by other authorities. - -One of the first advances which contributed materially to the -ultimate solution of the general paresis problem was the study of the -cerebrospinal fluid by Widal, Sicard and others after the introduction -of lumbar puncture by Quincke in 1890. This led eventually to -discoveries which were of great diagnostic importance. The isolation -of the spirochaeta pallidum, now known as the treponema pallidum, by -Schaudinn in 1905 settled the question for all time as to the cause -of syphilis. The adaptation of the principle of complement fixation, -the so-called Bordet-Gengon phenomenon, to the study of syphilitic -fluids by Wassermann, Neisser and Bruck in 1906 practically removed all -doubt as to the relation between that disease and general paresis. The -demonstration of the treponema in the cortex of paretics by Moore and -Noguchi in 1913 was practically the only other contribution necessary. -They have since been found in the cerebrospinal fluid. Notwithstanding -the fact that general paresis must now be looked upon as being a -manifestation of syphilis beyond all peradventure of a doubt, it is -nevertheless true that we are unable to explain why that disease does -not always yield to specific treatment. This is undeniably the case at -this time. Just why this should be so cannot be explained in the light -of our present knowledge. It is, however, presumably for the same reason - that tabes and other diseases of the cord and nervous system, -the specific origin of which cannot logically be questioned, are -equally resistant to salvarsan and mercury, whatever that reason may be. - -As soon as the findings of the Wassermann reaction became evident, -renewed efforts on the part of clinicians to find a cure for general -paresis naturally followed. One of the first suggested was the -Swift-Ellis treatment. This was based on the injection of salvarsanized -blood serum into the subdural space of the spinal canal. Results were -exceedingly encouraging for a while, but time showed that this was -not the solution of the problem. Intravenous salvarsan administration -was next tried. This, too, gave excellent results at first. The cases -which were apparently cured, however, eventually relapsed sooner or -later in almost every instance. The intraspinous use of salvarsan in -minute doses has been no more successful than the Swift-Ellis method. -Intracranial subdural treatments have been tried and salvarsan has -even been injected directly into the lateral ventricles. The logical -conclusion is either that the destruction of the nervous tissue has -already reached a stage which is beyond repair or that the treatment -does not reach the site of the disease. - -Clinically we are on much safer ground. In his third -edition Krafft-Ebing[171] referred to dementia paralytica as -"periencephalomeningitis diffusa," the term originally employed by -Calmeil. "Clinically this disease is manifested as a rule as a chronic -disease of the brain with vasomotor, psychic, and motor, functional -disturbances, progressive in course, with a duration of from two to -three years and nearly always a fatal termination." - -Régis,[172] before the cause of the disease was definitely -determined, defined general paralysis as a "cerebral disorder, -sometimes cerebro-spinal (diffuse chronic interstitial -meningo-myelo-encephalitis) essentially characterized by progressive -symptoms of dementia and paralysis (paralytic dementia) with which -are frequently associated various accessory symptoms, and especially -an insanity of the maniacal, melancholic, or circular type (paralytic -insanity)." - -Since the time the disease was described by Bayle, general paresis -has usually been spoken of as being represented clinically by three -different stages. White[173] speaks of a prodromal period, one of full -development and a terminal stage. In the first period he emphasizes -the importance of physical symptoms, more particularly the oculomotor -and tendon reflex disturbances. These include the sluggish reaction -to light (28.3 per cent) or an actual Argyll-Robertson pupil (45 -per cent), with an increased, decreased or absent knee-jerk, the -exaggerated form being the most common. The mental symptoms may be -entirely overlooked in the first stage. There is a gradual progressive -deterioration of the personality, with a loss of efficiency, -impairment of memory, and failure of judgment. There may be episodes -of excitement, depression or delirium, with or without hallucinations -and delusions, the latter being either hypochondriacal or grandiose. -"The demented type, without marked delusions or sensory falsifications, -is the truly typical variety of the disease and the dementia the -basal element of all forms" (White). There may be an incipient speech -disorder and beginning tremor. - -Characteristic of the second stage is a marked increase of the physical -symptoms already described, together with the appearance of seizures. -Muscular weakness develops and the patient often shows a marked gain in -weight. The mental symptoms are merely an exacerbation of those shown -in the first stage. The expansive variety constitutes the classic form -so often spoken of. There may be agitations, depressions, alternations -of these symptoms or even paranoid forms. - -In the third stage there is a continued exaggeration of the physical -signs of the disease with an advancing mental deterioration. The -patient becomes helpless and practically speechless, contractures -and bedsores develop, and death often occurs as the result of an -unusually violent seizure. The description of this disease in the -three traditional stages so often referred to is practically without -significance and of very questionable value. It is, of course, a -well-known fact that the disease may progress rapidly to a termination -in two or three years or may continue for an almost indefinite period -of time. It may manifest itself, furthermore, in various ways. The -physical signs show much greater constancy than the mental symptoms. - -Kraepelin[174] describes demented, depressed, expansive and agitated -forms of general paresis. The "demented" form he finds to be much -more common than the others. This is characterized by a progressive -mental deterioration with "paralysis." The onset is marked by a poverty -of thought, forgetfulness, moodiness, instability and indifference. -Consciousness gradually becomes somewhat clouded and the patient -more or less disoriented. Transitory delusions supervene. These are -of a depressive type, somatic or expansive in nature. The delusional -ideas as a general rule are rather childish. Memory disorder becomes -conspicuous and delirious excitements occur at times. All of this leads -to a gradual deterioration. Speech defects appear sooner or later and -conduct disorders are common. Kraepelin finds that fifty-three per -cent of his Heidelberg cases were of the demented form. At Munich they -constituted fifty-six per cent of the men and seventy-three per cent -of the women. Forty-four per cent of the cases died within the first -two years. - -The "depressive" form of paresis as described by Kraepelin is -characterized by emotional depression or anxiety with delusions of -various kinds. It may begin with a general sensation of illness and a -gradual weakness of memory or intellect followed by symptoms of mental -dulness. The unpleasant ideas are hypochondriacal in nature and often -of an extravagant type. The delusions are quite frequently somatic in -origin. Sometimes these are associated with self-accusation or there -may be complaints of persecution. Hallucinations occur at times. In -spite of this deplorable state of affairs a marked indifference on -the part of the patient is the rule. Excitement, violence or suicidal -impulses nevertheless occur, and stuporous states are described. -Kraepelin found that the depressive form constituted twelve per cent -of his cases at Heidelberg. He is of the opinion that the duration is -short, much more so than in some of the other types of the disease. -Fifty-eight and six-tenths per cent died within the first two years. -Convulsions, however, were less frequent. - -The "expansive form," according to Kraepelin, may begin with an -initial depression or show excitement early. Megalomanic symptoms of -the most extravagant variety soon appear. The marked mental weakness -is, however, very manifest. Hallucinations of sight and hearing -are frequently present but transitory. The mood is usually happy, -although hypochondriacal ideas occur for short periods now and then. -Excitability is more common, sometimes with unusual violence. The -course tends to a complete deterioration, with occasional exacerbations -of excitement. Kraepelin found that the expansive form constituted -about thirty per cent of his Heidelberg cases. Convulsions were less -frequent and remissions more common than in other types. He found that -this form of the disease, moreover, occurred later in life. Forty per -cent died within the first two years. Some cases, on the other hand, -were of long duration; one of seven, another of eight, and one of -fourteen years. He also noted mixed varieties with alternations between -excitement and depression. - -The "agitated" form as described by Kraepelin is that type in which -extreme excitements predominate. It is often of sudden onset. Grandiose -ideas, even more extravagant than those of the expansive form, appear. -A flight of ideas may be observed at times and stupor often intervenes. -The most severe cases are those which have been referred to by some -writers as "galloping" paresis. An actual delirium may lead to an early -termination in death. The agitated type constituted 6.3 per cent of -Kraepelin's cases. He finds this condition somewhat analogous to the -delirious states due to alcoholism. - -Remissions are more common in the agitated and expansive forms of the -disease and may vary in duration from a few months in some instances -to one of fourteen years reported by Dobrschansky. Nissl confirmed -the diagnosis of paresis at autopsy in a case observed by Tuczek -which had been stationary for nearly twenty years. Alzheimer reported -another with a known duration of thirty-two years. Kraepelin has found, -however, that fifty per cent of his paretics die within the first two -years. He reports unequal pupils in from fifty to sixty per cent of -those examined. He also finds that pupillary irregularity is one of the -earliest physical signs in many individuals. Complete loss of light -reaction was found in from fifty to sixty per cent of all cases, with -a reduced range of reaction in from thirty to forty per cent. He found -epileptiform or other attacks present in from thirty to forty per cent -of those studied. Decreased or absent patellar reflexes were noted -about twice as often as were increased reflexes. In from two-thirds -to three-fourths of all cases he found both the posterior column and -lateral tracts of the cord involved. - -The characteristic physical signs noted in all textbooks are described -in detail by Kraepelin[175] as common to all of the clinical forms of the -disease. The inequality, irregularity and immobility of the pupils, -the speech defect, difficulty in writing, tremor of the lips, facial -muscles and tongue, the marked changes in both superficial and deep -reflexes, the alterations in the gait, the muscular incoordination, -the presence of the Babinski reflex or ankle clonus, the sensory, -motor, vasomotor and trophic disturbances constitute a combination of -physical signs which is to be found practically nowhere else within the -domain of psychiatry. The seizures, either epileptiform, apoplectiform -or resembling syncopes, are almost pathognomonic when taken into -consideration with the physical signs alone. - -The pressure of the cerebrospinal fluid is from three to five times as -great as in normal individuals. The albumen content of the fluid is -increased about six times (Kraepelin). The increase in the globulin -content has been very frequently referred to in the literature of -general paresis. Kraepelin states that it also occurs in tabes, -syphilis, brain abscess, occasional cases of extra medullary tumors, -multiple sclerosis and in some infectious diseases. He attaches a great -deal of importance to the increase in the cellular elements of the -spinal fluid. "Cases with repeated normal findings are so rare that the -correctness of the diagnosis may be justly doubted." The Wassermann -findings no longer require comment. The colloidal gold test of Lange -is equally well known. Nowhere else in psychiatric procedure does the -laboratory render such valuable diagnostic assistance as is the rule in -cases of general paresis. A positive Wassermann reaction in the spinal -fluid, the presence of an increase in the albumen and globulin -content, with a marked lymphocytosis in the cerebrospinal fluid and a -positive gold test, is quite sufficient evidence on which to base a -definite diagnosis. The results of an examination of the spinal fluid -for diagnostic purposes at the time of autopsy are highly unreliable. -An increase in the cell count, which may be misleading, is found in -the spinal fluid of non-paretics in all cases after death. The number -of cells depends entirely on the time of examination. It is not at -all unusual to find from one to three hundred per cubic millimeter -when a count is made from twenty-four to forty-eight hours after -the death of the patient.[176] Another interesting fact is that the -presence of sugar always shown by Fehling's solution during life -cannot be demonstrated postmortem, at least after the lapse of a few -hours.[177] The significance of this change is not clear. Nor is the -increase in the globulin content of the spinal fluid, when taken alone, -pathognomonic of either general paresis or syphilis, as was pointed -out in 1909.[178] One of the most elaborate studies ever made of the -spinal fluid, that of F. W. Mott, shows that this increase is due to -degenerative processes of the nervous system which may be due to a -variety of causes.[179] - -In no other psychosis do we find such clear-cut pathological findings -at autopsy as are readily demonstrable in general paresis. We are very -largely indebted to the exhaustive researches of Nissl and Alzheimer, -(1904)[180] for our information on this subject. Macroscopically -adhesions of the dura to the calvarium and of the pia to the cortical -substance are quite common. Opacities of the meninges are practically -always present. Pachymeningitis hemorrhagica, externa or interna, is -common, often with the formation of extensive hemorrhagic membranes. -Ependymitis may be readily observed in the floor of the fourth and -lateral ventricles. There is usually a reduction in the general brain -weight, with atrophy of various parts, usually one side or the other -of the cerebrum. The sulci are widened and the frontal lobes are often -noticeably smaller in size. Less frequently the temporal, parietal -or occipital regions are affected. Often there are localized foci of -atrophy with cyst formation. The ventricles are frequently widely -dilated, with an increase of cerebrospinal fluid. - -Microscopic examination always shows a more or less diffuse -leptomeningitis with a markedly thickened pia infiltrated with -lymphocytes and plasma cells. In the superficial layers of the cortex -there is a neuroglia proliferation with characteristic "spider cells." -There is an obvious disturbance of the normal layering of the cortex -which is very striking. The adventitia of the vascular walls shows -an extensive infiltration by lymphocytes and particularly by plasma -cells which are often very numerous. Rod cells or "stäbchenzellen" -as described by Alzheimer are very noticeable as are also satellite -cells or free nuclei. The neurones are often diminished in number -and frequently show the "acute" or "grave" alterations described -by Nissl, as well as shrinkage, sclerosis, pigmentary deposits, -vacuolization, etc. The characteristic axonal alteration originally -described by Turner as occurring in central neuritis is sometimes -observed. Degeneration of the nerve fibres may be brought out by -proper staining processes. Intimal thickening of the vessel walls and -a capillary proliferation or budding should also be mentioned. Foci -of softening sometimes are to be found in the cortex. The presence -of occasional gummata is now conceded, although formerly denied by -Alzheimer. The changes in the cerebellum are not essentially different, -but are usually not so conspicuous. In the cord a pachymeningitis and -leptomeningitis are usually present, as well as the vascular changes -described above. The important findings, however, are the degeneration -of the posterior columns and lateral tracts, or mixed forms involving -both of these. Owing doubtless to defects in staining technique, the -demonstration of the treponema is difficult and unsatisfactory. It -must be admitted that some of the above histopathological changes in -themselves, the cell alterations, for instance, do not, when considered -alone, prove the existence of general paresis. The whole picture as -shown by the microscope, however, leaves no room for argument. The -postmortem diagnosis is absolutely conclusive. - -A consideration of the subject of general paresis without some -reference to the juvenile form, first described by Clouston in 1877, -would be manifestly incomplete. Although this term may be applied -to a type of the disease acquired in childhood, it is usually used -as referring to hereditary syphilis. Symptoms generally appear at -or before the age of puberty. As a general rule the child is more -or less defective mentally from birth, although this is not always -true. Ordinarily the course of the disease is one of progressive -deterioration, with an occasional episode of excitement. Convulsive -seizures are frequent, and contractures are often noted. These cases -are likely to be mistaken for idiocy and overlooked. The duration -usually extends over a period of several years. The pathology is -practically the same as that of the adult form of the disease. Almost -invariably a positive Wassermann is obtained on examining the blood of -the parents. It is equally interesting to note that the children of -syphilitic parents often show a positive Wassermann reaction without -any evidence of paresis, or at least for some time before it develops. - -The only question remaining at this time is whether general paresis -and cerebral syphilis are separate and distinct disease entities. For -many years this was held to be the case. Certainly gummata and other -syphilitic processes are to be found in the brain where there is no -such pathological picture as characterizes general paresis. In any -event the latter must be recognized as a very well defined form of -syphilis of the nervous system. In view of the very definite etiology, -symptomatology and pathology of general paresis, the various clinical -differentiations of Kraepelin and other writers are looked upon by many -as not being of very great importance. In any and all clinical types, -however described, we are unquestionably dealing with the same sharply -circumscribed disease process. This subject is one of academic interest -only. - -The American Psychiatric Association in its classification of psychoses -made no attempt to differentiate types. For purposes of statistical -study the following suggestions appear in the manual:— - -"The range of symptoms encountered in general paralysis is too great -to be reviewed here in detail. As to mental symptoms, most stress -should be laid on the early changes in disposition and character, -judgment defects, difficulty about time relations and discrepancies in -statements, forgetfulness and later on a diffuse memory impairment. -Cases with marked grandiose trends are less likely to be overlooked -than cases with depressions, paranoid ideas, alcoholic-like episodes, -etc. - -"Mistakes of diagnosis are most apt to be made in those cases having -in the early stages pronounced psychotic symptoms and relatively -slight defect symptoms, or in cases with few definite physical signs. -Lumbar puncture should always be made if there is any doubt about -the diagnosis. A Wassermann examination of the blood alone is not -sufficient as this does not tell us whether or not the central nervous -system is involved." - -A study of the statistics of the thirteen New York state hospitals -in the "pre-Wassermann" days and before we had acquired our present -accurate knowledge of the pathology of general paresis shows that there -were 84,152 admissions during the fourteen years ending on October -1, 1888. Of this number 5,697, or 6.76 per cent, were diagnosed as -general paresis. In the same hospitals, from 1912 to 1919 inclusive, -6,374 cases of general paresis were reported,—12.71 per cent of -the 49,640 first admissions. During the years 1918 and 1919 that -disease constituted 13.19 per cent of all admissions. This apparent -increase undoubtedly is due to the fact that modern methods have -materially improved facilities for accuracy of diagnosis. It is not -at all probable that the admission rate has doubled during the period -in question for any other reason. In the Massachusetts hospitals -during the year 1919, only 7.90 per cent of the first admissions were -diagnosed as general paresis. There was, however, an unusually high -rate of cerebral syphilis. In twenty-one hospitals in fourteen other -states, reports based on the present classification show a total of -18,336 admissions, mostly in 1917, 1918 and 1919. Of this number 1,233, -or 6.72 per cent, were cases of general paresis. Thus, in a total of -70,987 admissions based on the present classification of psychoses as -used by the American Psychiatric Association there were 7,845 cases -of general paresis in all,—a percentage of 11.05. It is, of course, -a well-known fact that general paresis is largely a psychosis of -densely populated communities. This is readily shown by the New York -statistics. During the year 1919, 9.6 per cent of the admissions at -Binghamton were cases of general paresis. The percentage at Buffalo -was 15.5; at Gowanda, 17.3; Hudson River (Poughkeepsie), 9.0; at -Middletown, 3.7; Rochester, 8.6; St. Lawrence (Ogdensburg), 9.2; -Utica, 10.1; and Willard, 13. In the institutions caring for the insane -of New York City 16.3 per cent were reported at the Manhattan State -Hospital, 13.5 per cent at Kings Park, and 14.7 per cent at Central -Islip. The percentage at the other institutions, except at Buffalo -and Gowanda, which care almost entirely for residents of the city of -Buffalo, is determined very largely by the transfer of patients from -the hospitals of New York City and the metropolitan district. General -paresis constitutes approximately ten per cent of the commitments in -the city of Boston. On the other hand, we find an admission rate of -2.3 per cent for the Vermont State Hospital (1917 and 1918), 1.5 per -cent for the Central State Hospital, Virginia (1919), 2.5 per cent for -the Columbia State Hospital (South Carolina) (1918), and a period of -two years at the Spencer State Hospital, West Virginia (1917 and 1918) -with 262 admissions and no cases of general paresis. Of 2,895 first -admissions reported by the Ohio state hospitals for the year ending -June 30, 1920, 438, or 15.12 per cent, were cases of general paresis. -It is interesting, at least, to note that Letelier[181] showed an -admission rate for this disease of seven per cent at the Casa de Orates -at Santiago, Chili. - - - - -CHAPTER V - -THE PSYCHOSES WITH CEREBRAL SYPHILIS - - -The indications are at the present time that the psychiatry of the -future will not deal with a consideration of general paralysis and -cerebral syphilis, as such, but will differentiate preferably between -parenchymatous and interstitial, or mesoblastic, syphilitic processes -of the nervous system. The retention of the designation general -paresis is little, if anything, more than a concession to the claims -of tradition. Cerebral syphilis may be said in a general way at this -time to include all syphilitic involvements of the brain other than -general paresis, which must be accorded the precedence due to priority -of recognition if nothing else. In the light of our present knowledge -we may speak in rather definite terms in considering cerebral syphilis -from the standpoint of pathology. On an anatomical basis it is usually -divided into three forms,—the meningitic, the endarteritic and the -gummatous types. It is, of course, not to be understood that these -represent separate and distinct processes. Combined forms are nearly -always to be expected and the different types practically always -coexist more or less. - -The onset of the disease may be expected anywhere from one to ten or -even fifteen years from the date of the initial lesion. The early -appearance of cerebral symptoms would indicate brain syphilis as -a general rule rather than general paresis. Oppenheim[182] in his -second edition says that cerebral syphilis often develops within a -year after infection, a majority of the cases being noted within two -years. He finds it a very rare occurrence after ten years. "Because," -as Barker[183] puts it, "of the lawlessness of the occurrence of -syphilitic lesions in the central nervous system, all clinical -classifications of these cases are based only on the predominance -of certain associations of lesions." Certainly the pathology of the -disease is quite varied in its manifestations. - -The meningeal form is the one most often encountered. This may appear -on the convexity or on the base of the brain and is spoken of as -being either localized or diffuse in character. It may or may not be -associated with gummatous formations or cortical vascular involvement. -The essential process is a leptomeningitis. The pia is thickened, -opaque and adherent to the cortex. The microscope shows the presence -of inflammatory elements consisting largely of lymphocytes and plasma -cells which may be confined entirely to the meninges or may extend -downward to the superficial cortical layers directly or by extension -along the adventitial sheaths of the vessels. An examination of the -cortex, however, shows a limitation of this invasion to the immediate -neighborhood of the meninges. The cortical involvement, in other words, -is entirely secondary and is not the important part of the pathological -picture that it always is in general paresis. The meningeal condition -is practically the same in the two diseases but more likely to be -localized in syphilitic processes. Dunlap[184] calls attention to -the important fact that in a group of cases occurring many years -after infection he found involvements of the deeper cortical layers -strongly suggesting general paresis pathologically and impossible of -differentiation clinically. In these cases, even in the deep cortical -vessel walls, occasional lymphoid and plasma cells were found, as -well as typical syphilitic endarteritis in some instances. There is -frequently, in addition to the simple meningeal involvement at the -base, a widespread gummatous infiltration of the pia-arachnoid or in -some instances numerous miliary granulomas. This is especially common -in the region of the chiasm and may involve the origin of various -cranial nerves, obviously in such cases determining the symptomatology -to be expected. The optic and oculomotor nerves particularly are -affected. The large vessels at the base are often involved either by -syphilitic inflammatory processes or by direct invasion of their walls -by gummas. An extensive specific meningo-encephalitis may lead either -to foci or extensive areas of actual softening. - -The endarteritis which occurs in syphilis is characteristic and -diagnostic. This has been studied exhaustively by Heubner. The smaller -vessels show an infiltration of lymphoid and plasma cells in their -adventitia, as well as in the perivascular lymph spaces. The larger -vessels show a great thickening of the intima which is consecutive, or, -as Lambert described it, "girdling" in character. This is associated -with a splitting of the membrana elastica. The proliferated intimal -tissue is very susceptible to degenerative processes. Thrombosis and -the formation of anemic infarctions may follow the obliteration of -the vascular channels. The involvement of the larger vessels may lead -to very distinctive focal symptoms. Thus, as Barker[185] has pointed -out, there may be an obliterating process in the middle cerebral with -hemiplegia and aphasia, invasion of the basilar artery with pontile or -bulbar symptoms, or an involvement of the posterior cerebral may -lead to hemianesthesia or hemianopsia, while an affection of the -vertebral may show a unilateral bulbar paralysis with hemianesthesia -of the same side and a hemiplegia of the opposite side. The extensive -involvements of the base are usually meningeal, with gumma formation -and with a secondary endarteritis in addition. Large solitary gummata -may, moreover, occur practically anywhere in the brain, although -they are somewhat unusual. On microscopical examination they show a -characteristic infiltration of the periphery and a caseous center. They -are more likely to occur in the course of a large vessel. - -The symptomatology of brain syphilis necessarily varies with the -nature, extent and location of the lesion. In the earlier stages of -a diffuse meningitis the prominent symptoms to be expected first are -headache and dizziness. In an individual with a definite specific -history a persistence of such symptoms should suggest salvarsan -therapy. Vomiting is a common complication. Cranial nerve palsies, -optic neuritis or hemiplegia in such a case would, of course, be -conclusive. Stuporous, confused or delirious states may occur, with or -without hallucinations. When the syphilitic process is an extensive -one with a widespread meningitis or gummatous involvement of the base, -numerous focal symptoms are to be expected. Choked disc, optic tract -lesions, paralysis of the ocular muscles, facial neuralgias, facial -palsies, deafness, or anesthesias may occur. Mental deterioration -naturally advances with the progress of the disease, but the -personality is much better preserved than in general paresis. Periods -of unconsciousness are not infrequent and convulsive attacks may -appear. These may be general or local and paralyses often follow. These -may assume the form of a hemiplegia or may involve only certain groups -of muscles. Ptosis is often noted. Paralysis of other eye muscles is -common, and pupillary rigidity is sometimes a symptom. Hemianopsia -and diplopia are often observed: An important feature of the disease -is the fact that these conditions are more or less transitory and -rarely become permanent. Apoplectiform attacks followed by hemiplegia -are results of gummatous growth or may be associated with areas of -softening. These are due to vascular disturbances. Aphasia is not an -unusual occurrence. Hemiplegias appearing suddenly in individuals under -forty years of age are likely to be of specific origin. Epilepsies -developing in later years should always be viewed with suspicion. -The Korsakow symptom complex has been found in some cases of brain -syphilis. Memory defect is present in most instances. When a marked -mental deterioration takes place it is usually late in the disease. -Argyll-Robertson pupils are infrequent in cerebral syphilis. Speech -defect is practically never so conspicuous as it is in general paresis. -Writing difficulties are also much less marked. Euphoria and grandiose -delusions occasionally occur in brain syphilis but much less frequently -than in general paresis. Hemiplegias, when they occur, are much more -likely to be permanent than they are in general paresis. Paranoid -complexes are sometimes clinical features of the disease and if they -persist strongly suggest syphilis rather than paresis. - -There should be a positive Wassermann reaction in the blood serum -of both diseases. It is more persistent, however, in the syphilitic -form. In the spinal fluid the reverse is the case and negative -results are often noted in cerebral syphilis. There is usually some -increase sooner or later in the albumen and globulin content in both -diseases. There may be a lymphocytosis in both, although usually -much greater in general paresis. A typical colloidal gold reaction -is more indicative of general paresis than syphilitic conditions. -Several clinical groupings have been proposed. Plant, for instance, -speaks of various forms of mental deterioration, pseudo-paresis, -paranoid types, epileptiform varieties, symptomatic disturbances and -affective reactions suggesting manic-depressive insanity. The important -contribution made by Kraepelin[186] to the literature of this subject -is worthy of careful study. He describes a syphilitic neurasthenia, -a mental disturbance due to the psychic effect of the disease, and -various conditions resulting from gummatous growths. His most important -group is a syphilitic pseudo-paralysis, which he divides into a simple -dementia, delirious forms, expansive types and a variety showing -the characteristic Korsakow syndrome. He also speaks of syphilitic -apoplexies and epilepsy, tabetic psychoses and syphilitic paranoid -conditions. - -Syphilitic neurasthenia as described by Kraepelin is an affection -which is likely to occur early in the disease and manifest itself -shortly after the initial infection. In the milder forms, evidences of -nervousness appear,—difficulty of thought, irritability, disturbances -of sleep, pressure in the head, with indefinite and changeable abnormal -sensations and vague pains. Later, feelings of anxiety, depression, -dizziness, mental dulness, a difficulty in finding words, transient -weaknesses, disturbances of sensation, nausea and a slight rise of -temperature are observed. He admits that there is some question as -to whether this constitutes a clinical entity and if so, whether it -is directly due to the infectious process or is to be attributed to -psychic disturbances. Nervous reactions of various kinds are to be -found in syphilitics without psychosis. Thus, Meyer in sixty-one cases -of secondary syphilis found eighteen with sluggish pupils, thirty-two -with increased reflexes, and twelve with general nervous manifestations -such as headache, vertigo, etc., appearing shortly after the period of -infection. In only five of these patients were there any evidences of -an organic disease. In twelve tertiary cases he found indications of an -involvement of the nervous system in only two. In thirty examinations -following lumbar puncture a lymphocytosis and an abnormal protein -content were observed. Buttino, in a study of thirty syphilitics, -reported that fourteen showed a diminished light reaction within one -year of the time of infection. Later, after unmistakable symptoms -of cortical involvement have existed for some time, neurasthenic -complexes are common. These take the form of a difficulty of thought, -absentmindedness, forgetfulness, and a reduction of interests. The mood -may be irritable, surly, depressed, anxious, fearful, and changeable, -showing at the same time considerable indifference and dulness. -Some are quiet and reserved while others are excited and violent. -Severe headaches may be common, more often at night. There are also -occasional attacks of dizziness or fainting, disturbances of sensation, -sleeplessness, sensitiveness to alcohol, and occasional diplopia. These -are preliminary to more severe disturbances, which simulate nervous -exhaustion, and are not strikingly unlike the earlier stages of general -paresis. They may be differentiated by examination of the spinal fluid. - -Another group of cases is characterized by conditions due to an -increased intracranial pressure. These are marked by thoughtlessness, -dulness, and indifference terminating in a complete lethargy and -somnolence, during which the patient occasionally demonstrates that he -is not so badly damaged mentally as he appears. Physically there may be -weakness, twitchings, fainting spells, convulsions, ataxias, paralyses, -dysesthesias, choked disc, etc. The basis of this disturbance is a -gummatous growth, its location, of course, largely determining the -symptoms. Kraepelin suggests the possibility of getting this disease -picture in a syphilitic as the result of a growth of some other kind—a -glioma or endothelioma. - -Slightly more than a third of the cases encountered in his clinic -showed the symptom-complex which he describes as syphilitic -pseudo-paresis. As a rule these cases are of the simple demented -type with a general mental deterioration. The patients show some -disturbance of apprehension and attention, tire easily and are quite -forgetful and dull. Delirious states may supervene, with clouding, -confusion and disorientation, as well as hallucinations of sight and -hearing. Memory is markedly impaired and confabulation may be noted. -Judgment is not so much interfered with as in paresis. The patients -have some insight into their condition and complain of headache, -difficulty of thought, etc. Occasional delusions are observed. These -may be of a hypochondriacal type or grandiose in character. As a rule -the mood is cheerful, but it may be depressed, anxious or fearful, -with suicidal tendencies. Sleep is disturbed and there is considerable -restlessness, usually at night. With all of these symptoms there -are the physical signs of a severe cortical involvement, dizziness, -fainting spells, twitchings, seizures or frank convulsions, occasional -paralyses, etc. Disturbance of sensation and motion may appear with -a perfectly clear consciousness at times. Aphasic symptoms are not -uncommon. The eye muscles are affected in many cases, with ptosis, -double vision, strabismus, etc. The pupils are usually immobile or -sluggish, frequently only one being involved. The field of vision is -narrowed and choked disc is common. Speech is affected, as well as -writing. All kinds of paralyses occur and they persist for some time. -The gait may be spastic or ataxic. The reflexes are usually increased -and often different on the two sides. Romberg's sign often appears. A -Babinski reflex and ankle clonus may be found. The patients are usually -untidy in their habits. Blood pressure is increased in some cases and -the pulse slow. There may be variations in temperature. Often there are -evidences of old syphilitic processes on the skin surface, enlarged -glands, residuals of choroiditis, etc. Usually Kraepelin found a -positive Wassermann reaction in the blood, but not in the spinal fluid, -which showed a slight cell increase, often from fifteen to twenty per -cubic millimeter, rarely in larger numbers. He found the course of the -disease rapid, but with occasional remissions. There may be a sudden -collapse and death. It usually terminates, however, in a profound -dementia, often with a hemiplegia and epileptiform seizures. There are -other conditions suggesting general paresis. Marcus, for instance, -has described a delirious, confusional state occurring usually in -the first year after the infection, sometimes later, but as a rule -developing suddenly. The patients become sleepless, confused, anxious -and disoriented. Numerous hallucinations appear, both of hearing and -vision, usually of a very unpleasant type. The patients often become -excited and violent or even suicidal. Physical signs more or less -similar to those already described are to be expected. According to -Marcus, these cases always respond to syphilitic treatment. - -A small group of cases, as pointed out by Westphal, shows excitements -strongly simulating the expansive type of general paresis. This form -begins ordinarily with a depression, sometimes appearing suddenly, -followed by irritability, marked restless excitement, headache, and -fainting attacks. Usually there are hallucinations, and delusional -ideas of a grandiose type. Above all there are pupillary disturbances, -increased or decreased reflexes, seizures, paralyses, etc., strongly -resembling paresis. All of these symptoms may disappear under -syphilitic treatment in time. Some cases, however, last for years, -dying as a rule in a seizure. Kraepelin also describes at some length a -group showing the Korsakow complex. He suggests that the fact that this -condition usually develops in alcoholics is not without significance. - -Kraepelin is of the opinion that the mental picture is the conspicuous -and characteristic feature of general paresis standing out more -prominently than the physical evidences of the disease. In syphilitic -pseudo-paresis, on the other hand, there is a clearer sensorium without -such marked disorientation, and memory is not usually so much affected. -At the same time, the physical signs are relatively more prominent, -although the speech difficulty and writing defects may not be so -marked. The pupils sometimes show no changes. Hemiplegias with ankle -clonus and a Babinski reflex are, however, disproportionately common. -The eye muscles are much more often involved than they are in general -paresis. Loss of pain sense is not so noticeable. An advanced form of -deterioration of many years standing is against a diagnosis of paresis -and favors cerebral syphilis. In these cases the physical signs drop -somewhat into the background. There are, nevertheless, stationary cases -of general paresis which can be differentiated with great difficulty if -at all. The development of pseudo-paresis is slower and more irregular. -After a seizure and a paralysis there may be a long remission. The -disease, furthermore, does not, like general paresis, always terminate -in death. - -Kraepelin finds the apoplectiform type of brain syphilis very common. -After a few premonitory symptoms such as headache, dizziness, -irritability, weakness of memory, etc., a typical apoplexy takes place, -leaving a hemiplegia with or without a speech defect. This sometimes -occurs without any loss of consciousness. The patient presents the -appearance of an ordinary hemiplegic with increased reflexes on one -side and ankle clonus followed by a Babinski reflex, etc. Writing is -usually affected as well as speech. There may not be another attack -for some years. There is, however, a progressive mental deterioration. -Occasional confusional states or excitements may be met with. In -the meanwhile, numerous physical signs appear, papillary changes, -disturbances of the reflexes, ptosis, tremors, hemianopsia, etc. -Epileptiform attacks may occur. The blood pressure is usually quite -high. There is an increase in the cells in the spinal fluid, often with -a negative Wassermann, although the blood serum is positive. Death -usually results from a seizure. Three-fourths of Kraepelin's cases -developed before the age of forty-five, which, of course, assists -materially in the diagnosis. - -In younger individuals usually, cerebral syphilis may manifest itself -in the form of an epilepsy. Kraepelin is of the opinion that these -conditions usually result from endarteritic involvements. In their -development they show nothing differing in any way from an ordinary -epilepsy. The attacks are usually mild at first, gradually increasing -in severity, and are much aggravated by alcohol. There are, however, -the usual physical signs of brain lues and later speech defects appear. -There is eventually an emotional and intellectual deterioration. The -changes in the spinal fluid are those described as characteristic of -the other form of syphilis. - -Kraepelin describes the paranoid forms as very uncertain in type and -not so well defined. Hallucinations and delusions play the principal -part with physical disturbances in the background. They become more or -less prominent, however, eventually. The patient is usually anxious, -restless, suspicious and develops delusions with characteristic ideas -of jealousy on a sexual basis. Full-fledged persecutory trends also -appear, usually with numerous hallucinations. Occasionally delusions -of sin and self-accusation are noted, although ideas of grandeur -mixed with complaints of persecution are more common. Consciousness -remains undisturbed as a rule and there is no disorientation. The -mood is changeable, at times depressed, tearful, anxious, irritable, -complaining, but often cheerful and self-satisfied. There is -usually more or less emotional dulness, with an indifference to the -surroundings. The emotional life is shallow and superficial. Sudden -excitements may occur at times with outbursts of anger. There are -usually no striking conduct disorders. There may be occasional seizures -of a mild form, fainting attacks, dizziness, rarely epileptiform -attacks or slight apoplectiform symptoms. Sooner or later the physical -signs of brain syphilis develop. The course of the disease is slow. -Similar pictures are noted in tabes. The therapeutic test is not to -be relied upon too strongly in making a diagnosis or differentiating -between paresis and syphilis. It must be remembered that after all -we are dealing here with one disease process. It has been found that -in many syphilitics, even in recent cases, a positive Wassermann -reaction, an increase in the cell count or in the protein content may -occasionally be demonstrated in the spinal fluid. - -In a study of 428 cases of neurosyphilis treated in Boston, Raeder[187] -reported that 129, or practically thirty per cent, showed definite -improvement, both physical and mental. He did not make any extravagant -claims as to final results to be expected. "The therapia praesens of -neurosyphilis is but a transition state in rational syphilography. -Medical science has discovered several good clues which must be -followed up; and others ferreted out and run down before the solution -of the problem is complete. Indeed the successful treatment of -paresis and tabes, as well as general vascular syphilis and visceral -tertiaries, such as the crippling cradio-pathia, etc., may ultimately -be realized in the field of preventive medicine. With chemotherapy, -however, Ehrlich has doubtless found the most vulnerable approach to -the treponemiatic diseases, but further research is necessary and other -combinations must be found before the life of this anthropophagus pest -is successfully snuffed out." - -Warthin[188] at autopsy found evidences of active syphilis in a series -of forty-one inactive or "cured" cases investigated by him. Eleven of -these had been treated, were supposed to have recovered and showed -no syphilitic manifestations at the time of death. Five had received -an extended course of salvarsan therapy and in twenty-five there -was no history of syphilis at all. Spirochaetes were demonstrated -by the Levaditi method in thirty-six of the forty-one cases—in the -aorta in thirty-two, in the testes in thirty-one, in the liver in -four, in the adrenals in six, in the pancreas in six, in the spleen -in one and in the nervous system in five. In some of these cases the -Wassermann reaction was reported as negative. Warthin concluded that -cured syphilis in many if not all instances is in a latent condition, -spirochaetes of a low virulence still remaining active. - -For purposes of statistical study the American Psychiatric Association -has not attempted any clinical differentiation of the various types -of this disease, a procedure which was felt to be inadvisable at -this time. The following suggestions appear in the manual as to the -classification of psychoses due to cerebral syphilis:— - -"Since general paralysis itself is now known to be a parenchymatous -form of brain syphilis, the differentiation of the cerebral -syphilis cases might on theoretical grounds be regarded as less -important than formerly. Practically, however, the separation of the -non-parenchymatous forms is very important because the symptoms, the -course and therapeutic outlook in most of these cases are different -from those of general paralysis. - -"According to the predominant pathological characteristics, three types -of cerebral syphilis may be distinguished, viz.: (a) Meningitic, (b) -Endarteritic, and (c) Gummatous. The lines of demarcation between -these types are not, however, sharp ones. We practically always find in -the endarteritic and gummatous types a certain amount of meningitis. - -"The acute meningitic form is the most frequent type of cerebral -syphilis and gives little trouble in diagnosis; many of these cases -do not reach state hospitals. In most cases after prodromal symptoms -(headache, dizziness, etc.) there is a rapid development of physical -signs, usually cranial nerve involvement, and a mental picture of -dulness or confusion with few psychotic symptoms except those related -to a delirious or organic reaction. - -"In the rarer chronic meningitic forms which are apt to occur a long -time after the syphilitic infection, usually in the period in which -we might expect general paralysis, the diagnostic difficulties may be -considerable. - -"In the endarteritic forms the most characteristic symptoms are those -resulting from focal vascular lesions. - -"In the gummatous forms the slowly developing focal and pressure -symptoms are most significant. - -"In all forms of cerebral syphilis the psychotic manifestations are -less prominent than in general paralysis and the personality is much -better preserved as shown by the social reactions, ethical sense, -judgment and general behavior. The grandiose ideas and absurd trends of -the general paralytic are rarely encountered in these cases." - -It is only of comparatively late years that the hospitals of this -country have shown the frequency of psychoses due to cerebral syphilis -in their reports. Statistical studies indicate that such mental -conditions are quite unusual as compared with other well recognized -clinical entities. In a total of 49,640 first admissions reported by -the New York state hospitals during a period of eight years only 342, -or .67 per cent, were reported as mental diseases due to cerebral -syphilis. The Massachusetts hospitals during 1919 reported only -twenty-seven cases, a percentage of .89. Twenty-one hospitals in -fourteen other states, in a total of 18,336 admissions, showed only 124 -cases (.67 per cent) of cerebral syphilis. This represents, therefore, -a total of 70,987 admissions with only 493 diagnosed as psychoses due -to cerebral syphilis,—a percentage of .69. When this is compared -with eleven per cent as shown by the admissions for general paresis -it is probably a very fair index of the comparative frequency of the -two diseases in our institutions. It is interesting to note that the -incidence of cerebral syphilis as shown by the hospitals of the various -states is almost exactly the same. The admission rate for the Casa de -Orates in Santiago, Chili, in 1918, as shown by Letelier, was .90 per -cent. - - - - -CHAPTER VI - -THE PSYCHOSES WITH HUNTINGTON'S CHOREA, BRAIN TUMOR AND OTHER BRAIN OR -NERVOUS DISEASES - - -Huntington's chorea is said to have been referred to first by C. O. -Waters of Franklin, N. Y., in Dunglison's "Practice of Medicine" in -1842. An article on the subject by Irving W. Lyon also appeared in -the _American Medical Times_ in 1863. The name by which the disease -is now generally known was the result of an elaborate description of -its symptomatology by George Huntington in the _Medical and Surgical -Reporter_ in 1872. He particularly called attention to the fact that -it is hereditary in origin, occurs in adult life, is associated -with suicidal tendencies and often exhibits mental symptoms. On -the important subject of heredity Huntington made the following -observation: "If one or both of the parents have shown manifestations -of the disease, and more especially when these manifestations have been -of a serious nature, one or more of the offspring almost invariably -suffer from the disease if they live to adult life; and if by any -chance these children get through life without it, the thread is broken -and the grandchildren or great grandchildren may rest assured that they -are free from the disease. Unstable and whimsical as the disease may -be in other respects, in this it is firm; it never skips a generation -to manifest itself in another; as soon as it has yielded its claims, -it never regains them." A well known monograph on the subject by Osler -appeared in 1894. - -McCarthy[189] refers to the mental condition associated with this -disease as "a severe and gradually progressive deterioration, -ultimately ending in absolute dementia. In some cases the mental defect -is noted from the onset of the symptoms, in others the mentality may -remain unimpaired for years. Mental deterioration is the rule, and it -is associated with a loss of memory and a tendency to self-destruction -which gradually develops. When the mental degeneration is well marked, -outbreaks of violence are sometimes noted. In one of the writer's -patients, as the disease progressed, the clinical picture of paresis -was presented. The chronic delusional state is more often noted than -would be inferred from Huntington's description." Hamilton,[190] who -made a clinical study of a considerable series of cases in 1907, -expressed the opinion that mental deterioration occurs in the majority -of instances before the onset of choreiform symptoms. He found a -special tendency to deterioration in the cases appearing early in -life, while irritability and delusional ideas were more often observed -in those developing in later years. Delusions of persecution and -deterioration, however, were symptoms more or less common to both -groups. Diefendorf,[191] in a study of twenty-eight cases in 1908, -called attention particularly to the irritability with occasional -outbursts of violence as well as attacks of despondency. He emphasizes -emotional deterioration and indifference. - -Kraepelin[192] also refers to the fact that the mental symptoms may -precede the choreiform manifestations in appearance, sometimes by a -number of years. The patients become forgetful, defective in judgment, -somewhat dull, show a poverty of thought and an incapacity for orderly -activities. Generally there is an emotional depression, often with -irritability and more rarely euphoric symptoms. Delusions gradually -develop. These are of a persecutory nature, although ideas of grandeur -appear at times. Suicidal tendencies are common. Disturbances of -perception and memory may be very pronounced. The relation of the -patient to his environment becomes very much confused. In some cases, -on the other hand, the mental symptoms are not very striking. Anxious -states, outbursts of anger or emotional excitements may appear at -times. Appetite and sleep are often interfered with. The pathology of -this disease is not characteristic. There may be a chronic meningitis -or extensive atrophies. The cells of the third layer of the cortex, -according to Kraepelin, are decreased in number with an increase of -glia nuclei. The remaining cells are shrunken with deeply staining -processes, and there is a considerable loss of tangential fibres. -Sclerotic changes with thickened walls are noted in the blood vessels. -Hyaline degeneration and miliary hemorrhages have been observed, -although Nissl and Alzheimer found no vascular lesions worthy of note. -The cortical changes, according to Räcke, are more pronounced in the -central convolutions, being much less conspicuous in the frontal and -occipital regions. Alzheimer found the corpus striatum particularly -involved. Here he noted a striking cell loss, with glia proliferation -but no vascular changes. D'Ormea, according to Kraepelin, traced the -disease through five generations in one family and Browning went as far -back as two hundred years in another. - -The observations on the subject of Huntington's chorea in the -statistical manual of the American Psychiatric Association are as -follows:— - -"Mental symptoms are a constant accompaniment of this form of chorea -and as a rule become more marked as the disease advances. Although the -disease is regarded as being hereditary in nature, a diagnosis can be -made on the clinical picture in the absence of a family history. - -"The chief mental symptoms are those of mental inertia and an emotional -change, either apathy and silliness or a depressive irritable reaction -with a tendency to passionate outbursts. As the disease progresses the -memory is affected to some extent, but the patient's ability to recall -past events is often found to be surprisingly well preserved when the -disinclination to cooperate and give information can be overcome. -Likewise the orientation is well retained even when the patient -appears very apathetic and listless. Suspicions and paranoid ideas are -prominent in some cases." - -Statistical reports from American institutions show that comparatively -few cases of Huntington's chorea are committed. In 49,640 first -admissions to the New York state hospitals only forty-eight, or .09 per -cent, were diagnosed as Huntington's chorea during a period of eight -years. The admission rate to the Massachusetts hospitals during 1919 -was exactly the same. In twenty-one hospitals in fourteen other states -twenty-four cases (.13 per cent) in 18,336 admissions were reported as -Huntington's chorea. There were only seventy-five cases (.1 per cent) -in 70,987 admissions to forty-eight hospitals in sixteen different -states. - - -_Psychoses with Brain Tumor_ - -Brain tumors are more common perhaps than is generally understood. -Cushing[193] shows that they were found in fifty-five, or 1.7 per cent, -of 3,150 autopsies at the Johns Hopkins Hospital. He refers to Siedel, -who observed them in 1.25 per cent of his cases in Munich and states -that Blackburn found them in about two per cent of 1,642 autopsies at -the St. Elizabeths Hospital in Washington. He also quotes Bruns as -saying that two per cent of all neurological cases show intracranial -growths. In the first twenty-five hundred surgical conditions admitted -to the Peter Bent Brigham Hospital in Boston eight per cent were -diagnosed as brain tumor. Cushing found that 66.6 per cent of 130 -carefully studied growths were gliomata. Nearly four per cent were -endotheliomas. In another series of seventy cases he found twenty-seven -gliomas (38.5 per cent), seventeen adenomas (twenty-four per cent), -seven endotheliomas (ten per cent), five interpeduncular and mixed -growths (seven per cent), and other forms in smaller percentages. Many -of the endotheliomas have undoubtedly been included in the past with -the sarcomas. This may also be said of gliomas. - -According to Cushing, growths in the brain may give rise to no -disturbance whatever, show well defined focal signs, occasion only -general manifestations, or have both general and focal symptoms, -depending on the location of the neoplasm. General symptoms may be -briefly summarized as follows:—headache, vomiting, choked disc, -vertigo, drowsiness, convulsions, disturbances of the pulse rate, -respiration and temperature, as well as mental disorders. The focal -signs depend wholly on the site of the growth. Cushing mentions the -following symptom complex as resulting from lesions of the frontal -lobes:—"Indifference, unpunctuality, mental enfeeblement, loss of -memory and power of attention, change in disposition with more or less -marked irritability or taciturnity or obstinacy or jocularity, etc., -often a rambling speech, lack of realization of the illness, and change -in the general conduct of life with habits of untidiness. These, in -greater or less degree, characterize most of the cases, although it is -often astonishing to find how inconspicuous the symptoms may be with a -very extensive growth. They may often be of rather abrupt onset and not -until the situation of the lesion is definitely disclosed and careful -interrogation made into the patient's previous mental state is it -possible to learn that in all probability some mental alteration has -been of long standing." - -Bruns did not find psychoses associated very often with frontal -lesions. Jacobi, however, in reviewing the literature of growths in -that region, found mental symptoms in forty-nine per cent. Schuster -observed them in from fifty to sixty per cent of all brain tumors. -Redlich[194] described mental conditions as being either incidental and -not related to the growth, or definitely caused by it, and was even of -the opinion that the neoplasm could in some instances be the result of -a psychosis. Two of Redlich's patients, moderately alcoholic, showed a -typical Korsakow syndrome. He refers to the fact that in cases reported -by Oppenheim, Friedrich and Fürstner, "Witzelsucht," or the tendency to -joke, disappeared after growths were removed from the frontal region. -A patient of Begerthal, who had hallucinations, delusions and somatic -symptoms, recovered after a tubercle was excised from the paracentral -lobule. A case of Friedrich's which showed an alteration of the -personality, erotic symptoms, sudden explosive laughter, poor memory, -etc., recovered after a sarcoma was removed from the right frontal -lobe. A patient of Thoma's after three attacks of mental depression -showed a gliosarcoma in the occipital lobe at autopsy. Schuster, Bruns -and Schönthal have reported cases of brain tumor with hysterical -manifestations. - -Redlich described the psychoses associated with cerebral growths -as being epileptiform in character and origin and resembling -post-epileptic psychoses in their symptomatology, with irritability, -excitement or violence, confusion, delirium and hallucinations, often -followed by partial amnesia. Epileptic manifestations may occur in the -form of equivalents during the development of the growth. Bernhardt and -Oppenheim have called attention to episodes of vertigo, irritability, -excitement, clouding and occasional delirium with amnesia following -intense paroxysms of headache. These attacks also strongly suggest -the characteristics of epileptic psychoses. Nothnagel, Bernhardt, -Oppenheim, Schuster, Ziehen and others attribute the mental symptoms -associated with brain tumor to increased intracranial pressure -producing an anaemia. Klippel, Maillard, Vigouroux, Kaplan and others -believe that they are due to toxins originating in the growth. This -view is based largely on the appearance of psychoses similar to the -Korsakow syndrome. Knapp in 1906 called attention to the prominence of -mental symptoms in growths occurring in the anterior portion of the -corpus callosum. These may be associated with intellectual defects, -apraxia, speech disturbances and stupor. Gianelli found mental -disturbances in 209 of 318 cases examined. - -Kraepelin[195] attributes the mental symptoms of growths to an injury -of the brain structure, changes in intracranial pressure, circulatory -disturbances, and the absorption of toxic substances. A growth of -considerable size but of slow development may permit of a readjustment -of pressure, etc., and show few symptoms. On the other hand, a -small neoplasm on account of its site or rapidity of growth may be -accompanied by profound mental disturbances resulting from chemical -irritation, obstruction of the aqueduct of Sylvius, or circulatory -interferences. Kraepelin quotes Schuster (1902) as finding psychotic -symptoms in all cases of growths in the corpus callosum, in two-thirds -of those of the hypophysis, in one-third of those of the cerebellum and -in one-fourth of the cases with involvement of the brain stem. These he -looks upon as pressure symptoms except in the case of the callosal -neoplasms. Schuster was of the opinion that growths in the cortex -usually lead to actual psychoses and those in the deeper areas to -dementia. He found a general mental deterioration in 423 out of a total -of 775 cases of brain tumor. The patients were indolent, inattentive, -clumsy, forgetful, dull, tired easily and lost more and more their -capacity and inclination for sustained exertion. Thought, decision and -mental processes generally, required an unusual amount of effort. The -patients usually became somewhat confused and disoriented in regard to -time, place and person, as well as incoherent in speech. In many cases -there is a marked memory disturbance with a tendency to fabrication -suggesting Korsakow's psychosis. Delirious states with hallucinations -sometimes accompany growths in the posterior lobes. Kraepelin has also -observed hallucinations in cases with tumor of the cerebellum. Many -develop hypochondriacal ideas, others have delusions of persecution or -self-accusation and suicidal tendencies. Rarely there are delusions of -grandeur. The mood is usually anxious, depressed and at times -irritable or apathetic. Occasionally the patients may, on the other -hand, be cheerful in spite of the hopeless condition they are in. -They may even show distractibility, flight of ideas, volubility and -excitement. There is more often a childish elation with a tendency to -joking and facetiousness. Schuster found this more common in frontal -involvements. Kraepelin also called attention to restlessness and -excitements often leading to violence. This may alternate with mental -dulness and cataleptic states. The patients may repeat words and make -meaningless response to questions, strongly suggesting katatonia. -Mental dulness becomes more and more marked, however, even reaching -a stuporous stage. To this is added, according to the location of -the growth, focal symptoms of various kinds—headache, disturbance -of vision, seizures, paralyses, aphasia, agraphia, articulatory -disturbance, ataxia, etc. Special symptoms arise where psychogenic -factors play a part,—excitements with paralyses or disturbance of -perception, etc. Hysterical stigmata may appear. Cases with growths in -the frontal region occasionally simulate general paresis but should be -distinguished without difficulty. - -The Association's statistical manual has the following to say of -psychoses with brain tumor:— - -"A large majority of brain tumor cases show definite mental symptoms. -Most frequent are mental dullness, somnolence, hebetude, slowness in -thinking, memory failure, irritability and depression, although a -tendency to facetiousness is sometimes observed. Episodes of confusion -with hallucinations are common; some cases express suspicions and -paranoid ideas. - -"The diagnosis must rest in most cases on the neurological symptoms, -and these will depend on the location, size and rate of growth of -the tumor. Certain general physical symptoms due to an increased -intracranial pressure are present in most cases, viz.: headache, -dizziness, vomiting, slowing of the pulse, choked disc and interlacing -of the color fields." - -The number of cases reaching hospitals for mental diseases is, of -course, small. In 49,640 first admissions to the New York state -hospitals in eight years there were sixty-seven cases (.14 per cent) -of psychoses with brain tumor. In 18,336 admissions to twenty-one -hospitals in fourteen other states there were eighteen cases (.09 per -cent) diagnosed as psychoses with brain tumor. There were ninety-three -cases (.13 per cent) in 70,987 first admissions to forty-eight -hospitals for mental diseases in sixteen different states. - - -_Psychoses with Other Brain or Nervous Diseases_ - -Cerebral hemorrhages, thrombosis and embolism are more or less -intimately associated etiologically, pathologically and clinically. -They all bear a rather definite relation to the general question of -arteriosclerosis and may all lead to cerebral softening. Apoplexy is -a term which was employed by Aristophanes, Demosthenes and Sophocles -and has been in general use for centuries. It was known to Chaucer and -was referred to in Shakespeare's works ("Henry IV"). It was studied -very elaborately by Sydenham and many other early writers. Charcot and -Bouchard in 1864 called attention to the relation existing between -miliary aneurysms of the cerebral vessels and hemorrhages. In a study -of the cerebral vascular lesions at the University College Hospital, -London, Jones (_Brain_, 1905) found records of one hundred and sixty -cases occurring during a period of sixty-five years. Of these, 123 -showed hemorrhages; twenty-four, thrombosis; and thirteen were due to -embolism. - -Thomas[196] states that: "The symptoms following acute vascular lesions -of the brain, whether the process be the rupture of a vessel or its -occlusion, are in many respects identical; and clinically it is often -impossible to determine which process has been effective." He calls -attention to the fact that in thrombosis the final closure of a vessel -may occur suddenly and the symptoms develop with great rapidity. On -the other hand, the rupture of a vessel may mean the escape of only a -small quantity of blood and after an embolism the circulation is not -always stopped immediately. In an analysis of 401 apoplectic attacks -Thomas found no loss of consciousness in 202 cases, although it was -interrupted or markedly disturbed in 199. Jones found a complete loss -of consciousness in 47.7 per cent of 201 cases of cerebral embolism -and a partial disturbance in sixty per cent. He reported consciousness -affected in seventy-five per cent of his cases of cerebral hemorrhage -and in 45.5 per cent of those of thrombosis. When it occurs it is -usually not the initial symptom in his experience, being preceded by -headache, vertigo, weakness in certain parts of the body, etc. An -analysis of the cases of embolism reported by Virchow, however, showed -a sudden loss of consciousness as the initial symptom to be the general -rule. Gowers is of the opinion that an initial softening is a more -common occurrence than hemorrhage. - -In the young, apoplectic attacks are usually due to cerebral softening, -thrombosis following acute disease or embolism resulting from -endocarditis. Between the ages of twenty and forty apoplexies usually -mean syphilitic thrombosis. In the later decades of life, either -hemorrhage, thrombosis, embolism or softening may occur. Thomas[197] -collected from various hospitals, statistics of 840 cases. Of these, -499 showed hemorrhages and 341 softenings. He is of the opinion that -the presence of premonitory symptoms for some days indicate thrombosis, -while shorter prodromal periods point to a hemorrhage. Rapidly -developing coma suggests hemorrhage, while a widespread paralysis -without much disturbance of consciousness is more common in thrombosis. -A marked fall of temperature and rise of blood pressure as a rule -means a hemorrhage. Repeated convulsions are more often associated -with softening or embolism. If the symptoms indicate a capsular lesion -it favors hemorrhage, and if of a cortical type, softenings are -more likely. A positive Wassermann reaction suggests thrombosis or -softening. The presence of endocarditis with heart murmurs points to -embolism. Thomas finds that, while the patient may recover from either -of these conditions without apparent intellectual defect, he is liable -to be petulant, emotional, depressed and tire easily. - -In psychoses following hemorrhage, thrombosis and embolism -Kraepelin[198] as a rule finds very little relation between the nature -of the lesion in question and the symptoms to be expected. Immediately -following the seizure the patients become dull, clouded, confused -and disoriented, and peculiar in their behavior. This is followed by -an active excitement with loud cries, resistiveness and struggling. -These acute disturbances usually subside, leaving, however, evidences -of the arteriosclerosis or syphilitic endarteritis which caused the -hemorrhage or thrombosis. Embolism may leave an apparently permanent -mental deterioration with aphasic and paraphasic manifestations which -often entirely clear up. In lesions of younger persons due to syphilis, -mental enfeeblement may follow. - -Our knowledge of the psychoses accompanying paralysis agitans is very -inadequate. The disease was first fully described by Parkinson in an -English publication in 1817, although, according to Camp, similar -cases were reported by Schwarz in 1766. The etiology of this condition -is unknown and the pathology is not at all definite. It seems to be -the rather general opinion of neurologists that mental disturbances -are quite rare in Parkinson's Disease. Camp,[199] for instance, has -the following to say on this subject:—"Mental conditions have also -been described, but usually the patient's mind is entirely clear. In -the very old the changes incident to senility, such as irritability, -childishness, etc., insomnia and memory changes, might be expected and -may require special treatment. Often these patients are emotionally -unstable and spells of forced weeping or laughter occur." Krafft-Ebing -refers to mental weakness in paralysis agitans and speaks of the -frequency of melancholia with hallucinations and suicidal impulses -occurring intermittently and appearing with exacerbations of the -disease. He speaks of premature senility as playing the most important -etiological rôle. McCarthy[200] expresses the opinion that: "Beyond -a tendency on the part of some patients to adopt a whining and -complaining manner, the mind remains very clear; in fact, the good -nature and complaisance of most of the patients, in spite of the -severity of the symptoms, is a matter of common observation. Dementia -may, however, complicate a case of the disease." On the other hand, -Parant, a French writer who made an elaborate study of this subject in -1883, described three distinct varieties of mental disturbance observed -by him. In the milder cases he found changes in the personality. -This is shown by irritability, egotism, restlessness, suspicion, -undue sensitiveness regarding their disease, mild persecutory ideas, -tendencies to depression, indifference and apathy. The second class -of cases described included mental deterioration with difficulty -of thought, loss of memory, etc. The third group includes definite -psychoses characterized generally by depressions with or without -hallucinations and delusions. Hallucinations of sight are said to be -common. Delusions of persecution are prominent and hypochondriacal -and somatic ideas frequently occur. Suicidal tendencies are very -pronounced. According to Ball, these episodes come and go "with the -aggravation of the sensory symptoms, and they seem to disappear when -the tremor decreases or ceases entirely." The usual tendency in these -cases, as shown by Parant, is to terminate in complete deterioration. - -Of the inflammatory conditions of the meninges Kraepelin[201] makes -special reference to mental disturbances associated with tuberculosis. -The patient is depressed, anxious, irritable and apathetic, often with -the first appearance of the disease. Dulness and memory disturbances -become more and more apparent. The patient soon becomes clouded and -disoriented, confused and delirious. Occasionally hallucinations -appear. The disturbance of consciousness becomes more and more marked. -The patient becomes incoherent, restless, noisy and often violent. -The excitement may reach the stage of an actual mania with delirious -confusion. Sometimes the symptoms are strongly suggestive of katatonia. -In alcoholics a condition very similar to delirium tremens develops, -terminating as a rule in stupor and coma. Speech disturbance, aphasia, -convulsions, hyperesthesia or muscular weakness may be observed in -such cases. Other forms of meningitis are quite similar but more rapid -in development and of shorter duration. In some instances, as after -epidemic cerebrospinal meningitis, states of mental enfeeblement may -follow the disease. - -It must be admitted that our information on the subject of multiple -sclerosis is far from being complete. In a discussion of the mental -symptoms accompanying this condition, Henderson[202] expressed the -following views:—"Cases of disseminated sclerosis which present -definite, well marked psychoses are extremely rare. When mental -symptoms do occur, they usually come on when the condition is well -advanced, the most common symptoms are mild euphoria, labile mood, -apathy and dullness, and a slightly defective memory. In some -cases, however, depression has been described as the outstanding -feature, while hallucinations of sight and hearing are not uncommon -accompaniments. In certain cases the mental symptoms may come on -early, and these are usually of excessive severity and are rapidly -followed by complete dementia." Dunlap has described cases associated -with general paresis and showing the characteristic lesions of both -diseases at autopsy. According to Kraepelin[203] mental disturbances -sometimes appear before physical symptoms are observed. These take the -form of depression, anxiety, fear, with occasional deliria, hysterical -manifestations, emotional dulness, variable moods and a marked -irritability. Later in the disease more marked euphoric or depressive -tendencies appear, with excitements and confusional states. Delusions -of a persecutory nature, or ideas of grandeur may be observed. -Hallucinations are infrequent. According to Kraepelin, from ten to -thirty per cent of the cases terminate in a general mental enfeeblement -which is not usually of an advanced degree. He also describes a lobar -cortical sclerosis with much more marked mental disturbances suggesting -dementia praecox. - -Various mental conditions have been attributed to tabes. Sachs[204] -speaks of depressions and neurasthenic conditions with irritability as -a special symptom. He has observed paranoid states and manic attacks, -sometimes with periods of "transitory dementia" with or without -aphasia. He also expresses the opinion that tabetics may develop -all of the symptoms of general paresis, although he says that the -coexistence of the two diseases is rare. Kraepelin[205] speaks of -milder forms of psychoses characterized by uncertainty of memory, -fatigability and emotional instability. Many cases exhibit a hopeless, -gloomy attitude with depression and fears, or they may be surly, -irritable and quarrelsome. Others show a surprisingly good humor. -The emotional disturbances often suggest general paresis. Kraepelin, -however, describes the characteristic psychosis of locomotor ataxia -as assuming a paranoid form and quotes Meyer as reporting paranoic -conditions in twenty-six tabetics and depressions of various types -in fourteen. He also speaks of hallucinatory excitements resembling -alcoholic conditions. These are characterized by a sudden anxiety -and restlessness with hallucinations of both hearing and vision. The -patients complain of poisoning and sensations of electricity, but -are cheerful in mood and well oriented. This condition may last for -weeks or months, ending in a sudden recovery, often with relapses. -Shorter hallucinatory delirious states resembling crises are also -referred to by Kraepelin. More chronic conditions are noted, with -hallucinations, persecutory delusions and ideas of grandeur. Delirium -tremens, manic-depressive attacks, katatonia or senile psychoses may be -associated with tabes. - -The literature of medicine contains many references to acute chorea. It -was referred to, according to Paton, by Plat as early as 1614 and was -discussed by Sydenham at some length. Wharton Sinkler, in describing -chorea in Pepper's "System of Medicine" in 1886, made the following -interesting remarks on the mental changes involved:—"The child is -irritable and feverish, cries and laughs readily, or is sullen and -morose. Sometimes he is violent to those about him but this is rare. -Intellectually the patient suffers somewhat. He is not able to study -as before, and the memory may be impaired. Sometimes there is a mild -form of dementia." Burr[206] divides these conditions into four -groups:—"First (and this includes the vast majority), patients in -whom there is peevishness, fretfulness, some loss of the power of -fixing the attention, and a slight loss of the moral sense shown by -disobedience and selfishness. Second, those showing in addition to -the above symptoms, night terrors, and transitory, visual, auditory, -or other hallucinations. Third, those with distinct delirium, wild -or mild, accompanied with fever. Fourth (and this group is very -small when we remember how common chorea is), those showing stupor, -or rather stupidity, and an acute dementia, which may follow the -condition described under three, or appear without any preceding -mental symptoms at all severe, and which is usually accompanied with -trouble on articulation not caused by choreic movements of the lips -and tongue, but the result of mental hebetude." White[207] refers to -the irritability and emotional instability of choreics and describes a -psychosis in "chorea insaniens" characterized by an acute confusion, -sometimes of a violent type with hallucinations, or a paranoic -condition with delusions of persecution. This may develop into a -stuporous state. Kraepelin describes the psychotic manifestations of -acute chorea as forms of delirium due to infection with characteristic -states of clouding, confusion, etc. Wechsler has expressed similar -views. - -Encephalitis lethargica is a disease which has received a great deal -of attention during the last few years. The term was first applied -by von Economo[208] to a series of cases observed by him in Vienna -in 1917, although, as he has pointed out, similar epidemics occurred -as early as in 1712. This condition is characterized particularly by -lethargy, facial and oculomotor paralyses and a rise of temperature. -Cases were reported from England and France by various observers -in 1918 and by Pothier, Neal and others in this country in 1919. -It has been suggested frequently that the disease is in some way -associated with influenza. The pathological findings have also been -confused with the African sleeping sickness due to trypanosomes. -After such prodromal symptoms as headache, malaise and drowsiness -with muscular weakness for a few days, a lethargic or stuporous state -usually develops, interrupted occasionally by delirious attacks. -Ptosis has been reported, sometimes with immobility of the pupils. -Paralyses of the facial and eye muscles are very common. Buzzard and -Greenfield[209] after a review of twenty-two cases suggested the -following symptomatological classification:—1. Cases characterized by -hemiplegia, hemianesthesia, hemianopsia, etc.; 2. Cases characterized -by symptoms resembling those of paralysis agitans:—the basal ganglia -group; and 3. Cases characterized by a disturbance of the cranial -nerve functions. In a publication issued recently by the United States -Public Health Service the various types of the disease were summarized -as follows:—1. A clinical affection of the third pair of nerves; -2. Affections of the brain stem and bulb; 3. Affections of the long -tracts; 4. The ataxic type; 5. Affections of the cerebral cortex; 6. -Cases with evidence of spinal cord involvement; and 7. The polyneuritic -type with involvement of the peripheral nerves. The Massachusetts -Department of Public Health has recently recommended the use of the -MacNulty classification, which is quite similar in some respects:— - - 1. Symptoms of a general nature referable to the central nervous system - with no localizing signs. - - 2. General symptoms with third nerve paralysis. - - 3. General symptoms with localizing signs of facial paralysis. - - 4. General symptoms with localizing signs extending down to the cord. - - 5. General symptoms with polyneuritic involvements. - - 6. Mild and abortive cases. - -Autopsies have shown meningeal and cortical congestion, degeneration -of the nerve cells, and thickening of the vessels with endothelial -proliferation of the glia. Venous thrombosis and multiple hemorrhages -also occur. In a study of the cerebrospinal fluid Boveri[210] found the -pressure slightly greater in many cases with an increase in the albumen -and globulin content and a mild lymphocytosis in occasional cases. The -findings are not characteristic or of great diagnostic value. Efforts -to isolate the organism responsible for this disease have so far been -unsuccessful. - -The mental symptoms associated with encephalitis lethargica have been -studied recently by Abrahamson[211]. He finds that the patient can be -aroused from the initial lethargy and responds quickly and coherently -to questions, relapsing again into an apparent sleep. Some irritability -is shown. The attitude "expresses a desire to be left alone." If the -somnolence disappears it is usually followed by a period of depression. -The patient complains of weariness and inability to sleep. Choreic -manifestations sometimes occur. The somnolence may terminate, on the -other hand, in a profound stupor resembling a drug intoxication with -a restless delirium. Even then the patient can be roused momentarily. -Responses are automatic with no evidences of emotional disturbance. -Flexibilitas cerea is often present. This condition may be followed by -a period of confusion, disorientation and amnesia suggesting Korsakow's -disease. There is usually a period of mental depression with poverty of -thought. Occasional hallucinations were also observed. - -An exceedingly important contribution to the literature of encephalitis -lethargica is an analysis recently made of the symptoms shown in -eighteen cases by Kirby and Davis.[212] "The psychic disturbances of -epidemic encephalitis present the general characteristics of an acute -organic type of mental reaction, corresponding more specifically to -a toxic-infectious psychosis. In the acute stages of the disease, -psychic torpor and delirium are the most frequently observed mental -disturbances although other clinical pictures may be encountered, -as the Korsakoff syndrome or more complex mental disorders in which -various affective and trend reactions give a special cast to the -psychotic disturbance." They report two types of sleep disturbance, -hypersomnia and hyposomnia. The former is characterized by drowsiness, -lethargy, stupor or coma, depending entirely on the degree reached. In -the latter the patient is sleepless at night and somnolent during the -daytime. Usually delirium was present at some time in both types of -the disease. Often there was a brief period showing a mild depression -or anxiety, following lethargy or delirium. Euphoria was observed -in a number of instances. In the unrecovered cases they often found -residuals—"depressive affects, emotional elevations, irritability, -explosive reactions, stubbornness, apathy, etc." Their findings may be -summarized perhaps in the statement that "definitely formulated and -persistent trends are infrequent in epidemic encephalitis ... we have -found much evidence of persisting emotional alteration with little -evidence of organic mental defects or dementia." - -A review of the statistics of American institutions shows that -psychoses associated with brain and nervous diseases other than -Huntington's chorea and brain tumor, which have already been discussed, -are exceedingly rare. The percentage of cases reported in the New -York hospitals was .95, in the Massachusetts institutions, 1.02, and -in twenty-one other hospitals only 1.56. In a total of 70,987 first -admissions there were only 787 cases (1.1 per cent). The relative -frequency of the various forms is illustrated by the statistics of the -admissions to the New York state hospitals during a period of eight -years. Of 462 cases, 160 were diagnosed as psychoses due to cerebral -embolism; twelve, to meningitis; twenty, to multiple sclerosis; -thirty-eight, to tabes; thirty-four, to acute chorea; and 163, to -other conditions not specified. These figures are astonishing when the -fact that 49,640 patients were admitted during that time is taken into -consideration. - - - - -CHAPTER VII - -THE ALCOHOLIC PSYCHOSES - - -According to Tuke,[213] one of the oldest of the Egyptian papyri in the -British Museum (Papyrus Sallier I) makes the following very interesting -reference to alcoholism:— "Whereas it has been told me that thou hast -forsaken books, and devoted thyself to pleasure; that thou goest from -tavern to tavern, smelling of beer, at the time of evening. If beer -gets into a man it overcomes his mind.... Thou knowest that wine is an -abomination, that thou hast taken an oath that thou wouldst not put -liquor into thee. Hast thou forgotten thy resolution?" It is difficult -to realize that this refers to one of the earliest periods of recorded -history. Hebrew, Greek and Roman literature are prolific in equally -significant testimonials to the antiquity of alcohol as an intoxicant. -It was referred to at considerable length by Aristotle, Plutarch and -Hippocrates. That Haslam appreciated the important relation existing -between alcoholism and mental disorders is shown by the following -comment on this subject written in 1808:—"Thus a man is permitted -slowly to poison and destroy himself; to produce a state of irritation, -which disqualifies him from any of the useful purposes of life; to -squander his property among the most worthless and abandoned; to -communicate a loathsome and disgraceful disease to a virtuous wife; to -leave an innocent and helpless family to the meagre protection of the -parish. If it be possible the law ought to define the circumstances -under which it becomes justifiable to restrain a human being from -effecting his own destruction, and involving his family in misery and -ruin. When a man suddenly bursts through the barriers of established -opinion; if he attempts to strangle himself with a cord, to divide his -large blood vessels with a knife, or swallow a vial full of laudanum, -no one entertains any doubt about his being a proper subject for the -superintendence of keepers; but he is allowed, without control, by a -gradual process, to undermine the fabric of his health and destroy the -property of his family." - -Curiously enough the word alcohol is of Arabic origin and was employed -originally to describe a powder used in applications to the eyebrows -for cosmetic purposes. It was subsequently used for centuries as -referring to a fine powder of any kind, as is shown by the writings -of Paracelsus and others. The chemical composition of alcohol was not -known until 1808, when it was described by Lavoisier. On the other -hand, Salvatori in 1817 and Hufeland in 1818 referred to dipsomania -as a disorder due to alcoholism. Esquirol, Trélat and other early -writers included it in the "partial" insanities. Morel described it -as an impulsive form of "délire émotif" and looked upon it as an -hereditary condition. It has been classified with the periodical -insanities and even as a form of melancholia. Magnan saw in it an -episode of the insanity of degeneracy. Magnus Huss was responsible for -the introduction of the term "chronic alcoholism" as descriptive of a -pathological condition in 1852. - -It is said that Caelius Aurelianus protested against the use of -intoxicants in the treatment of the insane. Notwithstanding this early -reference to a question of such importance, and the inauguration of -the great temperance crusade which began in 1808, it has been shown -by Tuke[214] that alcoholic beverages were issued in a routine way to -patients and employees of the British asylums for the insane less than -forty years ago. "Thirty superintendents hold that they have observed -very beneficial results from the course pursued. The improvement -usually refers not only to the patients, but to the discipline of the -asylum." The cost of beer supplied to the inmates at the Glamorgan -Asylum at one time was reported to be as high as two hundred and sixty -pounds per year (Tuke). Beer was not discontinued as a regular article -of diet for patients at the Derby Asylum until 1884. - -In 1844 Flemming[215] in his classification of psychoses mentioned -the following forms of alcoholic insanity:— Ferocitas et morositas -ebriosorum, anoësia e potu, anoësia semisomnis, delirium tremens, and -mania à potu. Clouston[216] described acute and chronic forms—mania à -potu, dipsomania, alcoholic dementia and degeneration. Krafft-Ebing[217] -speaks of hallucinations of the inebriate, delirium tremens, alcoholic -melancholia, mania gravis potatorum, hallucinatory insanity, alcoholic -paranoia, alcoholic paralysis and epilepsy. Delirium tremens he -ascribes either to repeated excesses (à potu nimio), abstinence (à potu -intermisso), insufficient nourishment, violent emotions, pneumonia and -other acute diseases, loss of sleep, injuries such as fractures, etc. -By hallucination of the inebriate (sensuum fallacia ebriosa) he refers -to the transitory hallucinations of the constant drinker. Meyer[218] -has described an alcoholic constitution "as shown by the lachrymose, -prevaricating, jealous deterioration of the drinker." - -Stöcker,[219] after an extended study of a considerable number of -cases, came to the conclusion that alcoholism is the result of a -constitutional condition but not the cause of characteristic psychoses. -Often, as was also shown by Bonhöffer, it is to be attributed to -a psychopathic personality either acquired or congenital. The -psychoses represented by the group of patients he examined included -manic-depressive insanity, dementia praecox, hysteria, epilepsy and -other miscellaneous conditions. He refers to dipsomania as an epileptic -equivalent. His conclusions in brief were as follows:—"Chronic -alcoholism in the first place is a symptom of a mental disease. It may, -however, so exaggerate stationary epilepsy, chronic mania, dementia -praecox, etc., which hitherto were latent, and perhaps would remain -still latent without alcoholic abuses, that it may lead to a sudden -outbreak of a turbulent disease manifestation. It may also give these -diseases peculiar traits or a peculiar coloring for some time, which -above all, may appear as the most striking phenomena, and thus cover up -the symptoms of the fundamental disorder. Furthermore, it may, also, -on the basis of this constitutional disease give rise to independent -clinical pictures." Karpas[220] in commenting on this says: "One must -remember that cravings play important rôles in our mental life. Some -of our cravings are gratified; others find realization in our dreams; -still others are repressed and compensated. In fact, our mental -life is nothing but a readjustment, of complex reactions. The poet -finds recourse in his phantasies; the philosopher gives vent to his -theoretical speculations; the scientist resorts to his inventions and -hypothetical theories; the well balanced, normal individual seeks -readjustment in healthy activities,—art, literature, science, -occupations, sport, etc., etc. But the individual with a poorly endowed -constitution finds refuge in neurosis, psychosis, alcoholism, drugs, -and other vicious habits. We must recognize that alcoholism is nothing -but a compensation for a complex, the fulfillment of which was denied -by reality." - -Kraepelin[221] described acute and chronic alcoholism, pathological -intoxication, alcoholic jealousy, delirium tremens, Korsakow's -psychosis, alcoholic hallucinoses, paralysis and pseudo-paresis. In -acute intoxication Kraepelin finds an inhibition of apprehension, -mental grasp and the elaboration of outer impressions with a -stimulation of the release of volitional impulses. A clouding of -consciousness develops, associated with emotional excitement and a -weakness of will power. Perception and mental reactions are delayed -and their accuracy decreased on mental tests. The discrimination -between louder sounds is uncertain, although the sensitiveness to -lighter sound impressions is increased as in the ether narcosis. -Busch found a limitation of the field of vision. The preservation of -memory impressions is imperfect. A solution of mathematical problems -shows a lowered mental capacity for work. The association of ideas -and composition of sentences is delayed. There is a tendency to -new word formation, phrasing and rhyming, with a certain amount of -distractibility. Goal ideas are often missed, and consistent, orderly -thought is not possible. Expression is rapid and impulsive, and is -often characterized by a loud tone of voice. - -After larger amounts of alcohol psychomotor activities are interfered -with as shown by the writing, and ataxia appears. The reflexes show an -increased muscular tension. Physical strength is markedly lowered, -although it may be increased for a very short time. Alcohol even in -small amounts interferes with productive mental processes. Ideas lose -in clearness and sharpness, fatigue occurs earlier and efficiency and -judgment are impaired. Still larger amounts retard apprehension and -comprehension and the intoxicated person no longer knows what is said -to him. All ability to control his conduct is lost. There is a tendency -to repetition in speech, rhyming and jargon. Capacity for mental work -is finally entirely gone and memory becomes confused. Psychomotor -stimulation and excitement appear early, terminating finally in -weakness. Emotional trends, at first happy and cheerful, are usually -irritable, later with outbursts of anger. Sexual excitement often -appears. Various physical disturbances have been described. - -In the pathological or complicated intoxications as described -by Kraepelin, unusual emotional disturbances such as violent -excitements occur. Anger or anxiety may develop with a clouding of -the consciousness, and lead to uncontrollable rages with impulses to -assault and kill. The most marked excitements occur in epileptics. -The outburst is usually sudden in these cases and is followed by the -most senseless and unjustifiable acts. Occasionally suicide is the -result. In hysterical and psychopathic individuals alcohol may cause -serious emotional disturbances, with clouding of consciousness or even -delusion formation. Chronic drinkers are very likely to have abnormal -symptoms at times. They often show a marked irritability followed -by a pathetic and tearful mood. Abusive treatment of members of the -family, jealousy, threats and violence are not uncommon. Delirious or -anxious states with persecutory ideas and hallucinations are sometimes -observed. These may exist only during intoxication. Alcohol often -produces extreme excitements in cases of manic-depressive insanity, -general paresis and dementia praecox. Pathological changes of various -kinds have been reported. In acute alcoholism Nissl found a destruction -of cortical cells in some cases and a disappearance of the stainable -lumps in others. The nuclei of the neurones were shrunken and sometimes -displaced. - -Various tests have demonstrated the limited mental capacity of the -chronic alcoholic. Will power is greatly reduced and fatigability -increased. Memory and attention are affected and falsification of -the past may occur. The patient learns nothing new and forgets the -important things. All productive efficiency is gone and interest is -lost. Weakness of judgment and loss of memory capacity lead to delusion -formation. These often take the form of ideas of jealousy. Delusions -of persecution, poisoning or grandeur may appear from time to time. -Frequently there are genuine hallucinations. Some cases terminate -finally in mental enfeeblement. Emotional changes are common in the -chronic drinkers. The alcoholic humor is characteristic. The capacity -for taking things seriously has been lost and there is a tendency to -undue levity, often with a marked feeling of self-satisfaction. Some -individuals, however, become moody, irritable or dull. Occasionally -anxious states appear, frequently with suicidal attempts. One of the -common symptoms of this condition is an extraordinary irritability -after drinking. This leads to quarrels, assaults and violence. -Consideration for others is completely lost. These attacks are often -followed by remorse. A prominent and significant feature of the -disease is the marked moral deterioration. All affection for family -and children may be lost. Selfishness is pronounced and the patient -spends all of his money for drink. Sexual excitement is sometimes -an important symptom. With all of this there is a constant craving -for alcohol. The patients have no insight into their condition and -attribute their headache and tremors to overexertion, etc. They always -deny using much alcohol and are absolutely untruthful on this subject. -Overwork necessitates drinking, or it only happens after a death in the -family, etc. Will power deteriorates rapidly. These individuals often -commit crimes and come into conflict with the law. Gastritis, cirrhosis -of the liver and numerous other diseases complicate the situation. -Dizzy spells and headaches are common, as well as tremors of the -tongue and fingers. Neurotic involvements are noted, with anesthesias, -hyperesthesias, paresthesias, and muscular atrophies as well as speech -defects. Epileptiform attacks are not infrequent in chronic alcoholism, -and were found in ten per cent of Kraepelin's cases. His investigations -showed that eleven per cent of the beer drinkers in Munich had -convulsions. Combinations of epilepsy and hysterical manifestations -with chronic alcoholism are not at all unusual. Rybakoff found a -hereditary taint in 66.6 per cent of his cases while Moli reported only -forty-seven per cent. Heredity was found to be a factor in thirty-seven -per cent of Kraepelin's Heidelberg cases and in seventeen per cent -of those at Munich. He describes various pathological findings in -chronic alcoholism. Meningitis with hemorrhagic membranes is common. -The convolutions are atrophied and the ependyma of the ventricles -thickened. Pigmentary deposits similar to those of senility are found -in the cells and vessel walls. There is an increase of both neuroglia -cells and fibres. Hemorrhages are occasionally found in the central -gray matter. - -When the suspicions of the chronic alcoholic lead to well defined -delusions Kraepelin speaks of "alcoholic jealousy" as constituting a -distinct psychosis. The patient sees in almost everything evidences of -infidelity on the part of his wife and is often inclined to question -the legitimacy of his own children. Assaults and violence are frequent -occurrences. Occasionally genuine hallucinations accompany this -condition. Suicidal and homicidal attempts are not uncommon. - -The onset of delirium tremens, first described by Thomas Sutton in -1813, is characterized by states of anxiety, fear, insomnia with -disturbing dreams, sensory excitement, hyperesthesias, flashes -of light, etc. The development usually is sudden, with a loss of -attention, disturbance of apprehension, restlessness, distractibility, -numerous hallucinations of the different senses, illusions, clouded -states with disorientation, tremors and ataxia. Touch, pain and -temperature sensations, according to Kraepelin, are undisturbed. -The field of vision is sometimes narrowed. Recognition of colors is -uncertain. There is a marked disturbance of the equilibrium, suggesting -some lesion either of the eye muscles or of the labyrinth. A decided -lengthening of the reaction time in associations has been shown by -various observers. Sensory hallucinations are common. The ability -to read correctly is entirely lost and what is read is meaningless. -A paraphasic form of reading has been described by Bonhöffer. The -attention cannot be held for any length of time. A dreamy clouded state -is characteristic. Disorientation is usually complete in the severe -cases. The hallucinations and illusions are very marked and sometimes -even suggest moving pictures to the patient. Hallucinations of vision -are more common than those of hearing. Peculiar skin sensations such as -feelings of electricity are spoken of. Hallucinations may be induced -by pressure on the eyeball and sometimes by suggestion. There is -occasionally a confusional form of speech suggesting dementia praecox, -with a tendency to coin new words and employ entirely meaningless -terms. Although consciousness is not always entirely clouded, events -transpire as in a dream, always confused by innumerable hallucinations. -An occupation delirium is common, the patient imagining himself busy -at his customary work. Delusional ideas regarding everything in his -surroundings are frequent. Ideas of grandeur sometimes occur. Never, -according to Bonhöffer, is there a complete disorientation as far as -personality is concerned. The patient always knows who and what he is. -Complete mental confusion is not the rule. Distractibility is usually -very well developed. Bonhöffer found an inability to supply omitted -words and syllables from well known phrases and memory for test words -and numbers was impaired. Articles read are repeated with many changes -and omissions. Memory for remote events is usually well preserved. -Sometimes there is a falsification of the past. The mood is anxious, -fearful, seldom irritable, at times actually humorous. Cheerfulness and -fear of death occasionally alternate. - -The course of the disease is characterized by great restlessness often -with a tendency to talkativeness. There is, however, no flight of ideas -or rhyming. Delusions of persecution occur in some cases. Anesthesias, -hyperesthesias, paresthesias, hypalgesias and sensitiveness of nerves -and muscles are noted. Romberg's sign is present in some instances. -Speech is often ataxic and paraphasic, and in advanced eases entirely -meaningless. Tremors of the tongue and fingers are very characteristic. -Writing is very much affected as a result. Epileptiform convulsions -sometimes occur. Rarely focal symptoms, facial paralysis and hemiplegia -appear for a short time. Reflexes are increased and ankle clonus -occasionally appears. Defective papillary reaction and unequal pupils -may be found, with diplopia and muscular weakness. Sleep is seriously -interfered with. Bodily weight is reduced and blood pressure lowered. -The temperature is usually elevated and the pulse accelerated. Albumen -and sometimes sugar is present in the urine. The delirium often stops -as suddenly as it begins, terminating in sleep, the patient being -clear when he wakes. The memory of events is not well retained on -recovery. The delirium may, however, become chronic and last for -months. Some cases terminate in a hallucinatory feeblemindedness. -This is likely to occur in psychopathic individuals. Hallucinations -of hearing are more common in such conditions. People read their -thoughts and influence their minds. They are subjected to hypnotism -and electricity. The delusional ideas may be of a sexual nature or -grandiose in character. The mood may be anxious or irritable. Suicidal -tendencies sometimes appear. Later a humorous trend is often noted. -Tremors and other neurological symptoms sometimes occur. Bonhöffer -found at autopsy a considerable fibre loss in the central convolutions, -the cerebellum and the column of Goll. In the large pyramidal and -motor cells of the anterior central convolution the processes were -deeply stained. Some nuclear changes were noted and occasional cells -destroyed. Nissl described a granular degeneration of the neurones -with a prominence of the "unstainable" substance, together with a -swelling and crumbling of the cell bodies. Alzheimer often found free -nuclei near the apical processes. In the glia cells and vessel walls -granular detritus was observed. Acute and chronic cell alterations -are more common in old alcoholics. Pachymeningitis hemorrhagica is -sometimes found. Kraepelin considers it very doubtful whether wine or -beer drinking ever causes delirium tremens, whisky and gin being the -etiological factors as a general rule. - -Korsakow's psychosis was first described in 1887. This is characterized -by a loss of memory, and falsification, with a marked tendency -to disorientation, and is often due to chronic alcoholism. It is -practically always accompanied by polyneuritic symptoms. According -to Bonhöffer, it usually follows delirium tremens. This occurred in -one-fourth of Kraepelin's cases. Occasionally it begins suddenly, but -as a rule gradually, during the course of a chronic alcoholism. The -patients frequently complain of dizziness, headaches and fainting -spells. In the foreground of this affection is the impairment of -memory. This is one of the characteristic features. The events of a -few hours ago are completely forgotten. Disorientation appears next. -This affects time more than anything else. The power of apprehension -or perception is very markedly impaired (one-sixth of the normal in -Kraepelin's cases) and the reaction time is greatly increased. He -also found memory reduced to one-third or one-fourth of the normal on -actual tests (repetition of words and syllables). Falsification of past -events is also demonstrable. This often leads to elaborate delusion -formations. The mood is usually anxious at first, later indifferent, -dull, suspicious, irritable, in some eases cheerful and even humorous. -The methods of life are completely changed. The patients neglect -themselves, lie in bed, etc. The physical signs are those of neuritis. -Muscular pains in the limbs appear, with evidences of loss of power. -Paraplegias and weakness of the grip are found. Romberg's sign is -frequently present. Anesthesias, hyperesthesias or paresthesias are -noted. The reflexes are usually decreased, rarely increased. Ataxia and -other difficulties of gait are common. The pulse is usually slower as a -result of involvement of the vagus. Speech difficulty, writing defects, -facial paralyses, weakness of the eye muscles, with inequality and -inactivity of the pupils, are to be expected. There are usually tremors -of the fingers. Epileptiform convulsions are not infrequent. Aphasia, -agraphia, apraxia, monoplegia, hemiplegic, etc., are observed in many -cases. Physical disturbances of various kinds due to chronic alcoholism -are also present. - -At autopsy acute and grave alterations are found in the cells of the -second and third layers of the cortex. A granular degeneration (Körnig -Zellerkrankung) of the cells is also referred to by Nissl. There is -some fibre loss in the central convolutions and the internal capsule, -as well as in the columns of Goll. Hemorrhages and thromboses are to -be found. Alzheimer found encephalitic foci with proliferation of the -cells of the vessel walls sending out fibroblasts in the neighborhood, -and a destruction of the nerve fibres. These foci are found in the -central gray matter of the third ventricle, roof of the aqueduct, -etc. There is a formation of new vessels and an outwandering of cells -often accompanied by numerous hemorrhages into the gray matter around -the aqueduct of Sylvius. Wernieke has described this process as an -"acute hemorrhagic polioencephalitis superior" and finds it very -commonly associated with Korsakow's psychosis. It occurs, however, in -other chronic alcoholic conditions. The peripheral nerves also show a -polyneuritis. Bonhöffer found Korsakow's psychosis in three per cent -of his delirious cases. Thirty-three per cent of Kraepelin's cases -were women and only 24.5 per cent were under forty years of age. -Chotzen found Korsakow's psychosis in three per cent of his male and in -twenty-one per cent of his female alcoholics. - -The acute alcoholic hallucinoses as described by Kraepelin are -characterized by well defined delusions of persecution and above all by -hallucinations of hearing, with a clear sensorium. In eighty per cent -of the cases the symptoms appear suddenly. Sometimes there is first an -abortive delirious attack. Usually a multiplicity of hallucinations of -hearing develop early. The patient hears threats and abusive language, -always directed against himself. Visual hallucinations also occur, -particularly at night. The other sensory fields are often involved. -At the same time well marked delusions manifest themselves. These -suggest every possible variety of persecution. Ideas of grandeur -are sometimes observed. All of these symptoms are worse at night -as a rule. Consciousness is usually fairly clear, and there is no -disorientation. There is often a mixture of anxiety and humor. Some -cases, however, are irritable and suspicious. Occasionally suicidal -tendencies appear. Conduct is usually not greatly disturbed and the -patient continues with his regular occupation. There is considerable -insomnia and a tendency to run around a great deal and act foolishly -at times. Physically, evidences of chronic alcoholism are always to be -found. The customary duration of these acute conditions is from three -to eight weeks, although they sometimes last for months. In a quarter -of Kraepelin's cases the termination was in deterioration. There is a -strong tendency to recurrence. The unrecovered cases are suspicious, -surly, quarrelsome and have hallucinations of hearing. This condition -may last for years. There are always occasional persecutory ideas. -One-fifth of Kraepelin's cases became chronic. Bonhöffer described a -paranoid type of long duration. The hallucinoses appear usually earlier -in life than Korsakow's psychosis but later than delirium tremens. In -Kraepelin's experience delirium tremens is three times as common as are -hallucinoses. He looks upon these two conditions, however, as different -clinical manifestations of "one and the same" disease process. - -Alcoholic paralysis, so called, is a mixture of chronic alcoholic -symptoms with those of general paresis. There is a mental deterioration -with ideas of grandeur, emotional dulness, hallucinations, delusions -of jealousy, speech defect, tremors and polyneuritis. Epileptiform -attacks are frequent. Most of these forms according to Kraepelin -belong to Korsakow's psychosis or polioencephalitis hemorrhagica -superior. Alcoholic conditions may also be complicated by syphilis or -arteriosclerosis. - -Since the alcoholic psychoses have been generally recognized as -such, there has been comparatively little difference of opinion as to -their differentiation. The classification of the American Psychiatric -Association is as follows:— - -"The diagnosis of alcoholic psychosis should be restricted to those -mental disorders arising, with few exceptions, in connection with -_chronic_ drinking and presenting fairly well defined symptom-pictures. -One must guard against making the alcoholic group too inclusive. -Overindulgence in alcohol is often found to be merely a symptom -of another psychosis, or at any rate may be incidental to another -psychosis, such as general paralysis, manic-depressive insanity, -dementia praecox, epilepsy, etc. The cases to be regarded as alcoholic -psychoses which do not result from chronic drinking are the episodic -attacks in some psychopathic personalities, the dipsomanias (the true -periodic drinkers) and pathological intoxication, any of which may -develop as the result of a single imbibition or a relatively short -spree. - -"The following alcoholic reactions usually present symptoms distinctive -enough to allow of clinical differentiation: - -"(a) Pathological intoxication: An unusual or abnormal immediate -reaction to taking a large or small amount of alcohol. Essentially an -acute mental disturbance of short duration characterized usually by -an excitement or furor with confusion and hallucinations, followed by -amnesia. - -"(b) Delirium tremens: An hallucinatory delirium with marked general -tremor and toxic symptoms. - -"(c) Korsakow's psychosis: This occurs with or without polyneuritis. -The delirious type is not readily differentiated in the early stages -from severe delirium tremens but is more protracted. The non-delirious -type presents a characteristic retention defect with disorientation, -fabrication, suggestibility and tendency to misidentify persons. -Hallucinations are frequent after the acute phase. - -"(d) Acute hallucinosis: This is chiefly an auditory hallucinosis of -rapid development with clearness of the sensorium, marked fears, and a -more or less systematized persecutory trend. - -"(e) Chronic hallucinosis: This is an infrequent type which may be -regarded as the persistence of the symptoms of the acute hallucinosis -without change in the character of the symptoms except perhaps -a gradual lessening of the emotional reaction accompanying the -hallucinations. - -"(f) Acute paranoid type: Suspicions, misinterpretations, and -persecutory ideas, often a jealous trend, hallucinations usually -subordinate; clearing up on withdrawal of alcohol. - -"(g) Chronic paranoid type: Persistence of symptoms of the acute -paranoid type with fixed delusions of persecution or jealousy usually -not influenced by withdrawal of alcohol; difficult to differentiate -from non-alcoholic paranoid states or dementia praecox. - -"(h) Alcoholic deterioration: A slowly developing ethical, volitional -and emotional change in the habitual drinker; apparently relatively few -cases are committed, as the mental symptoms are not usually looked upon -as sufficient to justify the diagnosis of a definite psychosis. The -chief symptoms are ill humor and irascibility or a jovial, careless, -flippant, facetious mood; abusiveness to family, unreliability and -tendency to prevarication; in some cases definite suspicions and -jealousy; there is a general lessening of efficiency and capacity -for physical and mental work; memory not seriously impaired. To be -excluded are residual defects due to Korsakow's psychosis, or mental -deterioration due to arteriosclerosis or to traumatic lesions. - -"(i) Other types, acute or chronic (to be specified)." - -Shadwell[222] states that in twenty-six Italian asylums 18.6 per cent -of their cases were directly or indirectly the result of alcoholism. -Twenty-one and one-tenth per cent of the males and 4.37 per cent of -the females admitted to the institutions of Switzerland from 1901 to -1904 were alcoholics. Twenty-one and thirty-seven hundredths per cent -of the admissions to the hospitals in Denmark between 1899 and 1903 -were suffering from alcoholic psychoses. He gives the admission rate -in Austria as fourteen per cent and in France, 12.5 per cent. Clouston -some years ago estimated the admission rate in Great Britain and -Ireland to be about twenty per cent. - -Pollock[223] has made a most interesting study of 1,739 cases of -alcoholic psychoses, the total number admitted to the New York state -hospitals between October 1, 1909, and September 30, 1912. Seventy-six -and five-tenths per cent of these were men, and 23.5 per cent, women. -The different conditions represented were as follows: Pathological -intoxication, .7 per cent; alcoholic deterioration, 7.7 per cent; -delirium tremens, 4.7 per cent; Korsakow's psychosis, 18.8 per cent; -acute hallucinosis, 36.7 per cent; chronic hallucinosis, 2.2 per cent; -paranoid states, 13.7 per cent; and all other forms, 15.5 per cent. -Among the males, acute hallucinosis predominated, while Korsakow's -psychosis constituted the largest percentage in the female patients. -Of the ascertained cases, .4 per cent showed a defective make-up, 10.3 -per cent were inferior and 89.3 per cent were reported as normal. In -seventy-four per cent of the cases there was no history of insane -heredity. The father of the patient was insane in 3.7 per cent of the -series and the mother in four per cent; 25.8 per cent in all had a -history of insane heredity. Thirty and five-tenths per cent of the -male and thirty-seven per cent of the female patients had alcoholic -fathers and three per cent of the men and 8.8 per cent of the women -had alcoholic mothers. Pollock found the percentage of intemperate -fathers twice as high in the alcoholic psychoses as in the patients -suffering from other conditions. In 94.1 per cent of the cases there -was no family history of nervous diseases. Eighty-one and one-tenth per -cent of the men and 93.4 per cent of the women came from cities. Of the -male patients 26.8 per cent were unskilled laborers; 16.1 per cent of -the women were seamstresses, and 11.7 per cent, the wives of laborers. -The alcoholic cases constituted fifteen per cent of the male, five per -cent of the female, and ten per cent of the total first rate admissions -during the three years in question. The rate of alcoholic psychoses was -over twice in as great in the foreign born population as in the native. - -Three thousand four hundred and sixty-two cases diagnosed as alcoholic -psychoses were admitted to the New York state hospitals during a -period of eight years (1912 to 1919 inclusive). Of these, pathological -intoxication constituted 2.91 per cent, delirium tremens, 5.97 per -cent, Korsakow's psychosis, 20.94 per cent, acute hallucinosis, 37.31 -per cent, chronic hallucinosis, 3.66 per cent, acute paranoid states, -5.01 per cent, chronic paranoid states, 3.78 per cent, and alcoholic -deterioration, 8.34 per cent. The remainder represented miscellaneous -types variously described. These figures, of course, relate largely -to a time when there were no restrictions on the sale of alcoholic -beverages. During 1918 and 1919 the admission rate for alcoholic -psychoses in New York was only 4.58 per cent. In Massachusetts in 1919 -it was 7.47 per cent, and in twenty-one other hospitals in various -states it was 5.04 per cent. A study of 34,935 first admissions to -forty-eight hospitals in sixteen different states during 1917, 1918 and -1919 showed the alcoholic psychoses to represent 5.07 per cent of the -total number. With the advent of prohibition the alcoholic psychoses -as far as this country is concerned have become a matter of little more -than historical interest. The admission rate in the New York state -hospitals for 1920 was only 1.9 per cent. - - - - -CHAPTER VIII - -THE PSYCHOSES DUE TO DRUGS AND OTHER EXOGENOUS TOXINS - - -Opium is a drug which has been in quite common use for many centuries. -According to E. M. Holmes of London, it was known to Theophrastus -nearly three hundred years before the Christian era and two different -forms were described by Dioscorides in the neighborhood of 77 A.D. -Nicander (185 to 135 B.C.) discussed at some length the effects of a -"drink prepared from the tears which exude from poppy heads." Pliny in -the first century A.D. recorded several cases of suicide by means of -opium, which he spoke of as not being a rare occurrence. The drug is -said to have been introduced into China by the Arabs in the thirteenth -century. An edict prohibiting opium smoking was issued by the emperor -Yung Cheng in 1729. It was not until 1909 that the British government -agreed to completely prohibit the importation of morphine into China. -The sale and use of narcotics has, however, been regulated in India -for many years. Morphine, the first alkaloid ever discovered, was -isolated and named by Sertürner, a German apothecary, in 1805. Over -twenty derivatives of opium have been reported since that time. The -real history of morphinomania, according to Erlenmeyer, began in 1864. -As far as can be determined, opium was not grown in America until 1865. -In 1906 it was estimated that over thirteen millions of people were -addicted to opium smoking in China alone. - -The literature of medicine contains numerous references to the mental -disturbances due to opium and morphine. Krafft-Ebing[224] says of -the habitual user that "Intelligence, it is true, is practically -spared, but the highest mental functions—character, ethic feeling, -self-control, mental energy, and force—always suffer.... In severe -cases we find, in addition, weakness of memory, especially defect in -the power of exact reproduction, difficulty of intellectual activity -that may reach the degree of torpor, occasionally psychic depression -reaching even marked dysthymia and taedium vitae, great emotionality, -and, in general, profound deficiency of resistive power to affects; and -besides, there may be episodically nervous restlessness, excitement, -even attacks of fear due to vasomotor causes, and occasionally -visual hallucinations." He also describes hallucinatory delirious -conditions due to abstinence which strongly suggest alcoholism. In -addition to clouded states of the same kind, Paton[225] speaks of the -early occurrence, in chronic cases, of marked symptoms of hysteria. -Apprehension and anxiety develop with mild suspicions and a moral -deterioration very similar to that induced by alcohol. There may be -considerable irritability and egotism, with a suggestion of flight -of ideas and motor restlessness. Hallucinations and delusions are -sometimes present, particularly if alcoholism is a complicating factor. -Hyperesthesias, paresthesias and anesthesias are common. Barker[226] -also speaks of a degeneration of character evidenced by ethical -defects, lying, egotism and loss of memory. Under abstinence symptoms -he includes restlessness, anxiety, despair, vomiting and delirium. -White[227] regards the neuropathic diathesis as the most important -cause of the morphine or opium habit. In habitual users he has noted -hallucinated states with a paranoid coloring or a definite delirium. -He has also observed delusions of persecution and poisoning, but -emphasizes the importance of the gradual mental deterioration. - -One of the most elaborate studies ever made of morphinism was that of -Erlenmeyer,[228] whose work on this subject reached nearly five hundred -pages in its third edition. The mental disturbances associated with -intoxication he divides into two groups—transitory and permanent. -The former includes anxious states, hallucinations of vision and -stuporous attacks; the latter, the intellectual and emotional -deteriorations already described. There is a definite character -change strongly suggesting "moral insanity," an artificial "senium -praecox" being induced. He also refers to distinct psychoses resulting -from chronic morphinism, the most common one being of the paranoid -variety. Abstinence symptoms of sudden development include collapse -and delirium. Restless anxiety and insomnia may usher in a mild -delirious condition. Of these he described two forms,—one, a quiet, -partially clouded dream state and another, with excitement, elation -and hallucinations. The first form is the more common. The second -is usually of short duration but may last for several weeks or even -months, often manifesting paranoid ideas. - -Kraepelin[229] calls attention to the important fact that morphine -stimulates mental activities as well as inhibiting psychomotor -processes, and is not therefore a logical drug for the production of -sleep. The habitué feels himself capable of much greater exertions -but is handicapped by an inhibition of will power. This psychological -mechanism determines the difference between the intoxication of -morphine and that of alcohol. Nissl found the cortical cells of dogs -poisoned with morphine decreased in size but not destroyed. The -stainable substance was rarefied and weakly stained, the achromatic -substance, on the other hand, being unusually prominent. In chronic -morphinism Kraepelin found memory uncertain, mental capacity -diminished and fatigability increased. There are alternating periods -of comparatively good health and dull somnolence with exhaustion or -nervous restlessness. The mood is variable,—depressed, discouraged, -hypochondriacal, irritable, or even confident and overbearing. Anxious -states occasionally occur at night and suicidal attempts may be made. -Character changes are also described by Kraepelin. The patients -become complaining, oversensitive to pain and to opposition, are -indolent, irresolute, irresponsible and neglect their work. Their -interest is more and more confined to the drug. Their untruthfulness -and deceitfulness are well known. Sleep is much disturbed, often by -visual hallucinations. Phantastic delusional ideas are also manifested. -Paresthesias and hyperesthesias are common. The reflexes are active -and usually increased. The gait is unsteady or even ataxic. Speech -disturbances, paralysis of the muscles of the eye, diplopia and loss -of accommodation have been noted. A typical Korsakow's complex was -observed by Heymann. Appetite is lost, bodily weakness and loss of -weight appear and sugar is often present in the urine. Perspiration, -dizzy spells, confusion and stupor may be caused by circulatory -disturbances. Sexual power is diminished, and menstrual disturbances -are frequent. These symptoms may appear early or may not develop for -years, depending on the individual case. Kraepelin also describes -forms similar to dipsomania in alcoholics. He attributes these to -epileptic or hysterical constitutions. Many of his cases were decidedly -psychopathic with tendencies to abuse the use of alcohol, tobacco and -coffee. Of thirty-eight patients observed by him, nineteen used only -one drug, ten of them were addicted to two, eight others to three, and -one patient to as many as five. Under abstinence symptoms he includes -exhaustion, restlessness, yawning, sneezing, anxiety, chilliness, -oppression, sense deceptions and pains in various parts of the body. -The patient is sleepless and sometimes goes into an excitement with -suicidal inclinations. In some cases a condition develops which -markedly resembles delirium tremens. In others, hallucinatory symptoms -are more marked. These manifestations may last for several days or for -a few weeks. Hysterical dream states with hallucinations and convulsive -seizures may also occur. - -Cocaine was first isolated by Gardeka in 1855, but was given the name -it now bears by Niemann. It did not come into extensive use until many -years later and was not employed generally in ophthalmological practice -until about 1884. Freud in 1885 called attention to the fact that small -doses of cocaine produced a stimulation of the mental activities with -euphoria and an increased capacity for both mental and physical work. -Mannheim,[230] who reviewed ninety-nine cases of cocaine poisoning in -1891, found that the first symptoms were drowsiness and deep sleep, -occasionally followed by coma and collapse. He observed that some -patients became restless and excited, dizzy, laughing and crying -alternately, while others were very talkative and uneasy, walking up -and down with a drunken gait. Usually he found a complete amnesia -afterwards. - -The first study of psychoses due to cocaine was made by Erlenmeyer[231] -in 1886. As he afterwards modestly observed, "This first report on -cocomania, which was founded on thirteen cases, completely exhausted -the subject, and nothing essential has been added to the symptomatology -then published." He found that it was almost always combined with the -morphine habit. This was probably due to the fact that cocaine, at one -time, was used extensively in the treatment of morphinism. Although the -assimilation of food is not affected and gastritis was not a symptom, -Erlenmeyer usually found a great decrease in bodily weight, as much as -twenty to thirty per cent in some cases within a few weeks. Sleep is -much disturbed and insomnia the rule. The most common form of mental -disturbance he found to consist of attacks of violent excitement -accompanied by delusions of persecution. Dangerous, impulsive assaults -may occur. Very often, however, there were transitory confusional -states with hallucinations of hearing and vision, succeeded by a mental -deterioration and loss of memory. Visual hallucinations usually appear -early. A common and peculiar symptom is the appearance of dark spots -and points on a white background, attributed by Erlenmeyer to multiple -scotomata. Auditory hallucinations he also found to be frequent. -Sensory deceptions give rise to peculiar ideas such as the presence of -the "cocaine bug" which the patient often tries to catch. Volubility -is another characteristic feature of the disease which he refers to. -As abstinence symptoms he describes forms of depression, with weakness -of will power. Barker refers to psychoses of an acute hallucinatory -confusional type as a result of cocainism. - -Krafft-Ebing speaks of episodic toxic deliria with visual and auditory -hallucinations resembling those of alcohol and accompanied by delusions -of persecution or jealousy with visions of multitudes of small animals, -etc. He has not observed delirious conditions due to abstinence. - -In acute cocainism Kraepelin[232] finds an increased pulse rate, a -lowering of blood pressure and the appearance of an excitement of -the intoxication type with an agreeable sensation of warmth and -well-being. There is an initial motor excitement followed eventually -by weakness. This is a somewhat similar reaction to that caused by -alcohol, but it is more marked. Small doses cause the habitué to feel -elated, talkative and inclined to prolific writings. He feels a greatly -increased efficiency but does not show a corresponding productivity. -Larger doses cause delirious excitement with a tendency to sudden -collapse. After a prolonged use of the drug a condition of nervous -excitement ensues, with an increasing susceptibility to intoxication, a -mild flight of ideas, a diminished capacity for mental exertion, loss -of will power and failure of memory. The patient is busy with entirely -useless activities, quite voluble, and writes incessantly. He becomes -unreliable, forgetful, disorderly and careless in his conduct. The mood -alternates between one of well-being, irritability, suspicious anxiety -and emotional dulness. Kraepelin speaks of the great loss of weight, -increased reflexes, dilated pupils, rapid pulse, etc. Insomnia is a -common symptom. The characteristic psychosis of cocaine, however, in -his opinion is a paranoid condition somewhat resembling the alcoholic -forms. The onset is usually sudden, with irritability, suspicion -and anxious restlessness, together with the sudden development -of hallucinations of various kinds. Auditory hallucinations are -particularly numerous and are very active. The patient's surroundings -appear strange and unreal. He sees all kinds of pictures of the most -realistic type. Tactile hallucinations are very common. The patient -often shoots at his imaginary persecutors or attempts suicide to escape -them. A typical symptom is the appearance of delusions of jealousy. -With all of this the patient is usually well oriented. Only -occasionally is there a clouding of consciousness and confusion. -Insight is, however, always lacking. Even with a clear sensorium -the delusional ideas are firmly retained. The mood is excited, -irritable, sometimes angry and exasperated, but most frequently -depressed and suspicious. The conduct is characterized by restlessness -and uncertainty. There is usually a marked volubility suggesting a -conscious delirium at times. The whole development of these conditions -is rapid, often within a few weeks. They disappear as quickly in many -instances. - -Chronic cocainism is very similar to the alcoholic conditions. From -a symptomatic point of view, however, the paranoid cocaine psychoses -occupy relatively an intermediate position between alcoholic delirium -and the paranoid states. - -In experiments on dogs Nissl found a stainability of the achromatic -substance in the neurones, a beginning shrinkage of the cell nuclei and -a slight increase of leucocytes in the pia and vessels. - -Chloral-hydrate, which has been employed medicinally since 1869, is -much less frequently a cause of mental disturbance than morphine or -cocaine. Krafft-Ebing describes its use combined usually with other -drugs as causing moroseness, depression and mental dulness. He speaks, -too, of a delirium due to sudden withdrawal. This condition, he says, -may also be caused by paraldehyde. The craving for chloral, on the -part of those who have acquired the habit, is much less intense than -that for morphine or cocaine. Other drugs are very readily substituted -for that reason. A prolonged use leads to digestive disturbances, -constipation alternating with diarrhea, jaundice, flushing of the face, -congestion of the conjunctiva, fulness of the head, palpitations, weak -pulse, dyspnea and general malnutrition with erythematous, urticareous -or pustular skin eruptions, etc. Hyperesthesias, anesthesias, -paresthesias, pains in the limbs, sensations of heat and cold, tremors, -occasional loss of muscular power and sometimes ataxia appear. The -reflexes are usually decreased. Epileptiform convulsions have been -observed although they are infrequent. The mental disturbances of -chloral have been studied by Wilson.[233] He describes the habitué as -"dull, apathetic, somnolent, disposed to neglect his ordinary duties -and affairs. He passes much of his time in a state of dreamy lethargy -or in deep and prolonged sleep, from which he awakes unrefreshed and -in pain." Headache is an almost constant symptom. It is associated -with "confusion of thought, inability to converse intelligently or to -articulate distinctly, and other evidences of cerebral congestion." -Vertigo is also common. The mental state is characterized by dulness, -apathy and confusion, alternating with periods of irritability and -restlessness. The depression is not so marked as in morphinism. -Inability to concentrate the mind, loss of memory, and intellectual -enfeeblement are terminal conditions. Occasionally in the worst cases -hallucinations, delusions, clouding and states of excitement are -observed. Abstinence symptoms are headache, insomnia, neuralgia, pains -in the limbs, nervousness, restlessness and formication. A delirium -similar to that of alcoholism has been referred to by various writers. - -Casamajor[234] has described two types of mental disturbance due to the -use of bromides,—a condition of apathy with dulness and an active -delirium. The first is characterized by apathy, dulness, somnolence, -weakness and failing memory, and is often observed in epileptics who -have been subjected to protracted periods of bromide treatment. He -has also reported toxic deliria showing marked hallucinations with -psychomotor unrest, fabrications and paraphasia. This may be associated -with unequal, sluggish pupils, increased or unequal patellar reflexes, -tremors, ankle clonus and an unsteady gait—a general condition -suggesting paresis. Hoch[235] also reported cases showing -hallucinations, clouding, disorientation, amnesia, fabrications and -aphasic disturbances, together with physical signs simulating general -paresis. O'Malley and Franz[236] described somewhat similar symptoms -in a case showing dilated sluggish pupils, exaggerated knee-jerks, -ankle clonus, tremors and unsteady gait, etc. The mental disturbance -was characterized by a confused dreamlike state, with hallucinations, -memory defect, a disturbance of attention, and a marked tendency to -fabrication. The fabrication in their opinion suggested a delirious -origin rather than the Korsakow complex. - -The first references to the psychoses caused by lead intoxication were -apparently those of Dehäne in 1771. Tanquerel des Planches published -his "Encephalopathia Saturnina" in 1836. He recognized three forms -of this condition,—the delirious, the comatose and the convulsive. -Edsall[237] describes as encephalopathies all of the cerebral symptoms -due to chronic lead poisoning. In addition to transitory hemiplegias, -aphasia and choreiform movements, he refers to the occurrence of -hysterical manifestations, such as hemianesthesias associated with -outbursts of excitement. Coma and clouded states often occur. These -may be accompanied by convulsions. In the delirious form there may -be a marked excitement with psychomotor activity. Hallucinations are -common, particularly in alcoholic cases. Delusions of persecution are -not infrequent. There is usually a rise of temperature throughout -the attack. The delirium may last from a few days to several weeks. -Symptom complexes strongly suggesting general paresis have been -reported. Krafft-Ebing speaks of psychoses characterized by mental -depression, feelings of oppression, irritability, mild delusions of -persecution and terrifying hallucinations. Epileptiform attacks, -paralyses and tremors are also mentioned. He refers to deliria which -may arise spontaneously or follow an initial stupor, and speaks of the -chronic lead psychoses as toxic hallucinatory confusional conditions. -Six cases of this nature were reported by Bartens in 1887. Oppenheim -has occasionally found hysterical symptoms associated with chronic -lead poisoning. Rayner[238] found mental disturbances preceded by -such premonitory symptoms as headache, restlessness, disturbed sleep, -terrifying dreams, tinnitus aurium, flashes of light, difficulty of -thought, and depression. This terminated in a few days in a delirium -characterized by anxiety and visual hallucinations. Other cases showed -a more marked depression and stupor, sometimes alternating with -delirium and violent excitement, accompanied by hallucinations and -speech defects. Amaurosis and convulsions are spoken of frequently as -common symptoms. Conditions similar to general paresis have been noted -by various observers. - -There have been very few contributions to medical literature on -the subject of psychoses caused by arsenic. In discussing forms of -poisoning due to that drug Edsall expressed the opinion that "marked -psychic symptoms are unusual." Casamajor makes the statement that "in -very severe cases memory disturbances have been noted, and in some the -typical Korsakow polyneuritic psychosis." According to Oppenheim a -rise of temperature associated with a delirium may be observed at the -onset of arsenical poisoning and may also occur later in the disease. -Psychoses due to arsenic were not referred to by Krafft-Ebing, Arndt, -Schüle, Ziehen or Kraepelin. - -Edsall[239] mentions as the symptoms of chronic mercurial poisoning, -headache, restlessness, mental depression and weakness. Most striking -features are tremors and a peculiar emotional disturbance referred to -as "erythism." Tremors of the lips and facial muscles are common and -speech disturbance and choreiform movements have been noted. Symptoms -suggesting neurasthenia and hysteria have also been reported. Naunyn -has described excitements due to mercury characterized by anxiety and -fears with hallucinations and sleeplessness. He also speaks of manic -attacks, depressions and mental deterioration as associated conditions. - -Argyria or chronic silver poisoning is said to be accompanied often by -a marked sensitiveness and occasional episodes of actual depression due -to the discoloration and pigmentation of the face. - -Psychoses due to various gases are occasionally encountered. -Illuminating gas is a rather common means of suicide, as is shown by -the newspapers. It has been found that the cause of death in these -cases is carbon monoxide, which is also often reported as responsible -for the asphyxiation of workmen in garages and other places where -gasoline motors are used. This occasionally results from the improper -ventilation of laundries, engine rooms, gas plants, iron foundries, -etc. These conditions have been very fully studied by O'Malley.[240] -The mental disorders due to carbon monoxide are described as being -characterized by a sudden attack of confusion and clouding associated -with a period of complete amnesia. There may be disturbances of -attention and Korsakow's psychosis is sometimes strongly suggested, -with memory impairment and tendencies towards fabrication. This -condition may be transitory or last for many months. On recovery -the patient usually has no recollection of any events taking place -after the time of the poisoning. Immediately following the initial -unconsciousness there may be excited periods or delirious states -with aphasic disturbances. In chronic cases delusions of persecution -are often observed. The psychosis frequently does not develop until -several weeks or months after the actual poisoning. Several observers -have referred to a mask-like expression of the face, with emotional -indifference, apathy and outbursts of laughter. The mood has been -described as characterized by emotional instability. O'Malley calls -attention to the important fact that the mental disturbance may have -been the cause of suicidal attempts rather than a result of the gas -poisoning. Confused delirious states due to carbon monoxide poisoning, -also conditions resembling Korsakow's disease, have been described by -Kraepelin. Several cases somewhat similar to that described by O'Malley -have been observed at the Boston State Hospital. - -An analysis of the statistics of American institutions shows that -psychoses due to drugs and other exogenous poisons are quite rare in -this country. They represented only .39 per cent of the admissions to -the New York state hospitals during a period of eight years. The number -admitted to Massachusetts hospitals is still less. In a total of 70,987 -first admissions to forty-eight hospitals in sixteen different states -there were only 324 cases due to exogenous poisons. This constituted -.65 per cent of the total number admitted. It is interesting to note -that during a period of eight years, when 49,640 cases were admitted to -the New York state hospitals, 154 cases of psychosis due to opium or -morphine were reported, five due to metallic poisons, eighteen caused -by gases, and nine of types unspecified. No case of uncomplicated -cocainism was reported during that period of time. - -The 314 drug habitués in the state hospitals of the entire country as -shown by the census of January 1, 1920, and reported by the National -Committee for Mental Hygiene, represented .15 per cent of the mental -cases under treatment in those institutions on the same date. The 808 -drug addicts shown by the same census in all of the institutions of the -United States, both public and private, represented .34 per cent of -the mental cases reported by them. The fact that the private hospitals -showed 4.5 per cent of drug cases in the same census is significant. -It indicates that these cases are largely cared for in institutions of -that type, and furthermore, that their number is very small. - -The result of the investigations made in 1919 by a committee appointed -by the Secretary of the United States Treasury is of great interest in -view of the number of drug psychoses treated in our state hospitals. -The committee's report[241] shows an estimated annual per capita use -of opium in Italy of 1.25 grains; Germany, two grains; France, three; -Holland, 3.5; and the United States, thirty-three grains. More opium -is consumed here than in any other country in the world. The committee -was of the opinion that ninety per cent of it was used for other than -medicinal purposes. The estimated number of habitués in New York -City at that time as reported by the City Commissioner of Health was -103,000. The questionnaire sent out by the committee to physicians -registered under the Harrison Act showed that the number of cases -under treatment for morphinism in various parts of the country was as -follows:—California, 3,338; Connecticut, 11,740; Illinois, 8,218; -Indiana, 8,438; Massachusetts, 14,770; New Jersey, 5,900; New York, -37,095; Pennsylvania, 10,202, etc. The estimated number of drug users -in the United States was given at one million, and the amount of money -expended by them annually was said to approximate sixty-one million -dollars. In view of these statements the number of psychoses reported -in the hospitals is astonishing. - - - - -CHAPTER IX - -THE PSYCHOSES WITH PELLAGRA - - -The origin of pellagra is shrouded in mystery. Although first described -by Casal, the name now attached to the disease was suggested by -Frappoli in 1771. He referred to it as of ancient origin at that time -and probably identical with the "pellarella" reported in Milan in -1578. Niles[242] is of the opinion that the peculiar malady existing -among the American Indians and mentioned by Baruino in 1600 was almost -certainly pellagra. It is interesting to note that he attributed it -to the use of corn. The disease was observed in Spain by Gaspar Casal -in 1735 and appeared in Italy about twenty-five years later. Of the -4,404 admissions to the St. Clement's Hospital at Venice between 1873 -and 1880 over thirty per cent showed symptoms of pellagra. In 1912, -according to Niles, the number of cases in Italy was estimated at -approximately one hundred thousand. The disease was apparently first -reported in France in 1818. It has been common in Egypt since 1892 at -least and is said to have occurred there as early as 1847. Cases were -reported in this country by John P. Gray at the Utica State Hospital -and by Tyler at the McLean Hospital, in Somerville, Massachusetts, in -1863. It is now thought to have been very common in the Andersonville -and Libby prisons during the civil war, although not diagnosed as such -at the time. - -Few cases were reported in this country prior to 1907, when it was -found to be present at the Columbia, South Carolina, State Hospital -by Babcock. Pellagra constituted seven per cent of the admissions to -that institution in 1908, fifteen per cent in 1909, twenty in 1910, -over twenty-seven in 1911 and twenty-six per cent in 1915. Sixty-one -per cent of the deaths in the hospital during the latter year were -due to that disease. The health officer of the state reported four -hundred cases in South Carolina in 1909 and six thousand in 1914. -Babcock is now of the opinion that pellagra undoubtedly existed for -twenty years or more at Columbia before its significance was known. -In 1910 the disease was found to be present in thirty different -states and represented about three thousand cases.[243] Of these the -largest numbers were in Virginia, North Carolina, South Carolina, -Georgia, Alabama, Mississippi, Louisiana, Texas, and Illinois. The -importance of this question had already been recognized and a national -conference was held on the subject at Columbia in 1909. During the -same year the governor of Illinois appointed a commission to make a -thorough study of pellagra in that state. The disease has been made -the subject of elaborate investigation and study by the United States -Public Health Service and several publications have been issued by that -department.[244] - -Notwithstanding the extended discussion and scientific research of the -last few years, the question as to the definite etiology of pellagra -has not as yet been positively settled. The maize or Indian corn theory -was first advocated by Mazari in 1810. He believed the symptoms to be -due to a deficiency in gluten. Sette in 1826 attributed the disease to -a fungus (scimelpige) growing on corn and producing a poison from the -oil in the grain. The smut of corn, "Ustilago Maydis," was suggested -as a possible factor by Pari in 1860. In 1872 Lombroso formulated his -toxic theory: "In pellagra we are dealing with an intoxication produced -by poisons developed in spoiled corn through the action of certain -microorganisms, in themselves harmless to man." He also announced the -discovery of "pellagrosein," a toxic substance extracted from spoiled -corn. In 1902 Ceni advanced the theory that the disease was caused -by the action of certain moulds such as the aspergillus fumigatus -and flavescens. The Illinois Pellagra Commission in 1911 came to the -conclusion after an elaborate investigation of the subject that the -primary etiological factor involved was a living microorganism of -unknown nature, that the probable source of infection was through the -intestinal tract and that a deficient amount of animal protein in the -diet probably acted as a predisposing cause. Funk in 1914 suggested -a vitamin deficiency in the diet brought about by the consumption of -overmilled corn. Voegtlin[245] in the same year expressed the opinion -that the disease was essentially a chronic intoxication,—"While the -agents at work in this intoxication are as yet unknown, I am inclined -to believe that toxic substances exist in certain vegetable foods, not -necessarily spoiled, which, if consumed by man over a long period of -time, may produce an injurious effect on certain organs of the body.... -It is probably more than a mere coincidence that the population of -that part of the world in which pellagra is endemic lives on a mainly -vegetable diet." - -In 1916 a study was made by Koch and Voegtlin[246] of the chemical -changes found in the nervous system in pellagra which was very -significant in its results. They found an increase in water with a -decrease in proteins and lipoids, the latter reaction being attributed -to a degeneration in the white matter. There was also a relative -increase in the cholesterol content, looked upon as a compensatory -protective function tending to replace the loss in lipoids. The most -marked chemical alterations were found in the cord. On feeding monkeys -and rats with an exclusive vegetable diet, changes in the chemical -reaction of the brain and cord of almost exactly the same type were -brought about experimentally. - -Goldberger[247] in 1916 made an interesting report of a series of -investigations carried on by the United States Public Health Service -at Jackson, Mississippi. A large number of cases of pellagra were -treated by largely supplementing the dietary with fresh meats, milk -and leguminous vegetables. The carbohydrate content was reduced at -the same time but corn was not entirely discontinued. Of 209 cases -studied, 172 remained under continuous observation with a recurrence of -symptoms in only one case. In a similar experiment made at the Georgia -State Sanitarium seventy-two patients, all of whom had shown attacks -previously, were treated for a year without symptoms. A number of -volunteers at the Mississippi State Penitentiary were given a test diet -consisting of wheat flour, corn meal, grits, cornstarch, white polished -rice, granulated sugar, cane syrup, sweet potatoes, pork fat, cabbage, -collards, turnip greens and coffee. Of the eleven convicts receiving -this diet, six developed a typical dermatitis with slight nervous and -gastrointestinal symptoms. The results of these investigations were not -offered by the United States Public Health Service as being conclusive -and incontrovertible evidence as to the etiology of pellagra, which -must still be looked upon as being somewhat in doubt. The dietetic -factors concerned in the production of the disease have been under -serious consideration for a century or more. - -This information was supplemented by a study of pellagra in the general -population of the cotton mill communities in South Carolina.[248] In -comparing the dietaries of pellagrous households with those of the -families escaping infection it was found that the former consumed -less meat, milk, butter, cheese and eggs. The value of their diet in -calories and proteins was lower. The proteins contributed, moreover, -were more largely from cereals, peas, beans, etc. The carbohydrate -content was also lower. They concluded that the particular points -involved were: - -"1. A physiologically defective protein supply, - -"2. A low or inadequate supply of fat-soluble vitamin, - -"3. A low or inadequate supply of water-soluble vitamin, and - -"4. A defective mineral supply." - -They were also of the opinion that the disease could be prevented by -"including in the diet an adequate supply of animal protein foods -(particularly milk, including butter, and lean meat)." - -Roberts[249] in 1920 made a study of twenty-five cases of pellagra -encountered in private practice. In every instance the disease -developed in families provided with an abundance of food of all kinds. -An analysis of the actual consumption, however, showed that "not one -of the patients ate a well rounded, balanced diet of meat, milk, eggs -or wholesome vegetables." Either they were suffering from a lack of -nourishment in every case or they were eating practically the same -diet that Goldberger used experimentally in producing pellagra. - -As defined by Barker[250] pellagra "is a disease characterized by -peculiar cutaneous, digestive, nervous and mental disturbances, usually -running a chronic course, with periodic exacerbation, but sometimes -developing acutely and proceeding quickly to a fatal termination." -He speaks of the disease as developing during the winter months -usually with neurasthenic manifestations—fatigability, insomnia, -slight vertigo, and feelings of apprehension, followed by digestive -disturbances later in the spring. The parts of the skin surface exposed -to the sun develop an erythema followed by a dermatitis. Nervous and -mental symptoms may appear later. In some cases the disease tends -to recur every spring. The skin lesions have been described as a -characteristic "mask" shown on the face, the pellagrous collar, a -bandlike eruption on the neck, Casal's "necklace" extending downwards -over the sternum, the pellagrous "butterfly," "gauntlets," etc. The -more common digestive disorders are stomatitis and glossitis, gastric -disturbances and diarrhea. Neurological symptoms observed include -hyperesthesia, paresthesia, anesthesia, tremors, paralyses, muscular -pains, increased reflexes and occasional convulsions. - -The literature of pellagra and its associated mental disturbances has -been elaborately reviewed by Babcock.[251] The following references -appear in a comprehensive study of this subject made by him in 1910. -Griesinger[252] described the pellagrous psychoses as characterized by a -vague, incoherent delirium, accompanied by loquacity and loss of memory -without any violent excitement or special disorder of the intelligence. -The depression gradually develops into a torpor of all the mental -powers together with muscular weakness, a condition resembling general -paresis. Mongeri[253] states that the psychoses usually begin with a -period of depression accompanied by hypochondriacal ideas. This is -followed by confusion and hallucinations of hearing. Delusions of -persecution appear, with a marked tendency to suicide by drowning. -Crimes of various kinds may be caused by the paranoid condition which -usually terminates in deterioration. In speaking of chronic and acute -forms Bianchi[254] says: "The former is characterized by general -depression, melancholia, confusion, slow dementia, paresthesias and -ataxic gait. Contractures and subsulti are absent, although in most -instances the reflexes are exaggerated. In the acute form we have -rapid elevation of temperature, 39° to 41° C.; intense neuro-muscular -excitement, subsulti, contractures, muscular rigidity, exaggerated -reflexes and confusion with phases of exaltation. There are numerous -intermediate forms in which we observe a great variety of psychical -phenomena, and also alternations of excitement and depression. Phases -of remission and of apparent recovery are observed, especially at -certain seasons." Régis[255] is quoted as follows: "It is recognized -that the most common form of psychosis in pellagra is mental confusion -with melancholy or dreamy delirium. This occurs more or less markedly -in most of the cases. It is manifested by inertia, a passivity, an -indifference, a considerable torpor; by insomnia, hallucinations often -terrifying, both of sight and hearing; by delirious conceptions -with fixed ideas of hopelessness, of damnation, of fear, anxiety, -persecution, poisoning; of possession by devils and witches, of refusal -of food, and so marked a tendency to suicide, and to suicide by -drowning, that Strombio gave it the name hydromania. This melancholy -depression, which can reach, in certain cases, even to stupor, is -always based upon a foundation of obtusion, of intellectual hebetude, -and of considerable general debility, which becomes permanent and -terminates by degrees in dementia, in proportion as the pellagrous -cachexia makes new progress. It is accompanied sometimes by a -polyneuritis. The mental confusion of pellagrins can, in place of -changing directly into dementia, turn to a chronic mental confusion. -One may observe in pellagra, as in every grave intoxication, a -morbid state resembling general paresis (pellagrous pseudo-general -paresis). This occurs especially in the cases where instead of habitual -melancholy ideas, the patients present ideas of satisfaction and of -wealth." Procopiu[256] found his patients "sad, apathetic, silent; -in the more advanced stage they are melancholy, and fall sometimes -into an absolute mutism, or respond with difficulty, and have the air -of not understanding what is said to them. Sometimes this melancholy -is accompanied with stupor, and leads the poor pellagrins into -dementia." He also speaks of the occurrence of sudden outbursts of -manic excitement. Tanzi[257] refers to the existence of both pellagrous -mania and melancholia but speaks of a characteristic amentia "which -manifests itself acutely in loss of time and place, loss of memory, -confusion, hallucinations, and paresthesias, from which there arise -morbid impulses and delusions. Pellagrous amentia, often assumes a -depressive form, which simulates melancholia, and in some cases either -from time to time, or throughout the whole course of the psychosis, it -is accompanied by exaltation, which gives it some resemblance to mania." - -Gregor[258] in 1907 made a careful analysis of seventy-two cases. He -classified these in seven groups: 1. Neurasthenia; 2. Acute stuporous -dementia; 3. Amentia (acute confusional insanity); 4. Acute delirium; -5. Katatonia; 6. Anxiety psychoses; and 7. Manic-depressive insanity. -The neurasthenic cases (9.72 per cent) exhibited headache, pain in the -gastric region, vertigo, paresthesia and lassitude, with a sense of -unrest and anxiety as well as ill-defined apprehensions. There was a -sense of mental incapacity and feeling of illness, together with a mild -depression and hypochondriacal tendencies. The cases diagnosed as acute -dementia (13.88 per cent) were of the same general type but with more -advanced symptoms. These showed a decided stupor, tending to remission, -deep mental depression, a sense of insufficiency and "peculiar -subjective troubles." The tendency to suicide was prominent and caused -this group to be called melancholia by some. Many cases showed the -gradual development of an affectless stupor. Catatonic symptoms and -stereotypies occasionally occurred. Memory disturbances were well -marked in this form. The psychoses disappeared invariably with the -symptoms of the pellagra. The Amentia group (44.44 per cent) included -long-continued cases with remission and intermissions. Terrifying -hallucinations and violent motor excitement appeared frequently, -followed by a stupor which was sometimes interrupted by delirium. -Hallucinations were usually present and some had dream states. These -cases often terminate unfavorably. Acute delirium constituted 2.7 per -cent of the seventy-two cases, and katatonia occurred in 13.8 per cent. -These cases passed rapidly into dementia. Anxiety psychoses (4.16 -per cent) were diagnosed in a few instances, but were complicated -by occasional stupors. Two and seven-tenths per cent of the cases -were classified as manic-depressive insanity. Mobley, according to -Babcock, found the following types represented at the Georgia State -Sanitarium:—1. Acute intoxication psychosis, with psychomotor -suspension; 2. Infective exhaustive psychosis, with psychomotor -retardation or excitation; 3. Symptomatic melancholia with psychomotor -retardation; and 4. Manic-depressive psychoses. - -Singer[259] in 1915 suggested the following classification of the -psychoses associated with pellagra:— - - 1. Disorders directly due to the pellagra toxin: - (a) Symptomatic depression; (b) Delirious pictures. - 2. Disorders based on peculiarities in personal make-up, the attack of - "insanity" being precipitated by pellagra; - (a) Manic-depressive disorders; (b) Hysteria; (c) Psychasthenia; (d) - Dementia praecox; (e) Paranoic developments; and - 3. Disorders due to definite brain changes with pellagra merely as a - complication: - (a) Arteriosclerotic dementia; (b) Senile dementia; (c) Presenile - psychoses; (d) General paralysis of the insane. - -He found mental disturbances of some kind in about forty per cent of -the cases examined. As a general rule they appeared after the patient -had shown evidence of several attacks of the disease. The psychoses -occurred in men between the ages of twenty-one and forty and in women -between forty-one and sixty. About ninety-five per cent of the mental -disorders were to be attributed directly to the effect of the toxin. -The remaining five per cent represented individuals with a defective -nervous organization or were purely incidental complications. -Singer found peculiarities in make-up associated frequently with a -predisposition to pellagra. He also expressed the opinion that chronic -forms of "insanity" are very rarely caused by the diseases. - -Sandy[260] made a study of 160 cases at the state hospital at Columbia, -South Carolina, in 1916 based on a classification of psychoses quite -similar to the one now in use. He found that thirty-five per cent -of these belonged to the infective exhaustive group. As a matter of -fact, this is the conclusion almost anyone would reach from reading -the observations of the earlier writers. These cases were usually -characterized by "more or less marked delirium, being accompanied -by some confusion and disorientation, there frequently being also -hallucinations accompanied by more or less agitation and restlessness." -Physically he found, besides well marked symptoms of pellagra, -evidences of severe exhaustion, loss of weight, emaciation, fever, -sordes, anorexia, and typhoid facies. "In the milder forms of these -'delirious pictures,' as Singer calls them in his contribution to the -report of the Thompson-McFadden Pellagra Commission, and as he pointed -out, the periods of clouding (of consciousness) may be quite brief -and episodic. In such cases in the intervals when the consciousness -is practically clear, the general attitude is one of symptomatic -depression." Sandy found characteristic manic-depressive forms in -eleven per cent of the series reviewed. The depressed types were more -common. Here he found retardation of speech and action with a dearth -of ideas. In these cases he looks upon pellagra as being merely an -exciting etiological factor. The prognosis was not so favorable, -however, as it usually is in manic-depressive psychoses, death often -being due to the development of central neuritis. In three per cent -of the total he found what could only be described as symptomatic -depressions, the emotional condition not being so marked as one would -expect in the manic-depressive group. In twelve per cent a diagnosis of -dementia praecox was made. In these the pellagra was merely an incident -and not an etiological factor. - -In several patients Sandy found a symptom complex strongly suggestive -of general paresis, thus confirming the findings of other observers. -These showed speech and writing defects, absent or sluggish pupillary -reaction, swaying in the Romberg position, altered deep reflexes, -disorientation, memory disorders and other evidences of deterioration. -The Wassermann reactions were negative in both the blood and spinal -fluid tests and no lymphocytosis was shown on cell counts. These -cases he thinks belong in the infective exhaustive group, and -usually die of central neuritis, a condition already referred to and -described originally by Turner and Meyer. Sandy also found pellagra -associated with various senile psychoses. This group constituted ten -per cent of those studied. Fourteen per cent of the series he left -unclassified owing to lack of history, etc. Some of these showed -simple deterioration, others suggested neurasthenia, and some, general -paresis. Of the remaining cases three were epileptic imbeciles, -three, constitutional inferiority with episodes of some kind, and -three were not insane. Cases associated with chorea and hysteria -were also observed. On analyzing these most important findings the -assumption would seem to be warranted that pellagra is an incident -in certain psychoses—(senility and dementia praecox), that it is a -precipitating factor in certain cases (manic-depressive), and that the -characteristic conditions due to the disease are toxic and assume the -infective-exhaustive form, occasionally simulating general paresis. - -The policy of the Association's committee on statistics in the -differentiation of these conditions is shown by the following quotation -on this subject from the last edition of the manual:— - -"The relation which various mental disturbances bear to the disease -pellagra is not yet settled. Cases of pellagra occurring during the -course of a well established mental disease such as dementia praecox, -manic-depressive insanity, senile dementia, etc., should not be -included in this group. The mental disturbances which are apparently -most intimately connected with pellagra are certain delirious or -confused states (toxic-organ-like reactions) arising during the course -of a severe pellagra. These are the cases which for the present should -be placed in the group of psychoses with pellagra." - -A study of recent statistics would tend to show that pellagra is not at -this time a factor of importance in our institutions. In Massachusetts -in 1919 the admission rate for this disease was .33 per cent. In New -York state hospitals during a period of eight years it was only .03 -per cent. In twenty-one hospitals in fourteen other states it amounted -to only 1.28 per cent. This includes a number of institutions in the -south. There were 263 cases (.37 per cent) in 70,987 first admissions -to forty-eight hospitals in sixteen different states. The admissions -reported from the southern institutions indicate that pellagrous -psychoses are comparatively infrequent as a rule. During the year 1918 -pellagra constituted 10.7 per cent of the admissions to the Columbia -State Hospital. During the biennial period of 1917 and 1918 the -admission rate at the Arkansas State Hospital for Nervous Diseases was -8.31 per cent. None were admitted to the Spring Grove State Hospital -at Catonsville, Maryland. In 1919 the admission rate at the Western -State Hospital at Staunton, Virginia, was 1.14 per cent, at the Central -State Hospital, Petersburg, Virginia, 1.39 per cent, and at the Georgia -State Sanitarium at Milledgeville, 2.49 per cent. One and sixty-one -hundredths per cent of the admissions to the Louisiana State Hospital -during 1920 were diagnosed as psychoses due to pellagra. Very few cases -are reported in the northern institutions. - - - - -CHAPTER X - -THE PSYCHOSES WITH OTHER SOMATIC DISEASES - - -Mental disturbances of various types associated with somatic -conditions and not sufficiently characteristic or circumscribed in -their symptomatology to constitute definite and separate psychoses -have long been recognized. That delirium is a complicating factor in -certain acute febrile diseases has been known for centuries. Aristotle -called attention to the occurrence of hallucinations and illusions -during the course of fevers. Hippocrates referred frequently, not only -to excitements, but to delirium and phrenitis. The word "delirus" -appears in several places in the works of Horace and many of the -early authors apparently used this term as synonymous with both mania -and melancholia. That was probably true of Sennert. Flemming in 1844 -mentioned fever delirium, hallucinatory and delusional clouded states -and an encephalitic form in addition to the various alcoholic types. -Sydenham referred to the mental symptoms associated with malaria and -Bright in his original "Reports" described other delirious conditions -at some length. Sir Thomas Watson showed that the brain was uninvolved -at autopsy in the acute rheumatic affections with apparent cerebral -complications. Mental symptoms have, of course, been associated -for hundreds of years with meningitic processes. Diabetic coma was -also recognized long since. Griesinger is said by some to have been -the first to call attention to the psychoses caused by the acute -infections. Post febrile mental disturbances were, however, referred -to by Sydenham, Baillarger, Westphal, Greenfield, Gubler and many -others. Delasiauve very elaborately described the psychoses associated -with typhoid fever in 1849. The mental disorders accompanying gout were -discussed at considerable length by Sydenham and were referred to as -early as 1699 by Philander Misaurus. - -According to Bucknill and Tuke[261], Misaurus made the following -very interesting suggestions in an article entitled "The Honour of -the Gout": "It would be worth inquiry, whether the gout is not as -effectual against madness; and we may reasonably believe that it is -so, if upon examination, it should be found that there are no gouty -people in Bedlam; and then for the recovery of these poor creatures to -their wits again, it will not need much consideration, whether they -ought not to be excused the hard blows which their barbarous keepers -deal them, and the Therapeutic method of Purging, Bleeding, Cupping, -Fluxing, Vomiting, Clystering, Juleps, Apozemes, Powders, Confections, -Epithemes, Cataplasms, with which the more barbarous Doctors torment -them, and instead of their learned Torture, indulged for a time only, -a little intemperance as to wine, or women, or so; or the scholar's -delight of feeding worthily, and sleeping heartily, whereby they might -get the Gout, and then their madness were cured." Clouston described -a very definite form of phthisical insanity. Van der Kolk made the -surprising statement that phthisis and mania often alternated in -regular cycles. Nasse classified the mental conditions associated with -fevers as either resulting directly from the febrile disturbance, -constituting a prolongation of the delirium after the temperature -subsided, or developing during convalescence. - -The German psychiatrists during the first part of the nineteenth -century were divided into two quite separate groups. One of these -insisted that all mental diseases were purely psychic in origin, and -the other, that they were in all instances directly attributable to -somatic disease processes. The former school was ably represented by -Heinroth and Ideler and the latter by Jacobi, Nasse and Friedreich. -This led to a controversy which lasted for many years. Heinroth's views -were illustrated by his statement[262] that "Insanity is the loss of -moral liberty. It never depends upon a physical cause; it is not a -disease of the body but of the mind—a sin.... The man who has during -his whole life before his eyes and in his heart the image of God, has -no reason to fear that he will ever lose his reason.... Man possesses -a certain moral power which cannot be conquered by any physical power, -and which only falls under the weight of his own faults.... From wrong -doing springs all misfortune, including the disorders of the mind." -His principal work was a "Lehrbuch der Seelenkunde," published in -Leipsic in 1818. The teachings of the psychic school were summarized by -von Feuchtersleben[263] as follows:—"The mind is the immediate seat -of the disease, the bodily suffering is secondary. Mental disorders -may be clearly traced to their origin, Sin, Error, Passion. Diseases -of the brain, on the contrary, and of all the organs, occur, even in -their greatest intensity, without mental disturbance, as also the -latter without the former. The psychical mode of cure is that which is -properly efficient; the somatic remedies in reality act psychically; -for instance through pain, diversion of the thoughts, stupefaction, -terror. Pathological anatomy has not discovered any decided relation -between disorganization of the brain and mental disorders." In 1836 -Friedreich[264]in opposing Heinroth's views outlined thirteen reasons -for believing that all psychic disorders were somatic in origin:—"1. -Because the mind cannot become diseased; 2. because the greater part -of the causes producing those conditions is somatic; 3. because in all -mental disorders there are somatic symptoms in addition; 4. because -they are too permanent for pure conditions of the mind; 5. because -they are subject to cosmical and telluric states; 6. because their -crises always take place in a material way; 7. because they are not -infrequently removed by strong material influences; 8. because the -somatic mode of cure alone has a direct sanatory effect, the psychical -at most an indirect effect on the body; 9. because the occurrence of -psychical indisposition on one side only, must arise from the duality -of the brain; 10. because the return of reason before death occurs in -cases not only of psychical, but likewise of somatic diseases, and may -be physically accounted for; 11. because mental disorders correspond -with the temperaments; 12. because it may be proved that there are -psychical conditions which depend on organic causes, and are therefore -very analogous to psychical disorders; 13. because chronic delirium -(mania) can be no other than febrile." Absurd as such discussions may -seem at this time, they are no worse than the theological debates -of that day. As a matter of fact, they were no more futile than the -efforts still being made to classify the various psychoses on some one -common ground, for any other than purely statistical purposes. - -Kraepelin[265] divides the psychoses due to infection into febrile -delirium, infection delirium, acute confusional states (amentia) and -exhaustions. The result of the infectious process, as he says, may be -merely to precipitate a manic-depressive psychosis, or an attack of -dementia praecox, general paresis or delirium tremens. It may also -be manifested in the form of a neuritis, myelitis, encephalitis, or a -meningitis. Bonhöffer in 1910 described several forms of "symptomatic -psychoses" due to infections and divided them into three main groups: -deliria, confusions and mental enfeeblements. He also referred to -epileptiform excitements, dream states, hallucinoses, manic types and -amentias either hallucinatory, catatonic or incoherent in character. - -Kraepelin speaks of several definite stages or forms of febrile -delirium. In the mildest of these there is a feeling of discomfort -with a sensation of fulness in the head and a marked sensitiveness to -external impressions. In the second stage a suggestion of clouding -becomes apparent and perception is distorted by hallucinations and -illusions. There is an increased activity of the mental processes -and consciousness soon assumes a dreamlike form. Hallucinations and -illusions are mixed with realities. The restlessness increases and -excitements or depressive moods may precede the appearance of the third -stage. In this there is a more pronounced disturbance of consciousness -with disorientation, confusion, flight of ideas, and variable emotional -reactions, sometimes with actual manic manifestations. Evidences of -stuporous tendencies may appear at times. In the fourth stage a state -of weakness develops, with picking at the bed clothes, tremulous -movements and a senseless muttering of words and syllables. This -terminates in complete coma. In smallpox, scarlet fever, erysipelas, -articular rheumatism and pneumonia there are often sudden confused -excited states, while in typhoid fever stuporous delirium is the -rule. Hendriks found the mental symptoms in typhoid greater during -convalescence and not closely related to the febrile reaction. He -describes a marked disturbance of attention with little involvement -of apprehension or comprehension, but marked loss of mental capacity -and sometimes a tendency to confabulation. Visual hallucinations -and loss of sleep are common symptoms. Often there is restlessness, -talkativeness, indifference, carelessness and disturbances of -volition. In articular rheumatism and scarlet fever, according to -Kraepelin, delirium sometimes develops with sudden rise of temperature. -Restlessness, talking in the sleep, volubility or dulness precede an -unusually violent delirium, sometimes terminating in stupor and death. -The basis of these conditions in all cases is the toxic infection -causing the fever, changes in metabolism, circulatory disturbances -and an involvement of various organs, particularly the brain. A rapid -and considerable rise of temperature usually causes delirium in -typhoid, smallpox and erysipelas while it has no such effect usually -in tuberculosis. This disturbance is a direct result of the influence -of the toxins on the cortex. Alcoholism constitutes another well-known -and common cause. In seventy per cent of the cases the duration was -less than one week and the delirium disappeared with the fall in -temperature. Some cases terminate in infection delirium or they may -precipitate genuine attacks of manic-depressive insanity, dementia -praecox or general paresis. - -The so-called acute alteration of Nissl was a very common change found -in the cortical cells at autopsy. This very generally involved the -entire cortex. Kraepelin describes another characteristic alteration -observed in cases of typhoid delirium. The Nissl bodies are clumped -together in the periphery, and are deeply stained, the processes also -being unusually dark. Some cells show a shrunken nucleus with swollen, -lightly stained bodies. Around these neurones there are usually large -accumulations of elongated glia cells. - -In the infection delirium, so called, the mental disturbance develops -in a case where there is no hyperpyrexia or where at least there is -no relation between the psychosis and the temperature. A restless -excitement ushers in the attack. Pressure in the head, mental -dulness, depressed or sometimes cheerful moods, uneasiness, disturbed -sleep and anxious dreams are common symptoms. Later a disturbance of -consciousness appears and a special type known as "initial delirium" -may develop. This is a common occurrence in typhoid fever. - -Aschaffenburg described two forms of initial delirium. The first is a -restless condition of clouding with hallucinations and delusions. The -second form, which may develop from the first, shows active mental -excitement. Mild in its onset, a confusional delirious state soon -develops with flight of ideas, hallucinations, delusions, and marked -anxiety. An initial delirium of this type often occurs in smallpox. -This assumes a particularly severe form with a tendency to suicide -and violence, strongly resembling epileptic dream states. Seizures -and epileptiform convulsions may occur. The delirium usually develops -from the third to the fifth day of the disease and mental enfeeblement -sometimes follows. The attack usually lasts from several days to a -week. It may continue as a fever delirium. About forty or fifty per -cent die. Nissl in one case found a marked congestion of the vessels -of the cortex, with an increase in the number of leucocytes, and a -widespread destruction of the neurones. The cell bodies were swollen -and the chromatin lumps destroyed. Karyokinetic changes were noted in -the glia cells. - -More or less similar delirious states occur in the course of -intermittent malarial fevers. These usually take the form of a marked -anxious excitement, often with stupor or a tendency to violence. -The attacks begin suddenly, last only a few hours and end in -sleep. Convulsions are frequently observed. These conditions occur -in the quotidian or tertian types but rarely in the quartan. The -delirium precedes a febrile disturbance or may take its place. It -is apparently due to an accumulation of plasmodia in the cerebral -vessels. In influenza, restlessness, confusion, anxious excitement -or hallucinatory deliria may be associated with a low temperature. -Polyneuritic manifestations have also been observed. The disturbance -is undoubtedly caused by the influenza bacillus or the action of its -toxins on the cortex. Abscesses are found in some instances. Deliria -with phthisis are rare unless there is a tubercular meningitis. In -the septic infections, conditions with marked clouding are often -observed, and are to be attributed to embolism, metastases, etc. -Muscular weakness, aphasia, perseveration and convulsions may be -present in these cases. Infection delirium also occurs in chorea. -This takes the form of a clouded dreamlike state with confusion of -thought at times, hallucinations, delusions, and emotional excitement -accompanied by characteristic choreiform movements. Apprehension, as a -rule, is unimpaired, but attention is disturbed and the patients are -forgetful and distractible. They do not have a clear grasp on their -surroundings. Occasional hallucinations appear. The mood is anxious, -excited, fearful or irritable, sometimes with outbursts of anger or -threats of suicide. The choreiform attacks are aggravated and speech is -affected. The reflexes are decreased and muscular weakness develops. -The pupils are dilated and sleep is interfered with to a marked degree. -This excitement lasts for a short time only, but often recurs. In nine -per cent of the cases (Kleist) death results from heart failure, septic -infection or other intercurrent diseases. Wassermann and Westphal -demonstrated streptococci in the brain in several cases of chorea. -Others have reported staphylococci in the blood. Choreic delirium is -usually associated with endocarditis or rheumatic infections, and -occurs in the acute type but not in the Huntington variety of the -disease. - -Delirious excitements, according to Kraepelin, also occur in acute -cerebrospinal inflammatory processes and may be due to furunculosis -or caused by infections from the mouth or the intestinal _tract_. -There is nothing particularly characteristic in such conditions aside -from their severity. They have been collectively described under the -designation of "acute delirium." Their differentiation depends entirely -on the demonstration of the source of infection. The anatomical basis -for these disturbances is always found in the cerebral cortex. The pia -is infiltrated with lymphocytes and plasma cells and leucocytes are -found in the perivascular spaces. There is also a proliferation of the -glia. The "grave" alteration of Nissl is often demonstrable. After -the infectious process passes its maximum intensity and the delirium -disappears, "residual" delusions may remain with a clear sensorium. -These may last for several days or even weeks. They frequently follow -typhoid fever. Occasionally hallucinations of sight and hearing persist -in the same way. - -"Collapse delirium" was first described by Hermann Weber in 1866. It -takes the form of a stuporous state with confusion of thought, dreamy -hallucinations, flight of ideas, an unstable emotional condition and -an active motor excitement. The onset is usually sudden, following a -period of sleeplessness and restlessness. Disorientation occurs early -and consciousness is markedly clouded. Phantastic hallucinations and -illusions are frequent. Excitement and confusion are also prominent -symptoms. Flight of ideas is common and the patient often sings or -expresses himself exclusively in verse or rhymes. Senseless and rapidly -changing delusions are noted. The mood is elated, erotic, anxious or -irritable, with outbursts of anger. Motor excitement is conspicuous -and there is no sleep. Usually food is refused and nutrition disturbed -with a great reduction of bodily weight. This condition is of short -duration, usually not more than a few days, often terminating in sleep -in favorable cases. Only a confused recollection of events remains -on recovery. Collapse delirium, according to Kraepelin, is purely -an infectious process and often occurs in pneumonia, erysipelas and -influenza, following the subsidence of the active symptoms of the -disease. It occasionally complicates articular rheumatism and scarlet -fever. The characteristic features in erysipelas are hallucinations -and delusions of a delirious type, while clouded states, confusional -excitements and flight of ideas are more common after pneumonia. -The symptoms usually develop after the temperature falls and other -evidences of weakness are present. Kraepelin, however, recognizes -infection as the only cause at this time, although he previously -described these as exhaustive conditions. - -Acute confusional states or amentia were described by Meynert in 1881. -These are characterized by a clouding of consciousness with multiform -manifestations of excitement both sensory and motor. Amentia is one of -the sequelae of infectious diseases. It takes the form of a subacute -development of a dreamlike confusion with hallucinations, illusions and -motor excitement lasting usually for several months. It is very closely -related to collapse delirium and the hallucinatory insanity of Hoche, -Fürstner and others. The early symptoms are sleeplessness and unrest. -The patients become anxious, forgetful, develop a fear of death, and -cannot control their thoughts, complaining of dulness and confusion -of mind. A difficult comprehension of external impressions develops. -They may be attentive and seriously troubled at not being able properly -to grasp their surroundings. A decided uncertainty and restlessness -results. Everything seems changed or false. There is at first a feeling -of inadequacy and a profound disturbance of thought which develops -into a well defined confusional condition. A dreamlike state follows, -sometimes with a tendency to fabrications. Rhymes, phrases and words -may be repeated frequently. There is a tendency towards distractibility -and flight of ideas with vague thoughts of persecution. Hallucinations -sometimes become apparent, and illusions appear. The mood is usually -one of irritable anxiety, suspicion and mistrust, seldom with complete -dulness. Occasional outbursts of anger take place. A restless behavior -is noted as a rule. Sometimes suicidal tendencies occur and mild -stuporous states follow. - -In another group of cases depression is an especially prominent -feature as occasionally happens after typhoid fever; or states of -excitement may exist with a flight of ideas and delusions of grandeur. -Before the febrile disturbance has disappeared signs of restlessness -are noted. Orientation is soon lost, apprehension is disturbed, the -patient becomes distractible and begins to show hallucinations. Ideas -of grandeur develop and fabrications are conspicuous and extravagant. -The mood is angry and irritable, sometimes cheerful or elated, but -very changeable. Restlessness, volubility, flight of ideas, senseless -rhyming, confused writing and tendencies to sing, etc., soon appear. -The sleep is very much disturbed. Very little nourishment is taken or -it is refused entirely. Bodily weight is greatly reduced. The reflexes -are usually increased, the pulse slow and the temperature subnormal. -The duration of the disease is usually not more than from two to -six months. Amentia usually follows typhoid, articular rheumatism, -smallpox and cholera, and occasionally occurs after pneumonia. Symptoms -invariably develop after the fever has subsided. After typhoid the -characteristic features are excitement with hallucinations, delusions -and variable moods; after articular rheumatism, disturbance of -apprehension, restlessness, depression or even stupor; and after -phthisis, hallucinations with preservation of consciousness and slight -confusion. - -Light forms of the infectious exhaustions, according to Kraepelin, may -appear after convalescence from the more severe illnesses. The patient -does not make a good recovery, is exhausted, cannot think clearly, -tires easily and is not able to read or write letters. Mental activity -is weakened and the patient remains in bed, apathetic and indifferent. -Consciousness, orientation and perception are undisturbed, although -hallucinations may appear when the eyes are closed or noises in the -ears may be noticed. The mood is gloomy, hopeless, and sometimes -irritable, with sudden attacks of anxiety at night. The patient becomes -suspicious and has fears of death or poisoning. Hypochondriacal -feelings with self-accusation may develop. Food may be refused and -suicidal attempts occur. Some cases are reserved and quiet, even -stuporous, expressing only a few delusional ideas at times. Sleep and -appetite are affected and weight lost as a consequence. These lighter -forms usually follow influenza, articular rheumatism, whooping cough, -tuberculosis or chorea. The duration is ordinarily brief—a few weeks -or months, followed by recovery. In some instances the disease may -progress to a complete enfeeblement of the mental processes. - -The exhaustive conditions in a large group of more severe cases are -ushered in by a delirium or confusional state with a depressed mood. -There is first a slight anxiety. Self-accusation and persecutory -ideas appear early. Hallucinations of hearing and vision develop. -The patients soon become clouded, inattentive, show difficulty of -thought and loss of memory, with mental dulness. All grasp upon their -surroundings is lost, they fail to recognize members of the family, -and answer questions unintelligently. They have no appreciation of -their condition and no memory for events. The mood is indifferent, -apathetic or whining. It may be irritable, quarrelsome or violent. -Usually they lie in bed and are entirely apathetic. Sometimes they -show automatic movements and have to be fed. The conversation is -often incoherent and meaningless. They are inclined to be emotional. -Sleep is usually interfered with and they are restless at night. The -appetite is lost. Occasionally evidences of brain lesions appear with -paralyses, speech disturbance or epileptiform seizures. The duration -is usually a matter of a number of months. At autopsy grave cell -alterations and glia reactions are common. Rod cells are also found. -Endothelial proliferation is frequently observed in the vessel walls. -Some cases terminate in a chronic condition which may improve somewhat -in time. There may be a persistent emotional and mental enfeeblement -with indifference, loss of memory, lack of judgment and impairment -of will. These "acute dementias" represent the terminal stages of -cortical infectious processes. They have been observed after typhoid, -rheumatism, erysipelas, cholera, smallpox and malaria. Usually after -tubercular peritonitis or articular rheumatism there is a simple -mental enfeeblement, while erysipelas is usually accompanied by mild -excitements and an elated mood. The typhoid cases usually showed -irritability, with outbursts of anger and confusional states with -hallucinations and delusions. They occasionally terminate in more -chronic conditions with permanent deterioration. - -After typhoid, influenza and septic infections, Korsakow's -"cerebropathica psychica toxaemica" sometimes occurs. This is the -polyneuritic psychosis similar to that caused by alcohol. There is, -however, a delirium or stupor at the same time. - -The post-rheumatic psychoses have been studied exhaustively by -Knauer.[266] Stuporous attacks were found in ninety-three per cent of his -cases, following acute infections. He describes four groups showing -psychotic manifestations:— - - 1. Anxious delirious excitements followed by stupor. - 2. Excitements alternating with stupor. - 3. Stuporous depression throughout. - 4. Amentia-like excitements throughout. - -The essential feature of Knauer's study was an analysis of -post-rheumatic stupors. He describes these as clouded or dream -states "not different from physiological sleep and the ordinary -artificial narcoses." In them he sees a disturbance of apprehension, -an interference with intellectual processes, a retention defect, and a -loss of the power of attention. Catalepsy was found to be present in -the majority of his cases. The loss of affect was described as being -more complete than in manic-depressive psychoses. He speaks of the mood -as sad, depressed, anxious, but above all, changeable. - -Generally speaking this group of psychoses due to somatic disease -is one which requires further study. We have comparatively little -statistical information on the subject as yet. The differentiation of -these conditions as outlined in the Association's statistical manual is -as follows:— - -"Under this heading are brought together those mental disorders which -appear to depend directly upon some physical disturbance or somatic -disease not already provided for in the foregoing groups. - -"In the types designated below under (a) to (e) inclusive, we have -essentially deliria or states of confusion arising during the course -of an infectious disease or in association with a condition of -exhaustion or a toxaemia. The mental disturbance is apparently the -result of interference with brain nutrition or the unfavorable action -of certain deleterious substances, poisons or toxins, on the central -nervous system. The clinical pictures met with are extremely varied. -The delirium may be marked by severe motor excitement and incoherence -of utterance, or by multiform hallucinations with deep confusion or -a dazed, bewildered condition; epileptiform attacks, catatonic-like -symptoms, stupor, etc., may occur. In classifying these psychoses -a difficult problem arises in many cases if attempts are made to -distinguish between infection and exhaustion as etiological factors. -For statistical reports the following differentiations should be made: - -"Under (a) 'Delirium with infectious diseases' place the _initial -deliria_ which develop during the prodromal or incubation period or -before the febrile stage as in some cases of typhoid, small-pox, -malaria, etc.; the _febrile deliria_ which seem to bear a definite -relation to the rise in temperature; the _post-febrile deliria_ of the -period of defervescence including the so-called 'collapse delirium.' - -"Under (b) 'Post-infectious psychoses' are to be grouped deliria, -the mild forms of mental confusion, or the depressive, irritable, -suspicious reactions which occur during the period of convalescence -from infectious diseases. Physical asthenia and prostration are -undoubtedly important factors in these conditions and differentiation -from 'exhaustion deliria' must depend chiefly on the history and -obvious close relationship to the preceding infectious disease. (Some -cases which fail to recover show a peculiar mental enfeeblement.) In -this group should be classed the 'cerebropathica psychica toxaemica' -or the non-alcoholic polyneuritic psychoses following an infectious -disease as typhoid, influenza, septicaemia, etc. - -"Under (c) 'Exhaustion deliria' are to be classed psychoses in which -physical exhaustion, not associated with or the result of an infectious -disease, is the chief precipitating cause of the mental disorder, -_e.g._, hemorrhage, severe physical over-exertion, deprivation of food, -prolonged insomnia, debility from wasting disease, etc. - -"Of the psychoses which occur with diseases of the ductless glands, the -best known are the thyroigenous mental disorders. Disturbance of the -pituitary or of the adrenal function is often associated with mental -symptoms. - -"According to the etiology and symptoms the following types should -therefore be specified under 'Psychoses with Other Somatic Diseases': - - "(a) Delirium with infectious disease (specify) - "(b) Post-infectious psychosis (specify) - "(c) Exhaustion delirium - "(d) Delirium of unknown origin - "(e) Cardio-renal disease - "(f) Diseases of the ductless glands (specify) - "(g) Other diseases or conditions (to be specified)." - -A study of 480 cases of psychoses with other somatic diseases reported -from the New York state hospitals during 1918 and 1919 shows the -following types represented:— - - _Number_ _Percentage_ - Delirium with infectious diseases 68 14.16 - Post-infectious psychoses 102 21.25 - Exhaustion delirium 94 19.58 - Delirium of unknown origin 36 7.50 - Cardio-renal diseases 69 14.37 - Diseases of the ductless glands 20 4.16 - Other conditions 91 18.90 - -An analysis of 140 cases from the Massachusetts state hospitals in 1919 -shows the following:— - - _Number_ _Percentage_ - Delirium with infectious diseases 48 34.28 - Post-infectious psychoses 25 17.85 - Exhaustion delirium 26 18.57 - Delirium of unknown origin 6 4.28 - Cardio-renal diseases 16 11.42 - Diseases of the ductless glands 1 .71 - Other conditions 18 12.85 - -Three hundred and sixteen cases from hospitals in nineteen other states -were reported as follows:— - - _Number_ _Percentage_ - Delirium with infectious diseases 69 21.83 - Post-infectious psychoses 30 9.49 - Exhaustion delirium 75 23.73 - Delirium of unknown origin 33 10.44 - Cardio-renal diseases 45 14.24 - Diseases of the ductless glands 15 4.74 - Other conditions 49 15.50 - -We have, thus, a total of 936 cases distributed as follows:—Delirium -with infectious diseases, 19.76 per cent; post-infectious psychoses, -16.77; exhaustion delirium, 20.83; delirium of unknown origin, 8.01; -cardio-renal diseases, 13.88; diseases of the ductless glands, 3.84; -and other conditions, 16.88 per cent. Four and one hundredth per cent -of the first admissions in Massachusetts, 3.45 per cent of the New -York admissions, and 2.07 per cent of admissions to twenty-one other -institutions during the same period of time were cases of psychoses due -to other somatic diseases. They constituted 2.81 per cent of 34,935 -admissions to all of the institutions above noted. - - - - -CHAPTER XI - -THE MANIC-DEPRESSIVE PSYCHOSES - - -The manic-depressive psychoses as first described by Kraepelin are -of comparatively recent origin. The history of the clinical entities -included in this new grouping, however, may be easily traced back to -the earliest days of psychiatry. Although these terms were not used -perhaps as they came to be later, mania and melancholia were, as has -already been shown, known in the Hippocratic era, over four hundred -years before the time of Christ. They were referred to again in the -works of Aretaeus in the first century A. D. and were recognized by -Celsus, Caelius Aurelianus and Galen. Daniel Sennert[267] of Wittenberg -(1572-1637) defined melancholia as a "delirium or deprival of -imagination and reason, without fever, with fear and sadness, arising -from dark and melancholy animal spirits, and occasioning corresponding -phantoms." Mania he described as a "delirium or deprival of imagination -and reason without fear, but, on the contrary, with audacity, temerity, -anger, and ferocity, without fever, arising from a fervent and fiery -disposition." - -Sydenham[268] recommended bleeding, followed by purgation, as the -treatment indicated for mania:—"Thus the humours, which in mania would -invade the citadel of the brain, are gradually drawn off towards the -lower parts, a fresh bias being given to them." - -Thomas Willis[269] made some very significant references to the -relation existing between mania and melancholia, in the seventeenth -century:—"After melancholia we have to treat of mania, which has so -many relations to the former, that the two disorders often follow -each other, the former changing into the latter, and inversely. The -melancholic diathesis, indeed, carried to its highest degree, causes -frenzy, and frenzy subsiding changes frequently into melancholia -(atrabiliar diathesis). These two disorders, like fire and smoke, often -mask and replace each other, and if we may say that in melancholia -the brain and the animal spirit are obscured by smoke and black -darkness, mania may be compared to a great fire destined to disperse -and to illuminate it." Morgagni,[270] "the father of pathology," also -saw a close relation between these two conditions as is shown by the -following quotation from his "De Sedibus et Causis Morborum;" etc., -in 1761. "Melancholia," he says, "is so nearly allied to mania, that -the diseases frequently alternate, and pass into one another; so that -you frequently see physicians in doubt whether they should call a -patient a melancholiac or a maniac, taciturnity and fear alternating -with audacity in the same patient; on which account, when I have -asked under what kind of delirium the insane persons have laboured -whose heads I was about to dissect, I have had the more patience -in receiving answers which were frequently ambiguous and sometimes -antagonistic to each other, yet, which were, perhaps, true in the long -course of the insanity." Flemming[271] in 1844 described a "dysthymia -atra" (melancholia), a "dysthymia candida" (cheerful dysthymia) or -"melancholia hilaris" characterized by elation with playfulness and a -"tendency to see everything in the most pleasant and cheerful light" as -well as a "dysthymia mutabilis," an alternating variety involving both -of the above forms. He also spoke of a "dysthymia sparsa" (apathica) -or "melancholia attonita," and a "vesania maniaca" or mania which -he divided into the acute, delirious, alcoholic, affective, and -puerperal types, together with an "occult amentia" embracing all of -these forms. Griesinger[272] in 1845 called attention to the fact -that "the transition of melancholia into mania, and the alternation -of these two forms, are very common." In 1851 Falret, senior, first -described circular insanity in his lectures at the Salpêtrière, quoted -by Tuke[273] as follows:—"We have also to mention another case of -intermittence observed between the periods of remission and excitement -in the forme circulaire des maladies mentales." "It is a special -form which we call 'circular' and which consists, not as has been -frequently said, in a change of mania into melancholia separated by a -more or less prolonged lucid interval, but in the change from maniacal -excitement—simple overactivity of all the faculties—into mental -torpor." - -In 1854 at the Academy of Medicine in Paris Falret presented his -"Mémoire sur la folie circulaire, forme de maladie mentale caractérisée -par la reproduction successive et régulière de l'état maniaque, de -l'état mélancolique, et d'un intervalle lucide plus ou moins prolongé." -In the same year Baillarger described his "Folie à double forme," -summarized by him in a Bulletin of the Academy of Medicine as follows:— - - "(1) Besides monomania, melancholia, and mania, there exists a - special form of insanity characterized by two regular periods, one of - depression, the other of excitement. - (2) This form of insanity: (1) presents itself in isolated attacks; - (2) reproduces itself in intermissions; (3) the attacks may follow - each other without interruption. - (3) The duration of the attacks varies from two days to one year. - (4) When the attacks are short, the transition from the first to the - second period takes place suddenly, and generally during sleep. It - takes place slowly and gradually when the attacks are prolonged. - (5) In the latter case, the patients seem to enter into a state of - convalescence at the end of the first period, but this return to - health is incomplete; after a fortnight, a month, six weeks or more, - the second period breaks out." - -This was described as "Folie à double phase" by Bellod, "Folie à formes -alternés" by Delaye, "Délire à formes alternés" by Legrand du Saulle, -"Die cyclische Psychose" by Ludwig Kirn and "Das circuläre Irresein" by -Krafft-Ebing. - -At a meeting of the American Association in 1886 the classification -of the British Medico-Psychological Association was adopted with the -omission of moral insanity and the addition of toxic insanity. This -included the following types of mania:—Recent, chronic, recurrent, -à potu, puerperal and senile, and classified melancholia as recent, -chronic, recurrent, puerperal and senile. In his "Clinical Lectures -on Mental Disease" Clouston in 1898 described eight varieties of -melancholia and six of mania, not including alternating forms. Kahlbaum -in 1882, reverting apparently to the phraseology of Flemming, spoke -of dysthymia, hyperthymia and mixed or circular forms—cyclothymia. -Many of the conditions afterwards classified under dementia praecox he -described as "vesania typica." - -It will be observed that, based somewhat on the conceptions of -Griesinger, states of mental excitement were generally characterized -as mania and all depressions as melancholia. As has been shown, the -view that there was some definite relation between these two conditions -had been gaining ground for many years and culminated in the "circular -insanity" concept. In the meanwhile over fifty varieties of mania and -thirty forms of melancholia were described by various authors. Aside -from an emotional exaltation and increased psychomotor activity, few -definite characteristics were insisted upon in a consideration of -mania. There was almost invariably a disturbance of sleep but always -with a sense of well-being and no feeling of exhaustion. The milder -type of the disease was often referred to as "hypomania." In the more -severe forms varying grades of violence developed. There was at times -a clouding of the sensorium, a temporary appearance of hallucinations -of sight and hearing, delusions of a persecutory or grandiose nature -and incoherence of speech. Impulsive acts occasionally were noted -during the height of the excitement. These attacks were frequently -preceded by brief periods of depression. Many cases made rather early -recoveries—others, however, were spoken of as having reached a -chronic stage. Many terminated in dementia. These very often showed -stereotypies, verbigeration, impulsive excitements, mannerisms and -other symptoms now held to be characteristic of dementia praecox. -Melancholia was looked upon as including all emotional depressions -with hallucinations and delusions as the prominent symptoms. The -mental state was essentially one of sadness but with fear, agitation -and anxiety appearing at times. There was, however, no attempt at any -differentiation between psychomotor retardation with genuine depression -and apathetic states or actual mental dulness. Mutism and resistiveness -were common. A refusal of food was rather to be expected. Stuporous -states with muscular rigidity frequently occurred. Various physical -changes were described. Cyanosis of the extremities was emphasized, -with loss of weight and a lowered temperature. Many of the cases -were untidy in their habits. Brief initial attacks of excitement -were mentioned as usually ushering in the disease. These depressions -recovered, became chronic, lasting for years, or terminated in a -partial or complete dementia. These were in substance the views of -practically all of the earlier writers on insanity. - -Sankey[274] in 1884 included in his idiopathic psychoses due to -pathological conditions, general paresis and "ordinary insanity." "This -is the disease which in its course presents such varying phenomena, -and has thus given occasion for multiplying the names." Prominent -in this group were the various forms of mania and melancholia and -it undoubtedly included dementia praecox. "Like other diseases it -may be artificially divided into separate stages, and this is useful -for facilitating description, but such artificial divisions must not -be looked upon as different species of disease." ... "Thus, a case -in the primary attack commences by symptoms of melancholy; these -may, when successfully treated, pass off, and the patient recover, -or the melancholic stage may be aggravated, and the patient die in -this stage;—the disease may exhibit symptoms of violence and become -acutely maniacal. There is no ground on this account to say, that the -patient has a new disease, any more than the appearance of an eruption -in an eruptive disease would be the inauguration of a different kind -of malady." Although obviously he had no idea as to the fundamental -differences between manic-depressive insanity and dementia praecox, he -unquestionably was one of the first to emphasize the fact that mania -and melancholia were often definite stages of one disease process. - -In 1896 Kraepelin described melancholia as essentially an involutional -condition. Under the heading of periodic constitutional disorders he -included mania, circular and depressive forms, the mania, melancholia, -and circular insanity of other writers. Schüle[275] in 1886 described -circular, periodical and alternating psychoses. In 1894 Ziehen[276] -included in his classification under the heading of combined psychoses -a "melancholisch-maniakalisches" form in addition to mania and -melancholia, which he spoke of as affective psychoses. - -It was not until 1899 that these conditions were clearly differentiated -by Kraepelin[277] and the purely emotional and recoverable forms -separated clinically from the deteriorative processes which he -has associated with dementia praecox. The former he described as -manic-depressive psychoses, which included mania, melancholia -and a majority of the circular and alternating types previously -described. This delimitation had a prognostic as well as an important -symptomatic significance. The emotional excitements were characterized -by an increased psychomotor activity, with a flight of ideas and -distractibility, usually associated with a clear sensorium. Graver -forms were, however, recognized, with a clouding of consciousness, and -disorientation, occasionally terminating in stupor. Hallucinations and -delusions when present were not prominent symptoms. The depressions -were characterized by an emotional disturbance in the form of sadness -with difficulty in thinking, associated with marked retardation in -speech and a motor inhibition. More advanced stages showed clouding, -disorientation, stuporous phases and hallucinations. He also recognized -alternating or circular as well as mixed types. The prognostic -importance of this clinical grouping was the tendency towards a -complete recovery from the individual attack, with, however, an -extreme probability later of a recurrence, the subsequent attacks -assuming either form of the disease. As a rule Kraepelin found that the -unfavorable types formerly included in the manias and melancholiac, -together with the hebephrenia and katatonia of his fifth edition, -presented the definite characteristics of the disease which he -described as dementia praecox. His views have been modified from time -to time. For instance, he at one time excluded the involutional and -anxiety psychoses from his manic-depressive group. Later these were -included. In his last edition he has described depressed and agitated -forms of dementia praecox, which would strongly suggest that his lines -of demarcation were not so clear as he believed them to be in 1899. Of -the manic-depressive psychoses he says, "Manic depressive insanity as -described in this chapter includes on the one hand the entire domain of -the so-called periodic and circular insanities, on the other, simple -mania, the larger part of the disease process described as melancholia -and also a not inconsiderable number of cases of Amentia. Finally -we include certain mild morbid emotional states, some periodical, -some continuous, which heretofore have been looked upon either as -introductory to more severe disturbances or as belonging, without being -sharply circumscribed, to the domain of individual makeup. As years -go by I have become more and more convinced that these all represent -manifestations of one disease process." The following classification -of manic-depressive psychoses was shown in Kraepelin's last edition -(1913):— - - Manic types: - Hypomania, Acute mania, Delusional and Delirious forms. - - Depressive types: - Melancholia simplex, Melancholia gravis, Stupor, Paranoid, Phantastic - and Delirious forms. - - Mixed types: - Depressive mania. - Excited depressions. - Mania with poverty of thought. - Manic stupor. - Depression with flight of ideas. - Retarded mania. - -The mixed and atypical forms are of special importance, as they occupy -the middle ground between the classical types of manic-depressive -insanity and dementia praecox. It is here that difficulties arise and -errors in diagnosis are made. They have never received sufficient -attention until recently. In practice many of these have undoubtedly -been classed with the dementia praecox group. The first of these as -described by Kraepelin is depressive or anxious mania—characterized by -a depressive mood with anxiety and excitement and, at the same time, a -flight of ideas. The patients are distractible, observant of everything -in their surroundings, and complain that thoughts obtrude themselves -upon them. Some have a mania for scribbling. Often there are delusions -of persecution, sin, and hypochondriacal ideas. The mood is one of -anxiety or despair. Impulsive acts are occasionally observed. They are -inclined to weep, wring their hands, pull out their hair and throw -themselves on the ground. - -Instead of a flight of ideas there may be poverty of thought and -retardation with excitement—an "excited depression." The patients -may be very wordy and monotonous in expression but are entirely clear -as to their surroundings. The mood is anxious and tearful, often with -delusions. There is a considerable excitement, but not of such a -stormy character as in the depressive or anxious mania. - -Mania with poverty of thought, an "unproductive" form, shows a more -cheerful mood but without a flight of ideas. This form Kraepelin speaks -of as a common one. Speech is monotonous and expressionless. The -patients present almost an appearance of feeblemindedness, although -exceedingly variable and changeable. The mood is cheerful and sometimes -irritable. The excitement is shown by jumping around, making faces, -etc., but without any occupational activity. This alternates with -periods of quiet when but little is said. They show no desire to occupy -themselves in anything useful. Sudden outbursts of violence often occur. - -Stuporous, almost cataleptic forms with occasional delusions of a -hypochondriacal type, fairly well oriented and with a clear sensorium, -are spoken of as "manic stupor." This is interrupted by excitement and -violence, with laughter, witty remarks and even eroticism. They often -have a clear memory of all occurrences. This stuporous type may appear -suddenly in an ordinary manic attack, or take place between excitements -and depressions. - -In the course of an ordinary depression a flight of ideas may also -replace the usual retardation—"depression with flight of ideas." The -delusions are interspersed with cheerful thoughts and the patients show -certain activities and an interest in their surroundings, although -still depressed and hopeless. When they begin to talk they complain -of an inability to control their thoughts. There is an inhibition of -speech but not of thought. They may be quite prolific in writing, and -may show a characteristic flight of ideas. This condition often merges -into genuine excitement. - -Kraepelin also speaks of an inhibited or "retarded mania," showing -a cheerful mood with flight of ideas and psychomotor retardation. -These eases are excited, distractible, inclined to witticisms with -"klang associations," but lie quietly in bed. He believes that there -is an inner tension manifesting itself at times in acts of violence. -Kraepelin also speaks of various other mixtures of depression, -anxiety and excitement. Specht has described an "irascible mania" -(Zorntobsucht) and Stransky a bashful mania (verschämte Manie). Dreyfus -has described a partial inhibition or retardation (partiellen Hemmung). -Hecker is responsible for a "grumbling" or faultfinding variety -of mania (nörgelnden Formen der Manie). In any event, Kraepelin's -conceptions constitute a distinct advance and have materially clarified -a much involved confusion of entities which seem to warrant complete -differentiation. His views have, of course, not been universally -accepted. The English school of psychiatrists has been slow in -expressing its approval of his theories. No textbook of late years -has appeared, however, in this country that has failed to recognize -the manic-depressive psychoses practically as Kraepelin originally -described them. - -The psychological mechanisms of manic-depressive insanity have been -studied exhaustively by Karl Abraham and other psychoanalysts. He -looks upon retardation as a symbol of death and interprets it as a -defensive reaction, the patient taking refuge in a retarded state to -avoid contact with the outer world. The ideas of poverty associated -with depressions he considered as symbolic of an inability to love and -occurring in individuals who have not obtained sexual gratification in -a normal way. When repression is no longer possible mania ensues and -the patient enters upon a new existence, all instinctive inhibition -being lost. The flight of ideas he looks upon as a reestablishment -of infantilism. He suggests these views, however, as tentative. The -delusions of the manic-depressive psychoses have been interpreted as -an expression of repressed complexes. White[278] would explain these -mechanisms as follows:—"Manic-depressive psychosis is the type of -extroversion reaction. That is, the patients instead of turning within -themselves (introversion) try to escape their difficulties (conflict) -by a 'flight into reality.' This flight into reality is the manic -phase of the psychosis with its flight of ideas, distractibility and -increased psychomotor activity during which the patient seems to be -at the mercy almost of his environment having his attention diverted -by every passing stimulus. The great activity can be understood as -a defense mechanism. The patient appears, by his constant activity -to be covering every possible avenue of approach which might by any -possibility touch his sore point (complex) and so he rushes wildly -from this possible source of danger to that meanwhile keeping up a -stream of diverting activities. He is at once running away from his -conflict—into reality—and trying to adequately defend every possible -approach.... This method I have described as a 'flight into reality' -which is the characteristic of the manic phase, while the failure to -deal adequately with the difficulty is manifested by the depression -of the depressive phase. In the depression the defenses have broken -down and the patient is overwhelmed by a sense of his moral turpitude -(self-accusatory delusions). This sense of being sinful is the -conscious appreciation of tendencies which should have been left behind -to become a part of the historical past (the unconscious) in the course -of the development of the psyche but which still demand expression.... -The benign character of the manic-depressive group of psychoses is -explained because of their extroverted mechanism. Reality is the normal -direction for the libido and because the direction is normal they more -readily result in recovery." - -The American Psychiatric Association, in its manual designed for -the assistance of hospitals for mental diseases in the compilation -of statistical data, makes the following suggestions as to the -delimitation of the manic-depressive psychoses:— - -"This group comprises the essentially benign affective psychoses, -mental disorders which fundamentally are marked by emotional -oscillations and a tendency to recurrence. Various psychotic trends, -delusions, illusions and hallucinations, clouded states, stupor, etc., -may be added. To be distinguished are: - -"The _manic_ reaction with its feeling of well-being (or -irascibility), flight of ideas and over-activity. - -"The _depressive_ reaction with its feeling of mental and physical -insufficiency, a despondent, sad or hopeless mood and in severe -depressions, retardation and inhibition; in some cases the mood is one -of uneasiness and anxiety, accompanied by restlessness. - -"The _mixed_ reaction, a combination of manic and depressive symptoms. - -"The _stupor_ reaction with its marked reduction in activity, -depression, ideas of death, and often dream-like hallucinations; -sometimes mutism, drooling and muscular symptoms suggestive of the -catatonic manifestations of dementia praecox, from which, however, -these manic-depressive stupors are to be differentiated. - -"An attack is called _circular_ when, as is often the case, one phase -is followed immediately by another phase, e.g., a manic reaction -passes over into a depressive reaction or vice versa. - -"Cases formerly classed as allied to manic-depressive should be placed -here rather than in the undiagnosed group. - -"In the statistical reports the following should be specified:—(a) -Manic type; (b) Depressive type; (c) Stuporous type; (d) Mixed -type; (e) Circular type; (f) Other types." - -Diefendorf[279] states that manic-depressive insanity comprises from -twelve to twenty per cent of the admissions to hospitals for mental -diseases. He reports defective heredity as being shown in from seventy -to eighty per cent of the cases. He also found about seventy-five per -cent of the patients suffering from this disease to be of the female -sex. Buckley[280] states that sixty per cent of the cases give positive -histories of "familial neuropathy and psychopathy." Paton[281] is of -the opinion that heredity is a factor in from eighty to ninety per -cent of all cases. Hoch has called attention to the constitutional -makeup of individuals subject to manic-depressive attacks and suggests -that they are usually of a moody, morose type, unduly optimistic or -temperamentally unstable. Kraepelin[282] found suicidal tendencies in -14.7 per cent of the female patients, and in 20.4 per cent of the men. -Nine per cent of his cases showed a manic makeup; 12.1 per cent, a -depressive temperament; 12.4 per cent were irascible or nervous; and -from three to four per cent exhibited cyclothymic tendencies. Of the -cases admitted to his clinic 48.9 per cent were depressive forms; 16.6 -per cent, manic; and 34.5 per cent represented both types in various -combinations. Melancholia simplex and gravis constituted 23.5 per cent -of the simple forms, 13.5 per cent showed phantastic delusions and 6.1 -per cent anxieties. Hypomanias made up four per cent, and acute mania, -9.8 per cent of the cases. Confused and stuporous states constituted -8.2 per cent and compulsions, one per cent. Lighter forms constituted -ten per cent, and more severe types, nine per cent of the admissions. -Stupors and clouding were found in 4.9 per cent and delusional states -in 4.9 per cent of the total. He quotes Walker as reporting, in a -study of 674 cases, that excitements contributed eleven per cent; -depressions, 55.7 per cent; and circular forms 33.3 per cent of the -male cases; and excitements, 6.2 per cent; depressions, 70.2 per cent; -and circular types, 23.6 per cent of the female admissions. In from -sixty to seventy per cent of Kraepelin's cases the first attack was a -depression. In two-thirds of them, after the first mild attack there -was a remission. In one-third of the cases, the depression terminated -in an excitement followed by recovery. When the disease begins with -a manic attack, two-thirds of the cases are followed by a remission. -He reports excitements with a duration of ten years and depressions -of fourteen years standing. In a study of 703 remissions he found -ninety-six lasting from ten to nineteen years; thirty-four, from -twenty to twenty-nine years; eight, from thirty to thirty-nine years; -and one of forty-four years. He is of the opinion that the length of -remission bears no relation to the duration of the attack. Of the -depressions, 167 had a remission of six years; forty-six of 2.8 years; -and twenty-seven of two years or more. Of the manic forms, fifty-three -had remissions of 3.3 years; twenty-four of 4.5 years; and twenty of -two years or more. Manic-depressive psychoses constitute from ten to -fifteen per cent of the admissions at Kraepelin's clinic. He found -hereditary taint in eighty per cent of his Heidelberg cases and quotes -Walker as reporting 73.4 per cent; Saiz 84.7 per cent; Weygandt, ninety -per cent; and Albrecht, 80.6 per cent. A history of alcoholism was -found in twenty-five per cent and syphilis in eight per cent of the -male patients. - -Rehm made an interesting study of the offspring of manic-depressives. -Of forty-four children in nineteen families, fifty-two per cent showed -evidences of psychic degenerations, twenty-nine per cent of which -consisted in an abnormal emotional makeup usually of the depressive -types. In 157 cases from fifty-nine families, Bergamasco found that 109 -showed manic-depressive psychoses. Kraepelin noted that the highest -percentage of the first attacks occurred between the ages of fifteen -and twenty. Reiss made a very significant analysis of the various -forms of the disease manifested by individuals possessing definite -predisposition. Thus, of the cases with a depressive makeup 64.2 per -cent had depressive attacks, 8.3 per cent, manic, and 27.5 per cent, -combined forms. Of those with manic temperaments, 35.6 per cent had -depressive attacks, 23.3 per cent, manic, and 41.1 per cent, combined -forms. Of the irritable individuals, 45.5 per cent had depressive -attacks, 24.4 per cent, manic, and 30.1 per cent, combined forms. Of -the cyclothymic persons, 35.3 per cent had depressions, 11.7 per cent, -excitements, and fifty-three per cent, combined forms. - -An analysis of the number of cases of manic-depressive insanity -admitted to American institutions is exceedingly interesting in -view of the opinions expressed by Kraepelin. From 1912 to 1919 -there were 49,640 first admissions to the thirteen New York state -hospitals. Of these, 7,499, or 15.1 per cent, were diagnosed as having -manic-depressive psychoses or allied conditions. During the years -1918 and 1919, when the Association's classification was officially -used throughout, the percentage of manic-depressive psychoses was -14.57. In the fourteen state hospitals of Massachusetts in 1919 there -were 3,011 first admissions. Two hundred and eighty-three, or 9.39 -per cent, of these were manic-depressive psychoses. In twenty-one -state hospitals in fourteen other states, practically all in 1917, -1918 and 1919, there were 18,336 first admissions. Of these 3,409, -or 18.59 per cent, were cases of manic-depressive insanity. Thus, of -the 70,987 first admissions reported from forty-eight hospitals in -sixteen different states there were 11,191 cases of manic-depressive -insanity, a percentage of 15.76. This may probably be looked upon as -fairly representative of the incidence of manic-depressive psychoses in -American institutions. - -When it comes to an analysis of the various forms of manic-depressive -psychoses reported, the indications are not so clear. In New York -during 1918 and 1919 there were 1,980 cases distributed as follows:— - - _Type_ _Number_ _Percentage_ - Manic 905 45.71 - Depressive 729 36.82 - Stuporous 53 2.68 - Mixed 245 12.37 - Circular 48 2.42 - -During the eight-year period referred to above in the New York -hospitals there were 6,091 cases of manic-depressive and allied -conditions, classified as follows:— - - _Type_ _Number_ _Percentage_ - Manic 2952 48.46 - Depressive 2014 33.06 - Stuporous 76 1.24 - Mixed 773 12.69 - Circular 199 3.26 - -The fourteen Massachusetts hospitals reported 672 cases in 1917 and -1918, classified as follows:— - - _Type_ _Number_ _Percentage_ - Manic 222 33.03 - Depressive 373 55.50 - Stuporous 4 .59 - Mixed 66 9.82 - Circular 7 1.04 - -In the twenty-one hospitals in fourteen other states there were 3,409 -cases of manic-depressive psychoses as follows:— - - _Type_ _Number_ _Percentage_ - Manic 1401 41.09 - Depressive 1365 46.04 - Stuporous 62 1.82 - Mixed 228 6.69 - Circular 94 2.76 - -The total from all of these institutions, of 12,152 cases, was -classified as follows:— - - _Type_ _Number_ _Percentage_ - Manic 5480 45.09 - Depressive 4481 36.87 - Stuporous 195 1.60 - Mixed 1312 10.79 - Circular 348 2.87 - -It will be noted that manic cases are more common than the depressive -in New York, the number of the former being fifteen per cent greater -than the latter. In Massachusetts the number of depressive forms is -twenty-two per cent higher than the manic. In the other states the -depressive types are less than five per cent higher than the manic. -In all institutions the mixed forms are more common than the circular -or stuporous. The stuporous forms constitute the smallest percentage -reported in all hospitals, except in 1918 and 1919 in New York. We -would be warranted, apparently, in the conclusion that in this country -manic forms are the more common, the depressive being second in -frequency, followed by the circular and stuporous types in the order -mentioned. - -The statement is, I think, also warranted that there is a considerable -difference of opinion as to the classification of the different forms -of manic-depressive insanity and that diagnostic procedure is far -from being standardized. Many of these discrepancies are doubtless -due to difficulties in differentiating between certain cases of -manic-depressive psychoses and dementia praecox. The hospitals -reporting lower percentages of the former usually show a much higher -rate of the latter. Certainly there is room for an honest difference -of opinion in many instances. It must be admitted, moreover, that our -fundamental conceptions of these two great groups do not permit of a -hard and fast line of demarcation between them in all cases. - - - - -CHAPTER XII - -INVOLUTION MELANCHOLIA - - -In 1896 Kraepelin first definitely outlined his views on dementia -praecox, to which he assigned hebephrenia, although he did not at -the time include katatonia in his delimitation of that disease. He -also described melancholia in his fifth edition, classifying it as -an involutional or retrograde presenile process (Das Irresein des -Rückbildungsalters). He had not as yet formulated his theory of the -manic-depressive psychoses although he described manic and depressive -forms of periodical constitutional disorders. In 1899 he discarded the -mania and melancholia of other writers altogether or rather included -them in his new manic-depressive group, but still retained melancholia -as a distinct entity occurring in the involutional period of life only. -As has already been shown, melancholia is a term which had been used -for centuries and in a general way applied to depressions of any and -all types. Kraepelin's manic-depressive psychoses and dementia praecox -very largely destroyed the integrity of this old-time conception. It -has been shown, furthermore, that depressive states often constitute -an integral part of the picture of general paresis. Symptomatic -depressions more or less distinct in character have been associated -with a number of somatic diseases. Senile psychoses, epilepsy, -various organic conditions, the psychoneuroses and the psychopathic -personalities have depressive manifestations well recognized and -readily classifiable. - -Kraepelin, however, pointed out the fact that there was another group -still unaccounted for—the anxious depressions of later life, which -he included under the designation of involution melancholia and which -did not belong to the manic-depressive group. This he described as -being preeminently a depression associated almost always with anxiety -and fear as prominent symptoms. Accompanying this condition there -are usually ideas of poverty, sin, or impending danger of some kind. -Delusions of self-accusation are quite common. Anxious restlessness -or agitated excitement is to be expected in a majority of the cases. -There is usually no clouding of the consciousness, although, as Hoch -expresses it, "the mental horizon may be more or less narrowed to the -depressive ideas." The memory as a rule is not impaired. Hallucinations -of sight and hearing are often present. Somatic delusions of a -hypochondriacal nature occur. Insomnia is usually marked. The tendency -of the disease is towards deterioration. Retardation and psychomotor -inactivity are not to be expected. Melancholia is to be differentiated -from manic-depressive insanity by the prominence of anxiety and -apprehension, the absence of any retardation or psychomotor inhibition, -the unusual frequency of self-accusation with ideas of sinfulness, the -clearness of the sensorium, the comparatively unfavorable prognosis and -the great frequency of suicidal impulses. The age, and the absence of -previous attacks, is, of course, exceedingly important in arriving at -a diagnosis. The onset of the disease is usually between the ages of -forty and sixty, but not infrequently it begins with the menopause in -women, and Kraepelin states that sixty per cent of the cases occur in -the female sex. He found a history of defective heredity very common. -The precipitating factor is often some mental shock, the illness -or death of friends, or disasters of various kinds. No distinctive -pathology of the disease has been described by Kraepelin. He was -uncertain as to the rôle played by arteriosclerosis in its etiology. -Diefendorf[283] reported that about one-third of the cases made complete -recoveries; twenty-three per cent were able to return to their previous -surroundings; twenty-six per cent terminated in an advanced state of -deterioration and nineteen per cent died within a period of two or -three years. - -In 1907 Dreyfus,[284] at that time an assistant of Kraepelin's, made -an elaborate study of the cases previously diagnosed as involution -melancholia in the Heidelberg clinic. During a period of fourteen -years, a total of seventy-nine were reported. A thorough investigation -by Dreyfus showed that two-thirds of these had made complete recoveries -or improved to such an extent as to be able to go home. Only eight per -cent showed a marked mental deterioration. He also found that over -half of the series had more than one attack, usually depressions. -One-third of the patients died and were thus eliminated from further -consideration. The duration of the attack was over three years in -one-third of the cases reviewed. Fifteen per cent recovered in from -three to five years, nine per cent in from six to eight years, and -eight per cent in from ten to fourteen years. He was of the opinion -that after a careful study of the hospital records the symptoms found -could all be explained on the basis of manic-depressive insanity, -usually of a mixed form. Kraepelin had reported that forty-nine per -cent of his cases deteriorated mentally. Dreyfus reduced this on -further observation to only eight per cent. On analysis he found, in -many instances, brief periods of manic elation, sometimes only a matter -of hours or a few days, evidences of excitability, manic suggestion in -the eagerness of the patient to communicate his troubles to others, -and inhibitory processes indicated by a lack of interest, loss of -affection or even difficulty of thinking. Dreyfus concluded that the -depressions of late years were not so common as had been supposed and -that a sufficient knowledge of their history showed that they had -usually exhibited previous attacks. He thought that the long duration -of the disease probably led to erroneous ideas as to its termination in -deterioration. - -Kirby[285] is of the opinion that Dreyfus based some of his findings on -insufficient evidence, as shown by his published case records:—"In -a considerable number of other cases the author's conclusion that -manic-depressive symptoms were present is based on extremely meagre -data. As an illustration one case may be referred to briefly. A man -fifty-three years old had an agitated depression lasting over two and -one-half years and terminating in recovery. The case record contains -no statement of any objective inhibition or feeling of subjective -insufficiency, neither are there any statements regarding flight -of ideas, or unusual loquacity. The diagnosis, however, is made of -manic-depressive insanity, with partial psychomotor inhibition and -flight of ideas. The assumption that these symptoms existed is based -entirely on the retrospective account from the patient, obtained three -years after recovery from the psychosis. He then declared that during -the attack he could not think calmly; it seemed that one thought -"knocked the other down," one thought "hunted after the other." He also -described a feeling as if there were a cap on his head, as if he were -nailed down. These retrospective statements are interpreted to mean -that there was partial psychomotor inhibition and flight of ideas. In -many other cases the reasoning is just as forced and the deductions -based on equally insufficient grounds.... The author's aim was to see -if the symptoms present fitted into certain schematic formula and thus -the analysis became rather a search for diagnostic signs supposed to -characterize a definite form of disease. Such a method leads away from -consideration of the mental disorder as a whole; a few minor features -are emphasized in the picture and because the patient recovers these -are raised to diagnostic importance—a little feeling of insufficiency -or a slight change of mood in a disorder which ends in recovery are -seized upon as evidence that a special kind of disease exists; as a -matter of fact, we would hardly miss just such symptoms in many other -psychoses. There is no attempt to get below the surface, to understand -the evolution of the disorder, or to use the facts in the development -in formulating the prognosis." - -In the introduction to the book written by Dreyfus in 1907, Kraepelin -nevertheless expressed the opinion that "These results show that -for the most of these disorders which have been designated as -melancholia there now exists no sufficient reason to separate them -from manic-depressive insanity." This at the time was looked upon as -definitely settling the fate of the melancholia concept and it was -abandoned by some. As a general rule, however, the psychiatrists of -this country seem to have accepted Kraepelin's original description -of the disease as being thoroughly justified. To use White's words, -"Many psychiatrists still believe, although Kraepelin himself accepts -Dreyfus' conclusions, that there is still a place for involution -melancholia distinct from the manic-depressive group." - -In his eighth edition Kraepelin[286] discusses melancholia as a -presenile condition and reviews the whole situation in considerable -detail. He shows that symptomatic considerations alone did not guide -him in his original conception of the disease. A great deal of weight -was attached to prognosis and certain forms were separated out and -differentiated from manic-depressive because they tended towards -mental enfeeblement. He calls attention to the fact that Thalbitzer -disputed the integrity of melancholia in 1905, classifying it as a -manic-depressive reaction. After reviewing the findings of Dreyfus he -admits that the conclusions of the latter are in the main correct and -that involution melancholia as originally described cannot be retained -as a definite entity. "The significant fact still remains," he says, -"that single attacks of depression are disproportionately common in -the involution period." Hübner, for instance, found twenty-one single -attacks of melancholia after the fiftieth year of age to only two -single attacks of mania. "The appearance of depressions, therefore, -through the revolutions of this period of life seems to be favored -to a special degree." He again states that he is unable to determine -what rôle is played in the involutional depressions by beginning -arteriosclerosis or the onset of senile conditions. He concludes, -however, that a form of depression, earlier described as melancholia, -is still to be separated from the manic-depressive psychoses although -not entirely clear as to its significance or exact delimitation.[287] - -These are the most severe and rapidly fatal forms of anxious -excitements, as a rule developing suddenly and included now in his -presenile group. "These cases are anxious, restless, sleepless, -self-accusatory and show delusions of persecution." The delusional -ideas are depressive, extravagant and hypochondriacal. "They have -offended everybody; are eternally damned; Satan is coming and will take -them; he is out there. Nature has changed, everything is different, no -mercy can come from heaven; there are ghosts in the house; the patients -find themselves in the infernal regions, are surrounded by hostile -powers, are in a bewitched castle. They will be carried away, thrown -into a fiery furnace, their arms and legs cut off, have their throats -cut in the presence of a thousand students, and be buried alive. They -have a cancer in the stomach, the husband is insane or has had a -stroke." Suicidal attempts are frequent. Sometimes grandiose ideas are -expressed, accompanied by hallucinations. Apprehension and orientation -are usually not disturbed. This is ordinarily followed by a period of -violent excitement with agitated wringing of the hands, striking the -breast, tearing the hair, etc. Confusional conditions with clouding may -appear, often terminating shortly in a pneumonia, erysipelas or heart -failure. According to Nissl, widespread and well marked changes are to -be found in the brain at autopsy. There is an extensive destruction -of ganglion cells, although that cannot be definitely associated with -the symptoms of the disease. Kraepelin leaves the question open as to -whether this should be looked upon as some form of "acute delirium" -such as manifests itself in the course of various psychoses. The -disease is usually one of the sixth decade of life, much more common in -the female sex, and cannot without further information be definitely -excluded from the involutional processes. He concludes his discussion -by saying that these conditions probably "have some relation to the -similar delirious senile forms to be discussed later." This is, of -course, a decided modification of his original views, although it -is quite clear that he still feels that there is an involutional -depression, now included, however, in the presenile group. - -In his chapter on manic-depressive insanity three years later -Kraepelin[288] referred to this question again as follows:—"Under these -circumstances I thought at first that the involutional depressions -described as special clinical forms, melancholia in the narrower sense, - which seemed to show essential differences in its general -characteristics, course, and to a certain extent in the history of its -development, should be separated from manic-depressive insanity. At the -same time I was aware of the fact that in a considerable number of the -involutional depressions, both on account of their clinical form and -their association sooner or later with manic states, their connection -with manic-depressive insanity could not be questioned. I therefore -made an effort to establish a practical differentiation, entirely -without satisfactory results. Further experience has demonstrated, as -was shown in the discussion of the presenile psychoses, that they do -not constitute grounds for the separation of melancholia. Deterioration -is explained by the development of senile or arteriosclerotic changes. -Some cases were of long duration, showing manic symptoms before -recovery. The frequency of depressions in advanced years we have -learned to be a legitimate development of the involutional period of -life. The substitution of anxious excitement for volitional inhibition -has proved to be an occurrence which is found in advancing years in -those cases which had an attack of the ordinary form in the decade -before (as shown in our cases 1 and 2). Hübner has, moreover, made -the observation that melancholia may show retardation in one attack -and not in the next. There remains, therefore, no adequate reason for -differentiating the involutional depressions heretofore described as -melancholia from manic-depressive insanity." - -Kehrer[289] has made a careful analysis of the facts brought out -by Kraepelin's statistical diagram showing the various age groups -represented by his manic-depressive cases. "From the fifteenth year -of life, at which age manic and melancholic attacks are most frequent -(about twenty-five per cent), the curve of the manic attacks falls -steadily (with only two important rises at the thirty-fifth and the -forty-fifth years) until it becomes less than five per cent at the -seventieth year, while the curve of the melancholic conditions with -equal constancy increases (with the exception of the fifty-fifth -year only), especially between the forty-fifth and fiftieth years, -from fifty-two to seventy-four per cent and finally to eighty per -cent. On the other hand, the curve of the manic first attacks falls -steadily from 28.5 per cent at the twentieth year to 3.5 per cent at -the sixtieth, with a slight increase at fifty from 12.7 per cent to -13.4 per cent, while in the male sex the same curve shows no further -increase after the thirtieth year, when it reaches its maximum (33.8 -per cent) and even shows a particularly sharp fall, from 22.2 per -cent to 5.9 per cent, between the fiftieth and sixtieth year.... -Based on this diagram Kraepelin concluded that the depressions of the -involutional period, which did not show special symptoms of some other -disease entity, could not be differentiated from those of the earlier -periods of life." - -Specht,[290] Hübner and Stransky have subscribed to these views. -Stransky expressed the opinion that "there is nothing in the form -of these depressions, either with or without anxiety, by which they -can be distinguished from those recognized as manic-depressive -insanity and that neither the course nor the age of onset offer any -convincing argument for their clinical independence." Rehm, on the -other hand, held that there were depressions of the involutional -period of life corresponding to Kraepelin's melancholia and not -belonging to manic-depressive insanity. He described these as lacking -the constitutional taint and characterized by a slow onset, without -previous attacks, fatigability, outspoken egocentric conduct, -hypochondriacal delusions of the deteriorative type and the appearance -of hallucinations. Bleuler,[291] Bumke, Seelert, Albrecht and others -still hold to the integrity of involution melancholia as a distinct -entity. "These forms," as Bleuler expresses it, "have as a rule a much -more protracted course. They progress slowly for one or two years, -continue to be mild, reaching their height in several years, and -decline slowly to their final conclusion. The inhibition is obscured -by great restlessness, genuine agitated forms are common, they tend to -recidivism much less than the others and show also much less heredity." -Albrecht, in 138 cases of functional psychoses of the involutional -period, only thirty-two of which were in men, diagnosed eighty-two as -genuine involution melancholia. In none of his cases did he find an -isolated attack of mania in that period of life. He differentiates this -condition from agitated melancholia, leaving the question open as to -whether this constitutes a pernicious form or is a presenile disease. -According to Bumke, psychic causes are more prominent in involution -melancholia than in the manic-depressive psychoses, the duration is -longer and they do not make such complete recoveries, the most common -termination being a depressive mental enfeeblement, with despondency -and an anxious hypochondriacal mood. For the genetic interpretation of -climacteric melancholia as well as the other involutional forms the -intimate association, according to Bumke, of endogenous with exogenous -factors is the point of greatest importance. "Involution only brings -the barrel to an overflow; it only adds exogenous to the individual -endogenous momentum so that the sum total leads to the outbreak of a -manifest psychosis." Seelert goes still further with the endogenous -exogenous theory of Bumke. "It depends on the type of the association -whether the organic anxiety psychosis, a melancholia or the depression -of a manic-depressive insanity develops in the later period of life. -In one the endogenous factors predominate, in the other the exogenous -and in melancholia (in its narrower sense) the two maintain a balance." - -Although, as has been noted, no characteristic pathological changes -have been associated with involutional melancholia, a condition to -which attention was called by Adolf Meyer should be referred to here. -In 1901, in an article in "Brain" on "The Parenchymatous Systemic -Degenerations mainly in the Central Nervous System" he proposed the -name "Central Neuritis" for a terminal affection previously described -by Turner in 1899 and occurring more frequently perhaps in involutional -melancholia than in any other psychosis:—"This alteration has -been found to occur in peculiar forms of end stages of depressive -disorders, near or after the climacteric period, alcoholic-senile -and alcoholico-phthisical cachectic states, idiocy, and perhaps also -general paralysis (Turner's case). Ordinary infectious and cachectic -states do not, however, appear to form an important link in the -causes."[292] The mental condition is usually anxious, agitated and -apprehensive, often terminating in a delirium followed by a stupor. -The disease may last for a few days ending in death or may recover -after several weeks. It is accompanied by progressive weakness, loss -of weight and wasting, a slight rise of temperature, and in many cases -attacks of diarrhea. Characteristic are muscular tension with rigidity, -twitching movements, incoordination and jactitation of the limbs. -The reflexes are usually increased. The onset is often quite sudden, -usually in the fourth, fifth or sixth decade of life. At autopsy a -striking condition, described as axonal alteration, is found in the -"Betz" and other large ganglion cells generally. The cell body -is somewhat swollen, the stainable substance is reduced to a -structureless powder and the nucleus is dislocated and appears -conspicuously in the periphery. There is also some "Marchi" -degeneration of the fibre tracts in the motor areas. The regions -involved, according to Meyer,[293] are "the cortico-thalmic connections -of the motor areas, the auditory radiation, the forceps, the pyramids, -the fillet, the restiform body, and to a lesser degree, the posterior -column of the cord, the intersegmental elements, and the segmental -efferent motor elements." - -In view of the attitude of the psychiatrists of this country as shown -by numerous expressions of opinion, the statistical committee of the -Association felt justified in retaining involution melancholia in its -classification of psychoses for the present and collecting data for -further consideration. The following suggestions were offered as to its -delimitation:— - -"These depressions are probably related to the manic-depressive group; -nevertheless the symptoms and the course of the involution cases are -sufficiently characteristic to justify us in keeping them apart as -special forms of emotional reaction. - -"To be included here are the slowly developing depressions of _middle -life and later years_ which come on with worry, insomnia, uneasiness, -anxiety and agitation, showing usually the unreality and sensory -complex, but little or no evidence of any difficulty in thinking. The -tendency is for the course to be a prolonged one. Arteriosclerotic -depressions should be excluded. - -"When agitated depressions of the involution period are clearly -superimposed on a manic-depressive foundation with previous attacks -(depression or excitement) they should for statistical purposes be -classed in the manic-depressive group." - -In view of the history of the development of the conception of this -psychosis an analysis of the hospital statistics on this subject is -of unusual interest. We now have reports of over seventy thousand -first admissions based almost entirely on the classification at -present used by the Association. In 49,640 first admissions to the -New York hospitals during a period of eight years there were 1,351 -cases diagnosed as involution melancholia—2.72 per cent of the -total. During 1918 and 1919, when the Association's classification -was followed in detail, these hospitals showed 480 cases, or 3.45 per -cent of 13,588 first admissions. Twenty-one public institutions in -fourteen other states reported 378 cases, or 2.06 per cent of 18,336 -admissions. Two and twenty-five hundredths per cent of the admissions -to the Massachusetts state hospitals in 1919 were cases of involution -melancholia. Reports from forty-eight different state hospitals show -that involution melancholia constituted 2.53 per cent of over seventy -thousand admissions. This shows a remarkable similarity in standards of -diagnosis as far as this psychosis is concerned. - - - - -CHAPTER XIII - -DEMENTIA PRAECOX - - -The dementia praecox of today, notwithstanding the numerous theories -which have been advanced as to its etiology and pathology and the -various fundamental conceptions which have been evolved in the -interpretation of its mental mechanisms, is essentially the disease -described by Kraepelin in 1899. The designation which he applied to -this psychosis or group of psychoses was not new, having been used by -Morel as early as 1860 and again by Pick in 1891. His views as to the -delimitation of the disease were, however, altogether different from -those of earlier writers and were destined to inaugurate a new era in -psychiatry. The grouping which he proposed would include certain types -of mania and melancholia and the psychoses of puberty and adolescence -described by Hecker and Kahlbaum together with various paranoid states -previously associated with paranoia, chronic delusional insanity, etc. - -Kraepelin thus at one blow destroyed the integrity of mania, -melancholia, terminal dementia and paranoia, entities which had been -practically unquestioned for centuries. This radical departure from -established psychiatric procedure was based on his observation that -various definite characteristics were common to certain cases in all of -these clinical groups and that they were of vital significance from a -symptomatic as well as a prognostic point of view. He called attention -to the fact that excitements and depressions often recurred or -alternated in the same individual without any tendency towards mental -enfeeblement. An analysis of the mental mechanisms and symptomatology -of these cases led to his well-known conception of the manic-depressive -psychoses. Other clinical groups equally well-defined, although not so -sharply circumscribed, showed consistent and progressive tendencies -towards mental deterioration. These were brought together and described -as dementia praecox. This may be looked upon as a logical development -of the progress made by the German school of psychiatrists. The first -step in this direction perhaps was the recognition of hebephrenia by -Hecker in 1871. He particularly emphasized the occurrence of this -condition at the time of puberty or during the adolescent period. This -has often been referred to as "silly dementia." The preliminary stage -or onset in many instances was characterized by a gradual change in -personality. This was evidenced by foolish behavior, silly actions -and a failure of adjustment to the patient's surroundings often -resulting in an abandonment of his usual occupation, with an evident -gradual intellectual deterioration. Initial attacks of depression -were frequent, usually with hypochondriacal ideas and only occasional -hallucinations or delusions. Transitory periods of excitement were -common sequelae. The emotional reactions were characterized by their -shallowness, the train of thought by incoherence, the conduct by -foolish and senseless acts and the intellectual reactions by an -advancing deterioration. "The weakminded silliness of the disease -picture," in the words of Krafft-Ebing, "is partly to be explained by -the original weakmindedness of the patient, which Hecker emphasizes in -the etiology of his cases." - -A more decided step in the development of the dementia praecox concept -was the description by Kahlbaum of katatonia in 1874. This may be -ushered in by an early stage strongly suggesting hebephrenia but -terminating usually in a depression followed by states of excitement, -stupor and dementia. The characteristic features of the disease are -the peculiar catatonic stupor so-called, and forms of excitement -differing materially from those exhibited in the manic-depressive -psychoses. Hallucinations and delusions are almost invariably present. -The delusions are likely to be of a most absurd and extravagant type, -accompanied by self-accusation in some instances but oftener by -feelings of influence referred to others or somatic ideas. States of -muscular tension appear early, with constrained attitudes and peculiar -mannerisms. The stupor which is such a prominent feature in the picture -is characterized by negativism shown by a resistance to all external -influences, mutism and a refusal to accept food. This may be associated -with rigidity due to extreme muscular tension which is often so marked -as to be described as cataleptic. Automatism may manifest itself in the -form of echolalia or echopraxia. The excitements are characterized by -impulsive acts of violence. Verbigeration and stereotypy are frequent -symptoms. Remissions are rather to be expected but the tendency of the -disease is towards a marked mental deterioration in the great majority -of cases. - -Schüle in 1886 suggested the term dementia praecox as one applicable -to the psychoses of adolescence. It remained for Kraepelin, however, -to establish the entity of these disease processes by including still -another type, the paranoid forms, which were left entirely unaccounted -for in the conceptions of Hecker, Kahlbaum, Schüle, Morel, Pick, or -any of the earlier writers. In this group he included cases with -persistent hallucinations, more or less loosely systematized delusions -of persecution and gradually increasing deterioration but with little -or no clouding of consciousness. - -In the last edition of his book Kraepelin[294] defines dementia praecox -as including "a group of clinical pictures having the common symptom of -a characteristic destruction of the internal associations of the psychic -personality affecting particularly the emotional and volitional -spheres".... "Although wide differences of opinion still exist on -many points, the conviction seems to be gaining ground more and more -that dementia praecox on the whole represents a well-defined disease -entity, and that we are justified in regarding the majority at least -of the apparently dissimilar clinical types here described as the -manifestations of a single disease process." Many objections have been -raised to the name applied to this psychosis by Kraepelin. It has been -pointed out that complete deterioration is not always the termination -to be expected in this group and that it is not always a disease of -adolescence. All of this was conceded by Kraepelin. He employed the -term as one answering the purpose "until a more thorough understanding -would suggest an appropriate designation." His conception of the -psychosis as described in the sixth edition of his book may, I think, -be said to have received the rather general approval of the psychiatric -world. While there has been no serious attack on his delimitation of -the disease entity itself, there has been a decided controversy as to -the psychological mechanisms involved and the fundamental principles -upon which his conceptions were based. Certainly no textbook of recent -years has failed to give a very serious consideration to the question -of dementia praecox. - -Stransky (1909) looked upon dementia praecox as the result of a lack -of coordination of the intellect, the emotions and volition, which -he expresses as an intrapsychic ataxia. This is illustrated by the -displacement of the affect so common in dementia praecox and its -association with an entirely incongruous idea. Thus, the patient laughs -while expressing an exceedingly depressing delusional belief or cries -while telling a joke. No emotion is displayed at the statement that -he is being buried alive or torn apart by some outside agency. This -would possibly explain the unprovoked rages of the catatonic and the -discrepancy between the catalepsy and mutism of a patient who is found -to be perfectly oriented as to his surroundings and the curious fact -that he is often thoroughly clear as to the exact day and date. - -Wernicke's theories regarding the elaboration of mental mechanisms -have already been referred to. He saw in dementia praecox and other -deteriorative processes the possibility of a dissociation of psychical -reflexes due to an interruption or disturbance located in the -psychomotor projection field, preventing its proper coordination with -the intrapsychic elaboration mechanisms. - -The psychological processes involved in schizophrenia as outlined by -Bleuler[295] (1911) have a very important bearing on the interpretation -of the symptoms of dementia praecox. The group which he described -under this designation is a very broad one, including "many atypical -melancholias and manias of other schools (as well as hysterical -melancholias and manias), the most of the hallucinatory confusions, -many of the amentias described by others (our conception of amentia -is much narrower), some of the forms belonging to acute delirium, -Wernicke's motility psychoses, primary and secondary dementias without -special designations, the most of the paranoias of other schools, -especially the hysterical paranoias and almost all of the incurable -hypochondrias, nervousness, compulsions and impulsions." To these he -adds the various "juvenile and masturbation forms," a large part of the -degenerative psychoses of Magnan, many prison psychoses and the Ganser -symptom complex. In view of the fact, as Bleuler[296] expresses it, that -"The name dementia praecox, which neither leads to dementia nor -is precocious in its origin, necessarily, gave rise to many -misunderstandings," he suggested the designation schizophrenia as more -appropriate. "Even if we cannot make a natural grouping, it would -appear that schizophrenia is not a disease in the narrower sense but -a group of diseases somewhat analogous to the organic group, which -includes paralysis, the senile forms, etc. Schizophrenia should -therefore be spoken of really in the plural. The disease pursues a -chronic course or progresses in attacks and may come to a standstill -at any stage or may even regress but never to a complete restitutio -ad integrum. It is characterized by a specific type of alteration in -thinking, feeling and relation to the outer world encountered nowhere -else. Accessory symptoms of a characteristic type are particularly -common.... Dementia praecox in any stage may come to a stop, and -many of its symptoms partially or entirely disappear but when it -progresses further it leads to dementia and dementia of a definite -type." A fundamental symptom, according to Bleuler, is the disturbance -of association of ideas. "The normal association of ideas loses its -stability; others enter at will and take their place. Thus the ideas -lose their relation to each other and thought becomes incoherent." -As Hoch[297] says of this disturbance, "Bleuler described it very -extensively, and yet somehow it is not so very easy to grasp the nature -of this disorder; it is evidently not so very different from Wernicke's -sejunction, though free from all localizing anatomical bywork. It is -conceived of as a more or less widespread primary interruption of -the associative connection of ideas. Actual or latent associations, -which, in the normal, determine the train of thought or combinations -of such ideas may remain without influence upon it in an apparently -aimless fashion, whereas other ideas which have no connection may -intrude themselves. Hence the train of thought is scattered, bizarre, -illogical, abrupt. This may be so slight that it is difficult to -discover, and in his description of mild conditions he says it may not -be found, or only after a thorough search; it accounts for much of the -scattering of ideas in chronic states, and, as we have said, it is -supposed to be the explanatory principle in acute incoherence. On the -other hand, similar phenomena may be due to the action of complexes, -and have to be explained psychogenically. But the psychogenic -explanation does not appear to him sufficient. It is somewhat difficult -to see, especially when we consider the extensive symbolization and -substitution, the indifference, the negativism, etc., why something -beyond these psychogenically explicable disorders is required." An -essential feature of Bleuler's[298] concept is "autismus." "The -schizophrenics lose their contact with reality, the mild cases -inconspicuously here and there, the severe cases, completely".... "When -we allow our fancies free reign in mythology, in dreams and in many -of the morbid states, thought will not or cannot concern itself with -realities; it follows the dictates of instincts and emotions. This -disregarding of the inconsistency with reality is characteristic of -autistic thinking." - -In his excellent review of Bleuler's schizophrenia already referred to, -Hoch[299] makes the following comments on this subject:—"A difficult -subject is autism. By autism Bleuler means that which we have called -the shut in tendency, the more or less complete shutting out of the -environment, or at any rate, all that which does not correspond to the -wishes. It may be so marked that the patients even shut out all sensory -impressions, close their eyes and ears, make their body as small as -possible by crouching. Bleuler regards this autism as a secondary -phenomenon, and looks upon it as one of the results of his association -disorder, whereas the autistic thinking is the day-dreaming, the -thinking without reference to reality. This autistic thinking -flourishes in schizophrenia—Bleuler thinks that the schizophrenic -defect in logic makes the exclusion of a great many external and -internal facts possible, and thus gives sway to a tendency which we -all have, namely, to live in fancies which suit us, something which we -indulge in but do not allow to influence our conduct, but which in the -schizophrenic assumes the value of reality." An outline of Bleuler's -views would not be complete without his definition of blocking,[300] -an important symptom. "Blocking is a sudden emotional inhibition of -the psychic processes and in itself not pathological." He found it in -normal individuals in nervousness and in hysteria. "Where it is not -based on adequate psychological grounds, is generalized or of long -duration, its presence warrants the diagnosis of schizophrenia." - -A study of the psychogenic factors concerned in dementia praecox -led Meyer[301] to the conclusion that the psychological processes -of the disease were due to abnormal mental mechanisms developing -in individuals unable to adjust themselves to their surroundings. -"The general principle is that many individuals cannot afford to -count on unlimited elasticity in the habitual use of certain habits -of adjustment, that instincts will be undermined by persistent -misapplication, and the delicate balance of mental adjustment and of -its material substratum must largely depend on a maintenance of sound -instinct and reaction type." This theory is supported somewhat by the -"shut in personality" found by Hoch[302] in his studies of the history -of a large number of cases developing dementia praecox. - -Elaborate analyses of the psychological mechanisms involved in dementia -praecox have been made by Jung and others. Freud believed hysteria to -be the result of a psychic trauma. The unpleasant idea associated with -this trauma is repressed into the subconscious because the individual -is unable to react to it in a normal way and it is forgotten, but not -until it is compensated for by a hysterical symbol or symptom which -takes its place. By means of psychoanalysis, the association test and -the study of dreams the nature of the psychic trauma can often be -determined. Jung[303] adapted these methods of study to a consideration -of dementia praecox. His investigations showed that many of the -seemingly meaningless manifestations of that disease are symbols or -substitutes for buried complexes. In some instances these remain in -their original form without transformation. Complexes associated with -a feeling of deficiency and injured pride may lead to suspicion and -delusions of persecution. Unfulfilled longings may be actualized in a -delirium or delusion of grandeur. Symbols and substitutes generally -are said to represent complexes which are antagonistic to the ego and -are therefore transformed and become unrecognizable. The peculiar -symptoms of dementia praecox as a rule are a result of the individual's -inability to make compensatory readjustments. In the paranoid forms the -patient entirely reconstructs his psychical life. White[304] attempts -to explain the meaning of some of these delusional formations in his -"Outlines of Psychiatry":—"The relation of the delusion to the complex -is often obvious if one is familiar with the more important of the -infantile material. A man believes himself pregnant, that a child -is in his stomach. This is obviously a regression to the period when -as an infant he had not understood that gestation was a particular -function of the female. Another patient enucleated his eye (castration -symbol); a colored man of about forty years of age invented a -perpetual motion machine (compensation for impotence); a man tries -to invent the greatest cannon on earth (compensation for small penis -complex); a homosexual man of the "sissy" type made wild claims of -physical prowess, fighting ability, and incessantly swore and used -vulgar language to demonstrate his toughness (over-compensation of -homosexuality); a woman complains that her sister's husband follows -her through underground passageways and shoots electricity into her -genitalia and anus (anal erotism); an oral erotic woman starves -herself in order to be tube fed; oral erotic patients often cut their -throats while under the erotic pressure; patients frequently say that -God talks with them or go to Washington to see the President (father -complex); in severe grades of introversion they sit in a dark corner, -head on breast, arms folded and legs and thighs flexed (intra-uterine -position); a young woman says her real parents are the King and Queen -of Norway (Œdipus phantasy); etc. Of course much of the delusional -material is not so obviously related to infantile material and must -be worked out at length with the individual to determine its meaning. -It must not be forgotten that a praecox may have, however, complex -reactions exactly like that of hysteria and the psychoneuroses. To that -extent such a patient is hysterical or psychoneurotic." - -The appearance of the last edition of his textbook showed that -Kraepelin has somewhat revised his views on the subject of dementia -praecox. He now speaks of a series of morbid pictures "brought together -under the designation endogenous dementias for the purpose of a -preliminary understanding." This embraces not only dementia praecox -but a new entity described as "paraphrenia."[305] This includes forms -"which, contrary to the usual manifestations of dementia praecox, are -characterized throughout their entire course by the marked prominence -of a characteristic intellectual disturbance while an independent -impairment of volition and particularly an emotional alteration are -lacking or only present in a mild form. For this differentiation it -seems to me that no more suitable expression than "paraphrenia" could -be employed for the designation of the disease processes experimentally -brought together here." He speaks of the following types:—systematica, -expansiva, confabulans and phantastica. - -The clinical forms of dementia praecox shown in his last edition are as -follows:—dementia simplex, hebephrenia, simple depressive or stuporous -dementia, depressive delusional dementia, circular, agitated and -periodic forms, katatonia, paranoid types (dementia paranoides gravis -and mitis, hallucinatory and paranoid feeblemindedness) and confusional -speech or schizophasia. - -His views as to the delimitation of these different types should be -expressed perhaps in his own words:[306] - -"Simple progressive deterioration as described by Diem under the -designation of 'Dementia Simplex,' consists in an imperceptible and -complete impoverishment and breaking down of the entire mental life." - -Of hebephrenia or silly dementia he says, "In this disease picture -there stands out particularly with the progressive deterioration of the -mental life, an incoherence of thought, feeling, and conduct." - -"As the third group of dementia praecox I should like to group -together, under the designation of simple depressive or stuporous -dementia, those cases in which, after an initial depression, with or -without the appearance of stupor, a terminal mental deterioration -gradually develops." - -"Those cases which progress to the marked development of phantastic -delusions we group together in the fourth form of dementia -praecox—depressive delusional dementia." - -"The next large group includes those cases in which severe and -protracted excitements develop." - -"The first sub group which on account of its course we may designate as -the circular form shows the nearest relationship to the disease picture -just described in that it also begins with a depression and usually -manifests active delusions." - -"As a second sub group, the agitated form, we bring together those -cases in which the disease begins with an excitement and then -immediately or after more or less frequent remissions and relapse -passes into the terminal stage." - -"In close relation to the cases brought together here we have to -consider a small group which either in the initial stages of the -disease or throughout its entire duration follows an outspoken periodic -course; these amount to less than 2 per cent of all cases." - -"The excitements of dementia praecox constitute an important part of -the clinical form—Katatonia—which we must now consider. Under this -designation Kahlbaum described a disease picture which in turn presents -the symptoms of melancholia, mania and stupor, the unfavorable cases -being accompanied by confusion and deterioration and is furthermore -characterized by the appearance of certain motor seizures and -inhibitions—in other words, the catatonic disorders." - -"In many respects a dissimilar picture is shown by those cases in -which the essential symptoms are delusions and hallucinations; these -we characterize as paranoid forms. The justification for including -them with dementia praecox I get from the fact that in them sooner or -later the delusion formation is invariably associated with a series of -disturbances which we find everywhere in the other forms of dementia -praecox." - -Cases "which do begin with a simple delusion formation but which in -the further course exhibit still more clearly the peculiar destruction -of the mental life and particularly the emotional and volitional -disturbances which characterize dementia praecox may be grouped -together under the name 'dementia paranoides gravis'." - -"As a fourth form of paranoid dementia praecox, I believe still -another group should be added, those which on the one hand show a -similar development and the same delusion formation as the paranoid -disorders just described but which on the other hand terminate in a -characteristic mental enfeeblement." These he would call 'dementia -paranoides mitis'." - -"A last very characteristic group of cases the discussion of which must -be included here, is formed by the patients with confusional speech." -These are the Schizophasias of Bleuler. - -It must be admitted that in view of Kraepelin's former contributions -on this subject this classification must be looked upon as somewhat -involved and confusing. It suggests an unnecessary complication of -an already difficult subject to no great advantage. These varying -conceptions are difficult to understand. Perhaps, as Meyer[307] -expresses it, "the symptomatology in its first formulation in 1895, -and later, emphasized too many things which prevail also in other -conditions, so that altogether too many errors occurred. In four -hundred and sixty-eight of Kraepelin's Munich diagnoses even between -1904 and 1906, 28.8 per cent were cases subsequently considered -to be manic-depressive (Zendig)—altogether too broad a margin of -uncertainty." - -In summarizing the whole situation the conclusion reached by -Buckley[308] would appear to be thoroughly established:—"Most -authorities agree, however, that the term dementia praecox includes -the psychoses which appear prior to mental maturity (early in some and -much later in others), with a tendency to permanent mental defect in -the long run, but which may follow a chronic course, may be divided -into attacks, or may improve or stop at any stage, but never with -restoration to absolute normal health." - -Notwithstanding the elaborate investigations of Alzheimer, Sioli, -Klippel, Lhermitte, Moriyasu, Goldstein, Nissl and many others, -no definite pathological basis for dementia praecox has ever been -established. - -For purposes of statistical study in the collection of data relative to -this disease entity, as in all other cases, the American Psychiatric -Association has endeavored to adhere to fundamental conceptions -generally accepted by the profession and has avoided as far as possible -adherence to the tenets of any one school. For purposes of uniformity -the following suggestions were made in the "statistical manual" as to -the classification of psychoses to be reported under the designation of -dementia praecox. - -"This group cannot be satisfactorily defined at the present time as -there are still too many points at issue as to what constitute the -essential clinical features of dementia praecox. A large majority of -the cases which should go into this group may, however, be recognized -without special difficulty, although there is an important smaller -group of doubtful, atypical, allied or transitional cases which from -the standpoint of symptoms or prognosis occupy an uncertain clinical -position. - -"Cases formerly classed as allied to dementia praecox should be placed -here rather than in the undiagnosed group. The term "schizophrenia" is -now used by many writers instead of dementia praecox. - -"The following mentioned features are sufficiently well established -to be considered most characteristic of the dementia praecox type of -reaction: - -"A seclusive type of personality or one showing other evidences of -abnormality in the development of the instincts and feelings. - -"Appearance of defects of interest and discrepancies between thought on -the one hand and the behavior-emotional reactions on the other. - -"A gradual blunting of the emotions, indifference or silliness with -serious defects of judgment and often hypochondriacal complaints, -suspicions or ideas of reference. - -"Development of peculiar trends, often fantastic ideas, with odd, -impulsive or negativistic conduct not accounted for by any acute -emotional disturbance or impairment of the sensorium. - -"Appearance of autistic thinking and dream-like ideas, peculiar -feelings of being forced, of interference with the mind, of physical or -mystical influences, but with retention of clearness in other fields -(orientation, memory, etc.). - -"According to the prominence of certain symptoms in individual -cases the following four clinical forms of dementia praecox may be -specified, but it should be borne in mind that these are only relative -distinctions and that transitions from one clinical form to another are -common: - -"(a) Paranoid type: Cases characterized by a prominence of delusions, -particularly ideas of persecution or grandeur, often connectedly -elaborated, and hallucinations in various fields. - -"(b) Catatonic type: Cases in which there is a prominence of -negativistic reactions or various peculiarities of conduct with phases -of stupor or excitement, the latter characterized by impulsive, queer -or stereotyped behavior and usually hallucinations. - -"(c) Hebephrenic type: Cases showing prominently a tendency to -silliness, smiling, laughter, grimacing, mannerisms in speech and -action, and numerous peculiar ideas usually absurd, grotesque and -changeable in form. - -"(d) Simple type: Cases characterized by defects of interest, gradual -development of an apathetic state, often with peculiar behavior, but -without expression of delusions or hallucinations. - -"(e) Other types." - -A sufficient number of reports has been received from hospitals using -this classification to warrant a preliminary survey of the information -available at this time on the subject of dementia praecox. Perhaps it -would be well to summarize first such information as is to be obtained -from other sources. Diefendorf[309] states that dementia praecox -constitutes from fourteen to thirty per cent of all admissions to -institutions, fifty-eight per cent of the total number being of the -hebephrenic, eighteen per cent, of the catatonic, and twenty-two per -cent, of the paranoid variety. Kraepelin[310] (1913) found that dementia -praecox constituted ten per cent of all admissions, classified as to -types as follows:—Silly dementia, thirteen per cent; simple depressive -dementia, ten per cent; delusional depressive dementia, thirteen per -cent; circular dementia, nine per cent; agitated dementia, fourteen -per cent; periodic dementia, two per cent; and katatonia, 19.5 per -cent. He reported a history of hereditary taint in seventy per cent of -his cases. Diefendorf found the onset of the disease in sixty per cent -of all cases before the twenty-fifth year, Kraepelin, in fifty-seven -per cent. Kraepelin[311] states that seizures occurred in twenty-one -per cent of his cases of silly dementia and in the other types as -follows:—simple depressive dementia, seventeen per cent; delusional -depressive dementia, twenty-seven per cent; circular dementia, twenty -per cent; agitated dementia, twenty per cent; katatonia, seventeen per -cent; paranoid dementia gravis, three per cent and paranoid dementia -mitis, five per cent. Unfortunately a survey of the other literature of -the day throws little additional light on these subjects. - -A study of the statistical reports made by Pollock for the State -Hospital Commission shows that during the five years ending on June -30, 1919, dementia praecox constituted 14.42 per cent of the 2,024 -voluntary cases admitted to the thirteen New York state hospitals. -During a period of eight years ending on June 30, 1919, there were -49,640 first admissions to the New York state hospitals; 12,199, -or 24.57 per cent, of these were diagnosed as dementia praecox or -conditions allied thereto. The "allied" conditions have not been shown -in the New York reports since 1917. In 1918 and 1919 there were 13,588 -first admissions, 3,753, or 27.61 per cent, of which were cases of -dementia praecox. This would indicate an increase in the incidence of -that disease in New York during recent years. The Massachusetts first -admissions for 1918 and 1919 show a total of 7,582 cases, 1900, or -25.05 per cent, of which were dementia praecox. It will be noted that -the percentage is practically the same as that of New York for the same -years. In a group of twenty-one other state hospitals, representing -fourteen different states using the Association's classification, -18,336 first admissions have been reported, 3,856, or 21.03 per cent, -of which were cases of dementia praecox. This represents a variation -from the New York and Massachusetts findings which can be explained on -various grounds, largely by the fact that these institutions represent -a rural population. We have thus in all 70,987 first admissions to -state hospitals, with 16,920 cases of dementia praecox, representing -23.84 per cent of the total number. - -A consideration of the different types of this disease as represented -by the various state institutions shows somewhat different results. -In New York during the years 1916-17-18-19 there were 6,135 cases of -dementia praecox shown in the first admissions, classified as follows:— - - _Type_ _Number of Cases_ _Percentage_ - - Paranoid 3579 58.34 - Catatonic 468 7.63 - Hebephrenic 1463 23.84 - Simple 625 10.19 - -In Massachusetts in 1917-18-19 there were 2,921 cases, distributed as -follows:— - - Paranoid 1248 42.72 - Catatonic 678 23.21 - Hebephrenic 828 28.34 - Simple 165 5.64 - -In a group of nineteen other institutions there were 3,184 cases, as -follows:— - - Paranoid 800 25.12 - Catatonic 438 10.61 - Hebephrenic 1666 52.32 - Simple 230 7.22 - -We have thus a total of 12,240 cases, a composite group classified -according to types as follows:— - - Paranoid 5627 45.97 - Catatonic 1584 12.12 - Hebephrenic 3957 32.32 - Simple 1020 8.33 - -Although this is probably the largest group of cases of dementia -praecox recorded we are, unfortunately, not warranted as yet in -attempting any final conclusions. The Massachusetts and New York -statistics of late years would, I think, justify the tentative -statement, at least, that dementia praecox admissions represent -approximately twenty-eight per cent of all cases coming into our -hospitals. - -When we attempt to analyze the types of the disease as reported, it -at once becomes evident that there are very divergent standards of -diagnosis. There is a radical difference shown in the consideration -of the so-called simple dementia praecox with a general average of -8.33 per cent. In Massachusetts there is a much higher percentage of -the catatonic forms, with a predominance in New York of the paranoid -variety. The proportion of hebephrenic types in the other nineteen -institutions is at wide variance with the reports of Massachusetts -and New York. In all probability the percentage shown in the analysis -of the total number from forty-six state hospitals is not far from -representing conditions existing in American institutions. A careful -study of more complete reports extending over a number of years should -settle this question to what may be spoken of as almost a mathematical -certainty. - -Pollock and Nolan[312] have made a study of 9,124 admissions of -dementia praecox to the New York hospitals during a period of six and -three-quarters years. Of these cases 52.2 per cent were men and 47.8 -per cent, women. The distribution shown by age groups is interesting -and significant, as is shown by the following table:— - - _Age Group_ _Percentage_ - Under 15 years .2 - 15 to 19 " 7.8 - 20 " 24 " 20.1 - 25 " 29 " 22.0 - 30 " 34 " 16.6 - 35 " 39 " 13.5 - 40 " 44 " 8.4 - 45 " 49 " 5.3 - -This would not appear to suggest an adolescent origin for this disease -to the extent advocated in our textbooks. The highest rate shown by -males was in the age group from twenty-five to twenty-nine years and in -the female cases, from thirty-five to thirty-nine years. Forty-nine per -cent were thirty years or over at the time of admission, forty-three -per cent were between twenty and thirty years of age and thirty per -cent, between thirty and forty. Nineteen per cent were forty years or -over at the time of admission. Pollock's[313] investigation, the most -exhaustive statistical study yet made of dementia praecox, shows that -fifty per cent of the cases have a family history of insanity, nervous -diseases, alcoholism or neuropathic or psychopathic traits, with a -full fifty per cent showing no evidence of unfavorable heredity. This -again is at variance with opinions usually expressed on this subject. -Forty-six per cent were of normal mental makeup and seventy-eight per -cent intellectually normal before the onset of the psychosis. Alcohol -was an assigned etiological factor in four per cent of these cases and -there was a history of intemperance in eight per cent of the others. -The incidence of dementia praecox is more than three times as great in -cities as it is in the rural districts. The average length of hospital -residence was sixteen years. The foreign born dementia praecox first -admissions were found to be principally from Austria, Germany, Hungary, -Ireland, Italy and Russia. Fifty-one and four-tenths per cent of the -cases were natives of this country and 48.3 per cent, of foreign birth. -It is interesting to note that in 1919, 39.9 per cent of the first -admissions to the New York institutions for the criminal insane were -cases of dementia praecox. The rate of admission was 37.1 per cent in -1918, 20.5 per cent in 1917, 30.8 per cent in 1916 and 32.8 per cent in -1915. Of the 37,607 patients in the New York state hospitals on June -30, 1919, 22,036, or 58.8 per cent, were cases of dementia praecox. One -hundred and thirty-eight were discharged as recovered during a period -of three years. This number represented 5.2 per cent of the cases of -dementia praecox discharged during that time, 2.01 per cent of those -admitted, 1.1 per cent of all discharges, and .6 per cent of all first -admissions. A review of the cause of death in 2,988 cases shows that -the rate for tuberculosis was thirty-three per cent during four years -when there was no influenza epidemic. This constituted over fifty-nine -per cent of all of the deaths due to tuberculosis during that period of -time. - -Dementia praecox with the highest admission rate of any of the -psychoses, its exceedingly unfavorable recovery rate, its extreme -susceptibility to tuberculosis, and representing as it does over -one-half of the population of our hospitals, must unquestionably be -looked upon as the most important form of mental disease with which -we have to deal today. The number of cases of dementia praecox in the -Massachusetts and New York hospitals justifies the statement that there -are approximately 120,000 persons suffering from this disease in the -institutions of the United States, their maintenance alone costing the -country twenty-five million dollars annually. Their permanent removal -would make it possible to close at least sixty institutions larger than -any state hospital in Massachusetts. - - - - -CHAPTER XIV - -PARANOIA AND THE PARANOID CONDITIONS - - -A discussion of the part played by paranoia, or the paranoid -conditions however characterized, in the psychiatry of the present -day, is essentially a review of the final chapter in the history of -a psychiatric conception which is several centuries old. The word -paranoia, like many other terms still in use, is of Greek origin -and was apparently applied by Hippocrates in a very general way to -"madness" of any or all forms. It almost certainly had no more definite -significance than that, in the works of Plato and Aristotle, nor can it -be said to have been used in its modern sense by Celsus or Aretaeus. -It seems to have meant something more in the vocabulary of Vogel, an -eighteenth century writer. Under the heading of paranoia, according -to Jelliffe,[314] Plocquet in 1772 included Paracope or delirium with -six subdivisions:—(a) pathetica, (b) phronestica, (c) entomica, -(d) encephalica, (e) hyperesthetica, and (f) sympathica. It was not -recognized to any great extent by the earlier writers of the French -school, but occupied a very prominent place in the development of -German psychiatry. Heinroth in 1818 included the paranoias in his -disorders of the intellect under the name of verrücktheit, a word that -was destined to become one of great importance later, and spoke of an -exaltation of the feelings which he called "paranoia ecstasia." - -Flemming[315] in his elaborate classification of psychoses in 1844 -described paranoid forms of "mania adstricta" or partial mania -(monomania). Stark, a contemporary of Flemming's, made what seems -to be a very direct reference to paranoia in his discussion of -"Wahnsinn," as did Weiss in 1842. Von Feuchtersleben in 1845 wrote a -very exhaustive description of "fixed delusions" which he classified -as either involving the personality (mania metamorphosis) or as being -ambitious, religious or relating to love (erotomania). He also spoke -of a monomania or mania sine delirio which he attributed to Pinel. The -exact significance of these conceptions cannot be determined. - -In 1845 Griesinger used the word verrücktheit as applying to a -secondary incurable condition, exhibiting delusions of persecution -and grandeur and usually developing after an attack of mania or -melancholia. He also defined Wahnsinn, which he compared to Heinroth's -"paranoia ecstasia," as including "states of exaltation characterized -by assertive, expansive emotions, associated with persistent excessive -self-estimation and extravagant fixed delusions which arise therefrom." -Magnan spoke of "folie systematisée progressive" and a "folie -systematisée des dégénérés." In his "Le Délire Chronique à Évolution -Systematique" he divided paranoia into a stage of subjective analysis, -one of persecution and a third of transformation of the personality. -Lasègue described this same condition under the name of persecution -mania in 1852. Falret and Ritti divided the course of this disease -into four periods, one of insane interpretations, one of visual -hallucinations, one of general sensory derangement and a stereotyped -state or mania of ambition. Morel was of the opinion that these -psychoses were always preceded by an initial period of hypochondriasis. - -Pritchard described as monomania a form of insanity "characterized by -some particular illusion or erroneous conviction impressed upon the -understanding, and giving rise to a partial aberration of judgment." -Esquirol devoted as many as one hundred and thirty pages to a study -of monomania, which he subdivided into seven forms:—the erotic, -"raisonnante" or moral insanity, the alcoholic, the incendiary, the -homicidal, the suicidal and the hypochondriacal. - -It was probably the work of Mendel in 1881 which was responsible for -the use of the word paranoia in its modern sense. He spoke of primary -and secondary paranoias.[316] The former was described as a "functional -psychosis characterized by the primary appearance of delusional ideas. -The delusions of primary paranoia, without being interfered with by -any opposing ideas, control the entire mental life of the patient. -The remaining ideas not affected by morbid processes stand in close -relation, but not in conflict, with the dominating delusions. The -feelings are determined by the content of the delusions and vary with -them. In the same way the abnormalities of conduct are due to the -content of the delusional ideas, with or without hallucinations." Régis -in 1892 described his systematized progressive insanity as involving -three distinct stages,—one of subjective analysis, a stage either -of persecution, religious exaltation or eroticism and jealousy, and -finally a megalomanic state ending occasionally in dementia. Cramer, -in an elaborate review of the literature of paranoia in 1894, refers -to twenty-eight different designations used by various writers in the -discussion of this subject up to that time. Serieux and Copgras (1909) -include deliria of interpretation and of vindication in their grouping -of these conditions. - -In the words of Meyer, paranoia eventually reached its high water -mark in the work of Krafft-Ebing.[317] He defined it as "a chronic -mental disease occurring exclusively in tainted individuals, frequently -developing out of the constitutional neuroses, the principal symptoms -of which are delusions." These are devoid of all emotional foundation -and from the beginning are systematized, methodic and "combined by the -processes of judgment, constituting a formal delusional structure. -Consciousness is not disturbed and judgment as a rule is not impaired -but is entirely based on delusional premises." The conduct of the -individual is determined by his hallucinations and delusions. The -process of development is slow and the disease remains stationary for -many years, but never ends in dementia. In a study of over one thousand -cases Krafft-Ebing[318] never observed a definite recovery, although -lucid intervals occurred, generally in the beginning of the disease. -The taint of paranoia he describes as heredity, in the form of abnormal -character, psychoses, constitutional neuroses and alcoholism. In a few -instances he reported developmental defects in the brain. He found in -all cases an anomaly of personality which determined the later form -of the paranoia. Suspicious, retiring, solitary persons were usually -persecuted. Rough, irritable, egotistical individuals developed the -querulent forms and the over-conscientious eccentrics became the -victims of religious paranoia. He attaches a considerable importance -to the influence of the unconscious or subconscious mind. "Its -predominance is shown in the dreamy, romantic, enthusiastic life of -such individuals, and in the fact that accidental delusions occurring -in sickness, dream pictures, and reminiscences from reading or plays, -are elaborated in the depths of the soul, and early burst forth in -the form of imperative ideas and desultory primordial delusions, -which become latent, but later find their ultimate evaluation in the -delusional ideas of the disease." - -It is interesting to note that Krafft-Ebing speaks of precipitating -factors as puberty, the climacteric, uterine disease and onanism. -There is a definite period of incubation followed by one of full -development in which judgment and reason are lost. Hallucinations -of hearing were found to be the more common form, followed in the -order of their numerical occurrence by disturbances of sensibility, -vision, taste and smell. Persecutory ideas, moreover, were said to be -much more frequent than delusions of grandeur. The terminal states -he speaks of as mental enfeeblements with a prominence of emotional -dulness, rather than intellectual defects. He divides the disease -into original paranoia and the later or acquired forms. Original -paranoia begins before or at latest during puberty. Hereditary taint -is always to be found. Conspicuous features are sentimental tendencies -inclining to hypochondria, eroticism with sensitiveness and emotional -instability. Delusions as to parentage are common, suggested often -by the fancied or real resemblance of the patient to pictures of -distinguished personages. Transitory ideas of persecution or grandeur -are nearly always present. The erotic element is more frequent in -females. Intermissions sometimes last for years. The termination is -often found in confusional states. The classic or acquired form of the -disease develops later in life, often during the involution period. Two -varieties are described,—the persecutory and the expansive. Subsidiary -types of the former are sexual paranoia, often with delusions of -jealousy, and querulous insanity with mania for lawsuits. The sexual -complex he attributes largely to masturbation or enforced abstinence. -The expansive group is divided into inventive or reformatory paranoia, -the religious and the erotic varieties (erotomania). The acquired -form as described by Krafft-Ebing is quite similar to the "folie -systematisée" of Magnan. It conforms, moreover, in a general way to -the views expressed in the English textbooks on delusional insanity -and is the paranoia of Spitzka, Chapin, Berkley, Peterson and many -other American psychiatrists. This conception of the psychosis was the -generally accepted one for many years. - -The institutional reports of that day showed large numbers of paranoics -in some of the hospitals. It was a disease that played an important -part in many murder trials and has received more attention from the -courts and newspapers than any other form of insanity, so-called, ever -described in the textbooks. There was a time, according to Kraepelin, -when from seventy to eighty per cent of the patients in the German -hospitals were diagnosed as cases of genuine paranoia. Certainly that -cannot be said of the institutions of this country. In the New York -state hospitals, for instance, during a period of sixteen years, from -October 1, 1888, to September 30, 1904, when the classical form of -paranoia was officially recognized in statistics, 84,152 admissions -were reported. Of this number 1,655, or 1.9 per cent, were diagnosed -as cases of paranoia. At the Matteawan State Hospital for the criminal -insane during this time 1,728 admissions were shown, with no cases of -paranoia. At the Dannemora State Hospital for insane convicts during -the same period there were 354 admissions, sixteen, or 4.51 per cent, -of which were paranoiacs. This is exceedingly interesting but extremely -difficult to explain. It is very hard to understand why no cases of -paranoia reached Matteawan during a period of sixteen years. The -percentage shown in the other institutions can be looked upon as being -fairly representative of the incidence of paranoia as the disease was -then understood. - -The decline and fall of the paranoia concept is to be attributed -to Kraepelin. In 1893 his classification included hallucinatory and -depressive forms of "Wahnsinn," both accompanied by persecutory ideas -to a rather prominent degree, and paranoia proper, which he described -as "Verrücktheit." This was defined as the "chronic development -of a permanent delusional system with complete preservation of -consciousness". In the sixth edition of his well-known textbook, which -appeared in 1899, he enlarged the dementia praecox group previously -described by him and added hebephrenia and katatonia to it as well -as describing a new and important "paranoid" form of that disease. -His own reasons for this were stated as follows[319]:—"The second -clinical group" (dementia praecox, paranoid form) "which I am inclined, -provisionally, to include under this head, is characterized by the -fact that extravagant delusions, usually accompanied by numerous -hallucinations, develop in a more coherent manner, and are maintained -during a series of years, either then entirely to disappear, or to -become entirely confused. Hitherto I have reckoned these forms, as -'phantastische Verrücktheit' to paranoia, as is the general practice. -It has, however, gradually become clearer to me that they are at all -events, more nearly allied to dementia praecox than to paranoia. -Whether we really have to do in this case only with a clinical variety -of the former disease or a distinct malady, the future must decide." -He did, however, at that time still recognize a small but well defined -group of cases as genuine paranoia. "On the other hand, there is, -without doubt, a group of cases, in which it is clearly recognizable -from the outset that a permanent, immovable system of delusions -slowly develops, with entire preservation of mental clearness, and -of the regulation of the course of thought. It is these forms for -which I would reserve the appellation of paranoia. It is they which -necessarily lead to a profound transformation of the entire view of -life; to a dislocation of the point of view which the patient assumes -toward the persons and events of his environment." In the eighth -edition of his book (1913) he separates out a considerable number -of cases and places them in an entirely new group designated as -"paraphrenias."[320] This is "a comparatively small group in which, -in spite of many similarities to the manifestations of dementia -praecox nevertheless on account of the much less marked development of -emotional and volitional disturbances the inner structure of the mental -life is considerably less affected, or in which at least the loss of -inner unity is essentially limited to certain intellectual functions. -Common to all of these clinical forms which cannot be sharply -differentiated is the marked prominence of delusion formation and the -paranoid colouring of the disease process. At the same time there are -also alterations in the disposition, but not until the last stages of -the disease that dulness and indifference which so often are the first -indications of dementia praecox." In other words, we are dealing with a -group which shows the paranoid features of dementia praecox but largely -lacks its deteriorative processes. This is a very decided change of -views and may be looked upon either as establishing a definite status -for a large number of cases not properly accounted for in the past -or as an indication of a tendency to return to former conceptions of -paranoia. - -Of the paraphrenias as described by Kraepelin "approximately one-half -show that slow but progressively developing mixture of delusions -of persecution and grandeur which Magnan has described under the -designation of 'délire chronique à évolution systematique.' Certainly -this disease of Magnan's, as far as can be determined from the -descriptions available, is not a clinical entity in the sense of the -views expressed here; we would unhesitatingly include with the paranoid -forms of dementia praecox many of the cases, with well developed -mannerisms and the coinage of new words, which progress rapidly to -mental enfeeblement. At the same time, however, 'délire chronique' with -its slowly progressing forms lasting for decades includes a number of -cases which form the nucleus of the first paraphrenic disease group to -be described." Whether or not the paraphrenia of Kraepelin is accepted -as having been established, it must be conceded that the question as to -whether anything remains of the original paranoia group is one worthy -of serious consideration. Many have discarded the term entirely. - -Kraepelin's paraphrenia is divided into the following -forms:—systematica, expansiva, confabulans and phantastica. The -systematic type is characterized by "the extremely insidious -development of continuously progressing delusions of persecution, with -the later appearance of delusions of grandeur without deterioration of -the personality." The expansive form shows "the prominent development -of delusions of grandeur with a predominant exalted mood and mild -excitement." The confabulans variety is a small group "distinguished by -the prominent rôle played by falsifications of memory." The phantastic -form shows "a marked development of phantastic, unsystematized, -changeable delusions." This was the paranoid dementia praecox of his -sixth edition. Of the cases heretofore assigned to the paranoia group -Kraepelin has expressed the opinion that about forty per cent belong -to dementia praecox. "A further somewhat larger part falls to the -paraphrenic forms to be described here." The practically negligible -remainder he apparently concedes to genuine paranoia. In his eighth -edition Kraepelin states that the latter constitute less than one -per cent of all admissions. He now limits the term paranoia to cases -arising from purely internal causes and showing a slowly developing -permanent system of delusions without any disturbance of thought, -volition or conduct. The delusional formations may be of various -types,—persecution, jealousy, self-importance (great inventions, ideas -of noble birth, etc.) or they may be of a religious or erotic nature. -The "querulents" he now classifies with the psychogenic disorders. His -present conception does not admit of the association of paranoia with -hallucinations. - -The most interesting and important feature, perhaps, of Kraepelin's -presentation is his insistence upon internal causes only as etiological -factors. He assumes a psychopathic foundation for the development of -the disease. In more than one half of his cases he found well marked -personal peculiarities. These were manifested in some instances in the -form of irritability, excitability and abnormalities of conduct. Other -individuals were suspicious, unreliable, lacking in will power and -over-ambitious. Homosexual tendencies were not infrequent. External -factors, such as unpleasant experiences, may influence the form of the -delusional expressions but should not be looked upon as explaining -their origin. They develop in an emotional soil definitely related to -the hopes and fears of the healthy individual and are to be looked -upon as a morbid transformation of perfectly normal mechanisms. In -addition to this he speaks of an increased self-consciousness, a -natural tendency to resistiveness, an undeveloped type of thinking, -psychological compensations for the disappointments of life, evidences -of developmental inhibitions, improper habits of thought leading to -morbid conceptions, etc. He refers to exaggerated self-consciousness -as the fundamental basis of paranoia. In this soil delusions develop -as a result of inadequate intellectual processes due to developmental -inhibitions. All of these views have been elaborated more fully in -his recent discussions of the subject of "comparative psychiatry."[321] -These mechanisms, he says, have not escaped the notice of the Freudian -school. Kraepelin feels, however, that their arguments "are not based -either on a clear conception of paranoia or on any evidence at all -acceptable." - -Bleuler's theory of the disease is summed up in the following quotation -from his "Affectivität, Suggestibilität, Paranoia"[322]:—"The exact -observation of the objective and subjective relations at the time of -the origin of the disease shows us therefore nothing more than the -appearance of errors, such as occur to normal persons under analogous -affects and a connection of accidental occurrences to a thought -complex which is kept continually awake by defects and his own trends -of thought, just as it is in a corresponding normal mental process. -The pathological feature is only the fixation of the error so that it -becomes a delusion, and then the further extension of the delusions so -that it finally becomes paranoia." In 1906 when this was written he -suggested no explanation for the extension of such errors and their -fixation in an actual psychosis. This might readily be interpreted as a -logical result of the paranoic "constitution." - -The development of paranoic states was summarized by Meyer[323] as -follows:—"A. Feeling of uneasiness, tendency to brooding, rumination -and sensitiveness, with inability to correct the notions and to make -concessions—paranoic constitution and paranoic moods. B. Appearance -of dominant notions, suspicious or ill balanced aims. C. False -interpretations with self-reference and tendency to systematization, -without or with D. Retrospective or hallucinatory falsifications, etc. -E. Megalomanic developments or deterioration or intercurrent acute -episodes. F. At any period antisocial and dangerous reactions may -result from the lack of adaptability and excessive assertion of the -sidetracked personality." - -Freud sees in paranoia a reversion to the homosexuality of the -developmental period of the individual with a projection of symptoms -resulting from mental conflicts due to a repression of complexes. -He described the sexuality of the infantile period as being purely -autoerotic in character, the sexual interests of the child being -centered in its own body. From this stage the object of interest is -gradually transferred to other individuals of the same sex, the normal -attraction to the opposite sex being a final development of later -years. Freud believes that in paranoia there is a fixation in one of -these early transitional stages. "Persons who cannot rise completely -out of the stage of narcissism and are thus prematurely fixed or -arrested in the evolution of their dispositions, are exposed to the -danger that a flood of libido which finds no outlet, sexualizes their -social tendencies and reverts the sublimations achieved in the course -of the development."[324] The resulting mechanisms may be looked upon -as defense reactions. The subconscious homosexual longings of the -individual are repressed but finally admitted to full consciousness -in the form of a projection, the sexual object usually being accused -of persecution, thus justifying the attitude of the paranoic towards -the cause of his troubles. In erotomania the antagonism is directed -not against the homosexual object but upon some person of the opposite -sex. Freud interprets the delusions of jealousy of the alcoholic as an -evidence of homosexual attraction, the individual justifying himself -by the charge that it is his wife and not himself who is the guilty -one. The delusions of grandeur he looks upon as a sweeping denial -of all extraneous influences, the individual building a defense for -himself by assuming a self-aggrandizement that leaves no room for -homosexual objects. Perhaps these mechanisms are, as Meyer suggests, -only another expression of the well recognized and more or less normal -tendency to accuse others of being at fault in some way when what we do -ourselves goes wrong. Certainly, if nothing more, they are exceedingly -ingenious and interesting theories. One cannot but be impressed by the -extraordinary skill of Freud in discovering the sexual origin of almost -any mental process with which we are familiar. The ready facility with -which his study of sexual conflicts and repressions can be shown to -serve as a complement to the anatomical, symptomatic, and prognostic -hypotheses of Kraepelin is also worthy of note. - -As has already been said, there is considerable question as to how -much, if anything, remains of the old-time paranoia concept. The -uncertainties attending diagnosis have given rise to the modifying -term "paranoid" which has been very generally used for many years. It -should be remembered that paranoia when at its best only constituted -approximately two per cent of all psychoses reported from institutions. -These various considerations have resulted in its not having a -distinctive place in the classification adopted by the American -Psychiatric Association and it has been given official recognition as -follows:— - -"From this group should be excluded the deteriorating paranoid states -and paranoid states symptomatic of other mental disorders or of some -damaging factor such as alcohol, organic brain disease, etc. - -"The group comprises cases which show clinically fixed suspicions, -persecutory delusions, dominant ideas or grandiose trends logically -elaborated and with due regard for reality after once a false -interpretation or premise has been accepted. Further characteristics -are formally correct conduct, adequate emotional reactions, clearness -and coherence of the train of thought." - -A study of the statistics of American hospitals shows quite clearly -the importance which should be attached to the paranoid conditions. -During 1918 and 1919 there were 13,588 admissions to the thirteen New -York state hospitals. Two hundred and fifty-six, or 1.88 per cent, of -these were cases of paranoia or paranoid conditions. During a period -of eight years there were 49,640 admissions of which 1,240, or 2.5 -per cent, were paranoid conditions. In Massachusetts sixty-four, or -2.12 per cent, of the 3,011 admissions during 1919 were reported as -paranoid conditions. In twenty-one hospitals in other states there -were 18,336 admissions. Of these, 789, or 4.3 per cent, were paranoid -conditions. These statistics show quite a small admission rate for -these psychoses in New York and Massachusetts. The rate in other state -hospitals is noticeably higher. As the percentage for dementia praecox -is considerably lower in the reports from these institutions than it is -in Massachusetts and New York, it is fairly reasonable to assume that -many cases shown as paranoid forms of dementia praecox in Massachusetts -and New York are classified with the paranoid conditions in the other -states. If we consider the total admissions from all of the hospitals -in question, we find 2,093 paranoid conditions in all, constituting -2.94 per cent of a total of 70,987 cases. It has already been shown -that paranoia, at a time when it was a well recognized entity, -constituted only 1.9 per cent of over eighty-four thousand consecutive -admissions. This clinical grouping has, therefore, obviously been -enlarged by adding paranoid conditions which could not probably be -classified as well recognized types of other psychoses. - - - - -CHAPTER XV - -THE EPILEPTIC PSYCHOSES - - -Ancient history contains numerous references to epilepsy. The "Morbus -sacer" of the Romans was apparently a subject of great interest to -Hippocrates,[325] who wrote, over two thousand years ago, "The sacred -disease appears to me to be no wise more divine nor more sacred than -other diseases; but has a natural cause, from which it originates -like other affections. Men regard its nature and cause as divine from -ignorance and wonder, because it is not at all like other diseases." -Presumably for a somewhat similar reason the disease was also referred -to as the "Morbus Sideratus," it being thought that those affected -were "star struck" or smitten in some mysterious and supernatural -manner. By others it has been suggested that the theory regarding the -divine origin of the disease was attributable to the seizures which -always preceded the prophesies of the priests of Apollo. Herodotus is -responsible for the statement that Cambyses, the king of the Persians, -was subject to the "sacred disease" from birth. Such historians as -Hippocrates and Euripides have definitely established the status -of Hercules as a confirmed epileptic. "Morbus Herculeus" was one -of the earliest designations of the disease. It was referred to by -Plutarch in his writings. Suetonius describes the emperor Caligula -as unquestionably afflicted with epilepsy. No less an authority than -Lombroso speaks of Napoleon, Molière, Julius Caesar, Petrarch, Peter -the Great, Mohammed, Händel, Swift, Richelieu, Charles V. Flaubert, -Dostoieffsky and St. Paul as all being victims of the same affection. -Truly this is a noble assemblage,—one which might readily make the -disease fashionable! - -Maudsley ("Body and Mind") was convinced that Swedenborg suffered from -a form of epileptic insanity. The following quotation from his diary -would lend some color to that theory:—"There happened to me something -very curious. I came into violent shudderings, as when Christ showed -me His Divine Mercy. The one fit followed the other ten or fifteen -times." After his fifty-fifth year, according to Maudsley, Swedenborg -was permanently insane. The historian Sloan in his "Life of Napoleon" -accepts as an established fact the statement that this great military -strategist was an epileptic. Appian's "Roman History" certainly -justifies Lombroso's reference to Julius Caesar: "At length, whether he -lost all hope, or else for the better preservation of his health, never -more afflicted with the falling sickness and sudden convulsions than -when he lay idle, he resolved upon a far distant expedition against -the Gatae and the Parthians." Washington Irving in speaking of some -of the peculiar experiences of Mohammed suggests that, "Some of his -adversaries attributed them to epilepsy." Even a very brief review of -the historical aspects of this disease should perhaps not omit the -contribution made by Shakespeare: "My Lord is fallen into an Epilepsie. -This is his second Fit." (_Othello_) - -Epilepsy and the mental disturbances associated with it are so -intimately related that they can hardly be considered separately. -Notwithstanding that fact it must be admitted that there is no sharply -circumscribed clinical entity properly definable as epilepsy. Nor is -there anything distinctive about the psychotic manifestations occurring -during the course of that disease, although Tuke's Dictionary mentions -over thirty different varieties. In the most exhaustive study of -epilepsy ever made in this country Spratling[326] reported that memory -defects were noted in ninety per cent of the patients examined by him. -It should be borne in mind that the group studied did not include -any committed mental cases. He found from eight to ten per cent so -slightly affected as to be legally "sane," "except at the brief moment -of attack." Fifty per cent were mentally incompetent with rational -intervals and forty per cent were "continually irresponsible." This -latter class included from twenty to twenty-five per cent of imbeciles -and idiots and from fifteen to twenty per cent recognizable as insane -"by law and medicine alike." The prevalence of mental disease in a -hospital population composed exclusively of epileptics is shown by his -statement that of 801 patients examined at Craig Colony forty-one could -not tell their own names; 166 did not know their age; 267 could not -name the year, 263 the month, and 226 the day of the week; 238 did not -know where they were; 378 were unable to state the year of their birth, -183 the last place of residence, 219 the name of the institution, and -248 the length of time there; in addition to this, 224 could not write -well enough to sign their own names. It is interesting to note that -the disease had its onset in 38.5 per cent of his cases before the age -of ten years, in 43.5 per cent between the ages of ten and twenty, -and in 9.5 per cent between the ages of nineteen and twenty-nine. -Gowers found that seventy-six per cent developed symptoms before -the age of twenty. Spratling classified the mental conditions found -in epileptics as follows:—Psychic epilepsy, epileptic automatism, -pre- and postparoxysmal mental disturbances, paroxysmal states -(epileptic mania), and interparoxysmal conditions. The latter included -transitory ill-humor, slight dulling or clouding of the intellect, -feeblemindedness, imbecility, idiocy, epileptic dementia and acute -confusional insanity which he says belongs to the manic-depressive -group. He warns against the danger of classifying as dementia -conditions due entirely to the use of bromides. - -L. Pierce Clark[327] looks upon epilepsy as the logical development -of a well defined individual make-up described as the "epileptic -constitution" and existing from the earliest childhood. In support -of that theory he has reviewed the contributions of other writers on -this subject. He found that Vogt called attention to the epileptic -"poverty of ideas, prolonged reaction time, egocentricity, many -religious reactions and acts of servility." Jung referred to a series -of superficial associations, influencing the ideas of the patient, -somewhat similar to those occurring in imbecility and sometimes -observed in normal individuals of the uneducated class. Roemer speaks -of a disturbance of "secondary identification" involving memory -pictures with special sense recognition unimpaired. Eintinger described -an essential poverty of affectivity and Wiersma, periodical variations -in attentiveness. Ritterhaus defined the epileptic mental content -as one of poverty of ideas, prolonged reaction time, egocentricity, -emotional reactions and circumstantiality. Arndt included in the -epileptic character peculiar inward fervor, characteristically -egotistic in nature, and resembling the alcoholic temperament. Bianchi -believed that the disease developed on a personality basis strongly -suggesting the criminal type. He spoke of an inadaptability to the -environment, the preponderance of individualistic instinct, cruelty, -laziness, evil life, precocious and excessive development of the sexual -instinct, irascibility and impulsiveness. Turner described an epileptic -"temperament." He found these individuals to be egotistical, conceited, -pretentious in conversation, emotionally unstable and sometimes -obstinate or over-religious. Hartmann and di Gaspero noted as -prodromal manifestations, abnormal changes of temper, excitability, -anxious fears, sudden depressions, restlessness, irritability, -distrust, memory falsifications, and violent impulses. Voisin found -that less than ten per cent of epileptics showed a perfect balance -in the emotional make-up. Hübner expressed the opinion that true -dipsomania occurs chiefly in epileptics. He found alternations in the -character of the individual in from ninety to ninety-five per cent of -his cases. - -Clark's[328] conclusions were summarized by him as follows:—"1. There -is more or less constant affective defect in all epileptics, sane as -well as insane; that such defect is due to an inherent make-up of the -psyche in which mainly an egocentricity and a highly sensitized feeling -are given to the individual; and that from this constitutional make-up -or alteration the ultimate deterioration of the psyche, intellectually -as well as emotionally, is gradually developed, step by step, and if -the state is not corrected that this finally and logically ends in -so-called epileptic dementia. 2. The epileptic alteration is seen to -proceed from the mental make-up or constitution of the individual -epileptic long before his malady reaches the convulsive stage and that -the one is but a further and final unfoldment of the former." As Clark -expresses it, "The nucleus of this personality defect is a temperament -of extreme hypersensitiveness and egotism and all that these two -main characteristics entail ... a personality defect which makes its -possessor incapable of social adaptation in its best setting and which, -if it remains uncorrected, renders the individual inadequate to make a -normal adult life." He looks upon the epileptic reaction as a "more or -less direct outcome of the epileptic's inability to stand the stress -and harassments of life from which he seeks automatic or unconscious -withdrawal." This exhibits itself as a loss of spontaneous interest, -day-dreaming, lethargy, somnolence, etc., terminating finally in -epileptiform attacks when the strain becomes too great. A rather -complete description of the "epileptic character" appeared in Schüle's -"Klinische Psychiatrie" in 1886. - -An analysis of these mental mechanisms leads naturally to certain -therapeutic indications. In view of the history of the bromide -therapy, since the time of its introduction by Laycock as the ideal -form of treatment in 1851, such suggestions should be given serious -consideration. Clark advocates the early use of educational methods in -correcting the defects of the epileptic constitution. Thus he would -obtain control of the egocentricity and hypersensitiveness by reducing -environmental stresses, teaching adjustment to the surroundings, and -finding suitable and normal outlets for the spontaneous desires of the -individual. He is of the opinion that in the apparently deteriorated -cases mental interests can be restored and emotional and mental -dilapidation greatly improved. He has reported a series of cases -showing that the frequency and severity of seizure can be greatly -influenced "with the more or less permanent arrest of the disorder -in not a few cases."[329] A subsequent study of the mental mechanisms -involved was summarized by Clark[330] in these words: "It is fairly -obvious that the mental content in epilepsy proves that the epileptic -regresses from the displeasurable difficulties of life, and in the -first states of the fit the stress alone may be uncovered; whenever the -patient reaches a deeper unconscious state, he gains the level of an -easily recognized sexual striving." - -Kraepelin[331] would differentiate between "symptomatic" forms of -epilepsy due to organic diseases, injuries or growths; and the -"genuine" variety not associated with any coarse brain lesion. He -describes as indications of impending attacks, occurring several hours -or even days before, headache, irritable ill-tempered moods, general -discomfort, weakness, palpitations, oppression, anxiety, vertigo, -nausea, hot and cold sensations, sense deceptions of various kinds, -muscular twitching, sexual excitement, disturbed sleep, unpleasant -dreams, etc. Binswanger found these symptoms present usually in the -severer forms of the disease. Finkh found them in twenty-five per cent -of his cases. Psychic, sensory, motor and vasomotor aura are described. -Kraepelin after discussing first the paroxysmal attacks occurring -in the disease speaks of the various forms of psychic epilepsy as -constituting the second important group of clinical manifestations -to be considered. These conditions may be looked upon as pre- or -post-epileptic insanity, depending on their relation to convulsions, or -may be entirely independent of them or considered as equivalents. - -The most common form of psychic epilepsy he describes as periodical -ill-humor. It begins sometimes with sexual excitement (Ducosté). The -patient becomes moody, surly, irritable, quarrelsome, gives up his -work, refuses to eat and complains of everything around him. In some -cases uneasiness, gloom or depression are manifested and suicidal -tendencies may develop. Consciousness is clear although the patients -complain that they cannot think or are confused and forgetful. Some -have headache, perspire, show dilated pupils, vasomotor disturbances, -nausea, etc. The picture is often complicated by alcoholic indulgence -with attacks resembling dipsomania. This sometimes results in an -epileptic clouded or dream state in which the patients become -blustering, abusive, and violent or make senseless journeys. They may -manifest a sudden impulse to wander from place to place without any -apparent reason. Sexual excitement frequently occurs, with masturbation -and exhibitionism, attacks on children or homosexual tendencies. -Usually there is no recollection of these episodes. Occasionally -expansive or ecstatic moods appear and rarely a flight of ideas is -noted. These attacks of ill-humor usually last from a few hours to -several days, often disappearing suddenly. Alcoholism always lengthens -the duration. In some cases active hallucinations and clouding of -consciousness occur. Dreams are common. Others show anxious states -with hallucinations and sometimes well marked delusions. An actual -delirium may appear, although usually only for a very short time. -The hallucinations and delusions may persist for months, suggesting -dementia praecox. - -A second large group shows a more marked clouding of consciousness. -These are the characteristic twilight or dream states of epilepsy. -Thought is confused, desultory, retarded or incoherent. Sometimes there -is a tendency to rhyme and repeat questions, or even a genuine flight -of ideas. The mood may be depressed, anxious or irritable, although -ecstatic states occur. The patient may become quiet, inaccessible, -stuporous or cataleptic. Some, however, become excited. Later, defects -of memory occur and amnesic periods may extend over a considerable -length of time. The patellar reflexes may be increased and the pupils -dilated and sluggish. There may be a contraction of the field of vision -or disturbance of color sense, tactile sensation, smell and taste, -with muscular weakness, Babinski reflexes, speech defects, dizziness, -uncertain gait, nystagmus, etc. Somnambulism is sometimes encountered -in epilepsy, although it is strongly suggestive of hysteria. The great -majority of cases present the picture of a simple dreamy stuporous -condition. Apprehension is clouded, the patients become confused, -cannot control their thoughts, mistake the persons around them, lose -themselves on the street, and wander away. They destroy their clothes, -undress in the street, etc. Sexual excitement, exhibitionism and -masturbation are common. Characteristic dream states may appear as -equivalents. - -A delirious confusion with hallucinations and delusions often -develops. Some cases have a very strong religious coloring and -believe themselves to be in heaven or hell—hear the voice of God, -angels, etc. Grandiose ideas may appear and wonderful adventures are -narrated. The mood is variable and may be either anxious, cheerful or -erotic. There is a marked tendency to violence and the patients may -be very restless and agitated. Delusions are common and often lead to -suicidal attempts. Some exhibit an anxious delirium accompanied by -numerous hallucinations. The patient is clouded as well as disoriented -and delusions develop early. Fabrications sometimes appear in this -condition. These deliria may last a few hours or several weeks. -Profound and more or less long continued epileptic stupors may -complicate the situation. - -A "conscious delirium" of longer duration is observed in some -instances. The sensorium is not so much clouded, and the patient -appears quite clear. Hallucinations and illusions usually develop -early in the attack. Pleasurable, grandiose ideas often appear. The -attitude in a general way resembles that of a confused disorientation. -Anxious moods may develop, or rarely cheerful tendencies. Consciousness -becomes dreamy, with hallucinations of a religious coloring. Patients -with an apparently clear sensorium may commit numerous foolish or even -criminal acts without any apparent insight into their significance. -Such conditions as this may last weeks or months. Self-accusation may -occur between attacks. These individuals are quite likely to start on -absolutely aimless journeys which may be the outcome of an alcoholic -debauch. The dream state in such cases may have a decided alcoholic -coloring with characteristic hallucinations or humorous tendencies. -This may be mixed with religious ecstatic manifestations. Dream states -only occur once or twice during the lifetime of an epileptic or may be -comparatively frequent. Many patients never have them. - -Aschaffenburg found fainting attacks in seventy-four per cent, -convulsions in forty-two per cent, stupors in forty-four, petit mal -in fifty-eight, dream states in thirty-six, and ill-humor in from -sixty-four to seventy per cent of his cases. In his Munich clinic -Kraepelin studied 515 epileptics. Eighty-six and eight-tenths per -cent of them had attacks of unconsciousness, probably often reported -as convulsions, 23.3 per cent had dizzy spells, 9.7 per cent stupors, -15.1 per cent petit mal, 3.3 per cent attacks of various kinds -without unconsciousness, 16.5 per cent dream states, 1.9 per cent -somnambulisms, 36.9 per cent ill-humor, 13.8 per cent excitements, -mostly alcoholic complications, and 2.5 per cent had status epilepticus. - -An epileptic weakmindedness develops in many cases. The field of -thought is contracted and egocentric in character with delayed -associations as shown by Jung. The patient is egotistical, interested -in petty details, and strongly inclined to religious tendencies. He -always minimizes the severity of the disease which, in his opinion, -is improving rapidly. He is likely to develop mild paranoid ideas and -feels that he has been mistreated or that others are prejudiced against -him. These individuals are usually moody, irritable, dull, emotionally -unstable and excitable. They are often overactive but not industrious. -Many show a persistent "wanderlust." Werther reported that between -seven and eight per cent of his cases were tramps or beggars. Quite -a few show criminal tendencies. They nearly always have a marked -susceptibility to alcohol which greatly aggravates their symptoms. -Kraepelin is inclined to look upon the epileptic personality as a -result of the disease and not the soil in which it develops. - -In the more advanced deteriorations or epileptic dementias there is -a marked mental dulness with poverty of thought, loss of memory, -irascibility and occasional violence. Kraepelin refers to a genuine -"epileptic physiognomy" which is often observed. Strabismus, nystagmus, -ptosis, tremors and many other neurological symptoms are frequently -found. Clark and Scripture have described a characteristic "voice" in -epilepsy. Besta found a subnormal temperature in sixty-six per cent of -his cases. Very elaborate studies of the blood have been reported from -time to time. The secretions and excretions have been made the subject -of exhaustive research and the changes in metabolism have been gone -into thoroughly. - -The pathology of epilepsy has been given careful consideration by -Alzheimer. In cases of status epilepticus he found extensive acute -alterations, more particularly in the Betz cells, with swelling of -the neurones, crumbling of the Nissl bodies, and dislocation of the -nucleus to the apex. Here and there the ganglion cells were entirely -destroyed and others showed regressive changes. Karyokinetic figures -are seen in the glia cells, which are usually swollen, show ameboid -changes and contain degenerative products. Accumulations of broken -down cell products are found around the vessels. A sclerosis of the -cornu ammonis, usually unilateral, was reported by Bourneville in -14.8 per cent, by Pfleger in fifty-eight per cent, and by Alzheimer -in from fifty to sixty per cent of the cases of epilepsy examined. -This consists of an atrophy of the cells in a well defined area and -their replacement by a network of fibres. The cells are shrunken or -entirely gone, while there is a great increase in the neuroglia -elements with many free nuclei. The walls of the vessels are thickened -and "stäbchenzellen" appear. The significance of these findings is not -known. Nissl looks upon them as only a part of a general involvement -of the cortex. Widespread cell changes were frequently reported by -both Nissl and Alzheimer. A marked increase in the neuroglia has been -found particularly in the superficial layers of the cortex,—the -so-called "marginal gliosis" of Chaslin. The vessels show an intimal -proliferation and a thickening of the walls, with occasional mast-cells -in the lymph spaces. Ranke has called attention to the presence or -persistence of "Cajal" cells in the ordinarily cell free layers of the -cortex. These are large transversely placed ganglion cells, common in -the superficial layers of the cortex of the newborn but not found in -the normal adult brain. This condition is looked upon as a cortical -development defect. These so-called "Cajal" cells are also found in -some of the mental deficiencies. Nevertheless it must be conceded that -there are no definitely characteristic pathological changes so constant -as to render certain the differentiation of this disease postmortem. - -No forms of insanity perhaps are clinically so difficult and -unsatisfactory from the standpoint of classification as are the -epileptic psychoses. The various mental manifestations of the disease -may very logically be described as: 1. Pre-paroxysmal episodes, 2. -Paroxysmal states, 3. Post-paroxysmal episodes, 4. Inter-paroxysmal -conditions to be specified, as excitements, depressions, anxieties, -confusion, stupor, dream states, paranoid conditions, etc., and 5. -Epileptic deterioration. There is some question as to whether the -various psychic epilepsies, so called, are sufficiently clear-cut to -constitute clinical entities. - -The delimitation of these psychoses for statistical purposes is -described in the Association's manual as follows:— - -"In addition to the epileptic deterioration, transitory psychoses -may occur which are usually characterized by a clouded mental state -followed by an amnesia for external occurrences during the attack. (The -hallucinatory and dream-like experiences of the patient during the -attack may be vividly recalled.) Various automatic and secondary states -of consciousness may occur. - -"According to the most prominent clinical features the epileptic mental -disorders should therefore be specified as follows:— - -"(a) Epileptic deterioration: A gradual development of mental -dullness, slowness of association and thinking, impairment of memory, -irritability or apathy. - -"(b) Epileptic clouded states: Usually in the form of dazed reactions -with deep confusion, bewilderment and anxiety or excitements with -hallucinations, fears and violent outbreaks; instead of fear there may -be ecstatic moods with religious exaltation. - -"(c) Other epileptic types (to be specified)." - -During a period of sixteen years in the New York state hospitals -(ending October 1, 1888) 3,167 of 84,152 admissions were cases of -"epilepsy with insanity." This meant an admission rate of 3.76 per -cent. It must be borne in mind, however, that the differentiation -between epilepsy with insanity and psychoses clearly due to epilepsy -was not attempted at that time. During a subsequent period of -eight years in the same institutions, when what is essentially the -present classification was in use, the admission rate for epileptic -psychoses was 2.42 per cent. In 1919 with 3,011 first admissions to -the Massachusetts state hospitals only fifty cases (1.66 per cent) -were reported as showing psychoses due to epilepsy. Six hundred and -twelve cases, constituting 3.33 per cent of 18,336 first admissions, -were reported by twenty-one hospitals in other states. An analysis -of a total of 70,987 first admissions in forty-eight state hospitals -therefore showed that 1,865, or 2.62 per cent, were epileptic -psychoses. After reading the statements contained in various textbooks -regarding the extraordinary frequency of epileptiform seizures in -dementia praecox, it is difficult to escape the conclusion that -the percentage of epileptics has been underestimated rather than -exaggerated. - - - - -CHAPTER XVI - -THE PSYCHONEUROSES AND NEUROSES - - -The words neurosis, psychosis and psychoneurosis are of obscure origin -and have had a varied significance from time to time. Murray[332] -defines psychosis as a psychological term indicating "a change in -the psychic state; an activity or movement of the psychic organism, -as distinguished from neurosis" which he speaks of as a "change in -the nerve-cells of the brain prior to, and resulting in, psychic -activity." Huxley in discussing this subject in 1871 made the -following differentiation: "In all intellectual operations we have to -distinguish two sets of successive changes—one in the physical basis -of consciousness and the other in consciousness itself; one set which -may, and doubtless will, in course of time, be followed through all its -complexities by the anatomist and the physicist, and one of which only -the man can have immediate knowledge. As it is very necessary to keep -a clear distinction between these two processes, let the one be called -neurosis and the other psychosis." - -Von Feuchtersleben used the latter word in its present psychiatric -significance in his "Lehrbuch der Aertzlichen Seelenkunde" in 1845. -Its repeated appearance in the first volume of the _Allgemeine a -Zeitschrift für Psychiatrie_ in 1844 would strongly suggest a frequent -use of the term in the German psychiatry of that day. It was unknown -in English works until quite recently, although the word is found in -Maudsley's "Responsibility in Mental Diseases" (1874)—"No wonder that -the criminal psychosis which is the mental side of the neurosis, -is for the most part an intractable malady, punishment being of no -avail to produce reformation." Lewes, in "The Problems of Life and -Mind" published after his death in 1879, makes a very significant -remark: "Pathologists call it a psychosis, as if it were a lesion of -the unknown psyche." Clouston's 1911 edition makes no reference to -psychoneuroses as such. - -The word neurosis has been much more extensively employed in medical -literature. William Cullen, a well-known professor in the University -of Edinburgh, in his "First Lines of the Practice of Physic" in -1774, said: "I propose to comprehend, under the title of neuroses, -all those preternatural affections of sense or motion which are -without pyrexia, as a part of the primary disease." In his "Synopsis -Nosologicae Medicae" in 1785 he divided diseases into four general -classes: Pyrexia or febrile diseases; neuroses or nervous diseases, as -epilepsy; cachexiae or diseases resulting from bad habit of the body, -as scurvy; and locales, or local disease, as cancer. Brachet,[333] who -was one of the earlier writers on the subject of hysteria, defined that -disease in the following words in 1847: "Hysteria is a neurosis of the -cerebral nervous system, which manifests itself more or less brusquely -by crises of general chronic convulsions and by the sensation of a -globe ascending in the course of the oesophagus, at the upper extremity -of which it becomes fixed, causing there a menace of suffocation." -Briquet, another French writer, expressed somewhat similar views -in 1859. The word neurosis as now used may be said to refer to a -functional disturbance of the nervous system, which, if directly due to -etiological mental factors, is spoken of as a psychoneuroses. - -Just what diseases are to be included under the grouping of neuroses -and psychoneuroses is another question. Practically all of the older -authorities, at least, have agreed on hysteria and neurasthenia. -When we get beyond this point, however, there are wide differences -of opinion. Oppenheim, in his second edition, under the heading of -neuroses, included hysteria, hypnotism and hypnosis, neurasthenia, -morbid fears, imperative ideas, astasia-abasia, traumatic neuroses, -hemicrania, headache, vertigo, epilepsy, eclampsia, chorea minor, -Huntington's disease, paralysis agitans and many other conditions. - -Krafft-Ebing[334] was responsible for the following delimitation of the -psychoneuroses, which he admits to be "somewhat dogmatic" and has -used for many years largely for didactic purposes: "1. Parasitic, -accidentally acquired diseases in individuals whose cerebral functions -were previously normal and whose disease could not be foreseen. 2. -Disease based upon temporary disposition (grave physical disease and -the simultaneous action of powerful exciting causes), hereditary -predisposition not excluded, but only latently present in the brain -of one easily affected, but previously normal in its functions. 3. -Tendency to cure of the disease and infrequency of relapses. 4. Slight -tendency to transmission to descendants, and when it occurs, in benign -forms (psychoneuroses). 5. Typic course of the disease picture. Mania, -as a rule, arises from a melancholic initial stage; and so-called -secondary conditions are the terminations of primary conditions. The -disease picture, even when it appears, has a certain duration and -independence. The whole course of the disease is quite narrowly limited -in time, and goes on either to recovery or dementia. 6. No tendency to -periodicity of the attacks or the grouping of symptoms. 7. Sanity and -insanity are sharply defined, and in striking contrast." In this group -he includes mania, melancholia, acute curable dementia and primary -hallucinatory delirium. He describes hysteria, neurasthenia, etc., -under the psychic degenerations with paranoia and speaks of them as -constitutional neuroses. His psychoneuroses certainly do not come -within the general acceptation of the term at this time but represent -the views of a certain school of German writers. - -More recently the words neurosis and psychoneurosis have been used as -synonymous terms by many writers. Kempf has even gone so far as to -suggest discarding the word psychosis completely. In any event, the -view that we should only designate as psychoneuroses such functional -conditions as are clearly due to psychic causes seems to be gaining -ground. The term neurosis is generally applied at this time to diseases -primarily physical rather than mental in their symptomatology. The -prominence of psychogenic factors has been given great weight in recent -literature. In the second edition of his work on Psychiatry, Diefendorf -makes the following statement: "Neuroses are commonly designated as -a group of diseases characterized by changing and transitory nervous -disturbances, to be distinguished from psychoses by the fact that the -symptoms do not involve the mental field. But in practice psychoses -without nervous symptoms or neuroses without mental symptoms are not -encountered." - -Since the term was first introduced by Morel in 1860, many French -writers, such as Régis and Magnan, have emphasized the importance of -the insanity of degeneracy. This included moral insanity, the sexual -perversions and various other psychopathic conditions as well as -the obsessions, compulsions, impulsions, phobias, doubts, etc., now -recognized as psychogenic in origin and usually assigned collectively -to the psychoneuroses under the designation of psychasthenia. In his -sixth edition Kraepelin included both hysteria and epilepsy in his -group of neuroses, while constitutional peculiarities of character, as -well as compulsive and impulsive insanity with sexual perversions, -were classified under the psychopathic states (degenerative insanity). -In his seventh edition epilepsy was described as a separate entity. In -the eighth edition we find a new grouping. The psychogenic conditions -are divided into nervous exhaustion (neurasthenia), the dread neuroses, -induced insanity, the paranoid conditions of the deaf, the traumatic -neuroses, the prison and the "querulant" psychoses. Hysteria now -appears separately. Under the constitutional psychopathic disorders -he discusses nervousness, compulsion neuroses, impulsive insanity and -the sexual perversions. In view of these varying conceptions which are -fairly representative of the literature of the day, we are certainly -on safe ground in confining a consideration of the psychoneuroses to -hysteria, neurasthenia, psychasthenia and various other conditions -characterized by anxiety and fears. - -Hysteria has long been a subject of interest and controversy. It -has been a topic of discussion since the time of Esquirol and even -Sydenham. It was studied exhaustively by Brachet in 1847. Briquet -in 1859 defined hysteria as "an encephalic neurosis whose apparent -phenomena consist principally in the perturbation of the vital actions -which serve to manifest the affective sensations and passions." Lasègue -wrote an elaborate treatise on the subject in 1864. It was discussed -in detail later by Möbius, Charcot and many others. To Möbius hysteria -was "a congenital morbid mental state where diseased bodily conditions -are produced by ideas." During the last twenty or thirty years many new -and interesting theories have been advanced. Binet sees in hysteria -a condition of double consciousness, the two states almost entirely -independent and separated by periods of amnesia. Janet's[335] interesting -conception of the disease is covered in full in his definition: -"Hysteria is a mental disease belonging to the large group of the -diseases due to weakness, to cerebral exhaustion; it has only rather -vague physical symptoms, consisting especially in a general diminution -of nutrition; it is above all characterized by moral symptoms, the -principal one being a weakness of the faculty of psychological -synthesis, an abulia, a contraction of the field of consciousness -manifesting itself in a particular way; a certain number of elementary -phenomena, sensations and images, cease to be perceived and appear -suppressed by the personal perception; the result is a tendency -to a complete and permanent division of the personality, to the -formation of several groups independent of each other; these systems -of psychological factors alternate, some in the wake of others, or -coexist; in fine, this lack of synthesis favors the formation of -certain parasitic ideas which develop completely and in isolation -under the shelter of the control of the personal consciousness -and which manifest themselves by the most varied disturbances, -apparently only physical." He summarized this as a complete doubling -(dédoublement—literally undoubling, as translated by Corson) of the -personality. On analysis there is fundamentally much in this view -strongly suggestive of the theories of Breuer and Freud. - -Babinski interprets hysteria as a purely psychic functional disturbance -due to suggestion. He would eliminate from this field all symptoms -which cannot be induced by suggestion and relieved by methods of -persuasion. The ordinary physical manifestations of the disease, such -as anesthesia, hyperesthesia, paralyses, convulsions, etc., Babinski -describes as stigmata. His theories lead him to suggest "pithiatism" as -the correct name for hysteria. - -A revolutionary and epochmaking contribution to the literature of -this important subject was the publication of their "Studien über -Hysterie" by Breuer and Freud in 1895. The latter has made various -further expositions of his views more recently. What the ultimate -outcome of the hysteria problem may be, only time can determine. No -consideration of the subject, however, is complete, nor should any -definite conclusions be attempted, without a thorough understanding -of theories which have a material bearing on the mental mechanisms -involved in all of the psychoneuroses. Breuer and Freud advanced the -suggestion that hysteria is always the result of a psychic trauma. -The mechanisms involved may be very briefly summarized. Studies of -everyday life show that the peculiar amnesia often observed for certain -names and events does not mean usually in the average individual a -mere fading of memory with the lapse of time. Freud found that the -inability to recall things in such cases is largely due to the fact -that they are for some reason or other unpleasant in nature and -therefore not desirable to remember. They are accordingly pushed into -the background as it were, by burying them in the subconscious strata -of the mind and intentionally obliterating them from memory. When the -ordinary well balanced individual is confronted with an unpleasant -situation he meets it as best he can, by the exhibition of normal -reactions of various sorts. He treats the matter lightly, dismisses -it as a joke or "laughs it off." His dignity may be maintained by a -display of anger or resentment. The mental equilibrium may be restored -by a resort to profanity, tears, violence, or even physical flight. -An emotional outlet in the form of hate or thoughts of revenge may be -necessary to settle the question and finally dispose of it by "getting -it off the mind." There are unpleasant situations which for various -reasons cannot be met and treated in this ordinary way. The mental -shock of the "psychic trauma" may, for instance, be the result of an -occurrence which is so distasteful and repulsive as to be incompatible -with the present existence. There being no other escape from such a -difficulty, it is rejected by the psychic censor, to use Freud's -expression, and repressed or forced into the subconscious. This is -the inadequate reaction which takes place in hysteria and leads to a -dissociation and rudimentary splitting of the consciousness. Freud -finds that in practically every instance the repressed and painful -idea is due to a psychic trauma resulting from some incident of a -sexual nature; furthermore, that it usually dates back to the time of -childhood. These buried sexual complexes are completely disposed of by -what Freud speaks of as the process of "conversion," the associated -affect being radiated, as it were, into the physical sphere where it is -converted into a memory symbol in the form of an hysterical symptom. -The mental symptoms of the disease he explains as the results of the -elaboration and development of hypnoid states or erotic day-dreams of -the individual. Freud[336] summarized his views in a series of formulae -"which strive to progressively exhaust the nature of hysteria" as -follows:— - -"1. The hysterical symptom is the memory symbol of certain efficacious -(traumatic) impressions and experience. - -"2. The hysterical symptom is the compensation by conversion for the -associative return of the traumatic experience. - -"3. The hysterical symptom—like all other psychic formations—is the -expression of a wish realization. - -"4. The hysterical symptom is the realization of an unconscious fancy -serving as a wish fulfilment. - -"5. The hysterical symptom serves as a sexual gratification, and -represents a part of the sexual life of the individual (corresponding -to one of the components of his sexual impulse). - -"6. The hysterical symptom, in a fashion, corresponds to the return of -the sexual gratification which was real in infantile life but had been -repressed since then. - -"7. The hysterical symptom results as a compromise between two -opposing affects or impulse incitements, one of which strives to -bring to realization a partial impulse, or a component of the sexual -constitution, while the other strives to suppress the same. - -"8. The hysterical symptom may undertake the representation of diverse -unconscious nonsexual incitements, but can not lack the sexual -significance." - -The practical application of these theories of Freud is illustrated -by the line of treatment suggested. By his method of "catharsis" the -repressed and forgotten painful idea is restored to the conscious -sphere of the mind and a normal reaction brought about by "affording -an outlet to the strangulated affect through speech." To accomplish -this result it is obviously necessary to find out what the psychic -trauma was that originally caused the repression. For this purpose he -uses psychoanalysis, hypnosis and the study of dreams. Psychoanalysis -is nothing more or less, as Campbell says, than a sort of "scientific -confessional", a complete analysis of the mental mechanisms of the -individual in a search for the buried complexes. It has largely been -preferred by Freud to hypnosis, the latter often being impracticable -for various reasons. The association test of Sommer was very -successfully adapted to the determination and explanation of buried -complexes by Jung. Freud's views as to the analysis of dreams in -the unravelling of mental mechanisms are set forth in full in his -"Traumdeutung" (1900). He describes a dream as being "the more or less -disguised fulfilment of a suppressed wish." Owing to the activities of -the psychic censor we may have either manifest or latent dreams. The -former are recalled on waking; the latter are distorted or forgotten -and indicate the repressed wish. He classifies dreams as, those which -represent an unexpressed wish as being fulfilled, those which represent -the realization of the wish in some entirely concealed form and those -which represent it in a form insufficiently or partly concealed. -Freud justified his emphasis of the sexual element in his studies of -the psychoneuroses by the publication of his "Drei Abhandlungen zur -Sexualtheorie." In this he calls attention to the neglected importance -of sexual factors in the developing mentality of the child and shows -that these influences are manifested long before the age of puberty. -He even maintains that the normal child is homosexual as well as -incestuous at a certain stage. These erotic impulses are largely -unconscious and become submerged, playing an important part later in -the development of the neuroses. - -Kraepelin has devoted one hundred and sixty pages of his work on -psychiatry to a consideration of the subject of hysteria. The mental -symptoms of the disease are all described as being definitely -associated with twilight or dream states (Dämmerzustände). These he -refers to as including somnambulisms, definite excitements, attacks -assuming a characteristic silly or "puerile" form, confusions, deliria -of various kinds, the Ganser complex, prison stupors and double -personalities (retrograde amnesia). He does not accept Freud's views as -to the influence of the sexual life in the etiology of hysteria. - -Neurasthenia was first described by Beard of New York in 1880. As has -already been shown, it was referred to by Kraepelin as one of the -psychogenic neuroses. Freud is much inclined to question the existence -of such an entity as the classic neurasthenia described by Beard. He -feels that most of the cases can be traced to a definite association -with some other psychosis. He does, however, recognize a neurasthenic -complex which is entirely sexual in origin and attributes it to the -excessive masturbation of adult life. The symptoms, according to Freud, -are a result of the inadequate sexual relief afforded by the habit, -and are those of nervous exhaustion, a sense of pressure or fulness in -the head, spinal irritation, hyperesthesias, paresthesias, diminished -sexual power, and occasionally a mild form of emotional depression. He -would also differentiate another psychoneurosis of sexual origin—the -anxiety neurosis (Angstneurose). He mentions an increased irritability -as a prominent symptom often in the form of an oversensitiveness to -noises. The characteristic feature, however, is a state of anxious -expectation. This may manifest itself in a mere uneasiness and general -tendency towards pessimism or may approach a state of hypochondriasis -with paresthesia and annoying somatic sensations. Fear of sudden death -may be experienced. There may be physical symptoms such as disturbed -heart action (palpitation or tachycardia), disturbance of respiration -(dyspnea or asthmatic attacks), profuse perspiration, periods of -trembling, dizziness, attacks of inordinate appetite, diarrhea, etc. -Nocturnal frights are common. The symptoms as outlined above are -accompanied by a marked anxiety. He finds anxious psychoses usually -in women, in the form of virginal fears in adults, the anxiety of -the newly married, similar states occurring in widows or intentional -abstainers, and fears occurring at the climacterium. This condition -in women he believes to be due as a rule to coitus interruptus or -ejaculatio praecox. Similar anxieties in men, according to Freud, are -due to abstinence, frustrated sexual excitement, coitus interruptus or -senile conditions. Masturbation may also be a factor. He also admits -that there are causes other than sexual, in the form of overwork, -serious illnesses, etc. The mental mechanism involved is a "deviation -of the somatic sexual excitement from the psychic, and in the abnormal -utilization of this excitement occasioned by the former." - -In 1903 Janet formulated his conception of psychasthenia, describing -it as a clinical entity. In this grouping he included the obsessions -of doubt, phobias, imperative ideas, impulsive obsessions, compulsions -and other conditions described by various authors. The essential -mechanism to be considered, according to Janet, is a "lowering of the -psychological tension." This results, as White expresses it, in an -inadequate perception of the realities of the outside world. Meyer has -spoken of psychasthenia as "a lowering of general interest and tendency -to rumination over what is accessible to the patient in his memory, -but is not squarely met, and where the normal reaction is replaced -by rumination, substitutive acts and panics." These conditions are -described by Freud as belonging to the "Zwangsneurose" or compulsion -neuroses. The obsessing ideas force themselves into the consciousness -of the individual, who is perfectly clear as to their inconsistency -but cannot escape them. These he also looks upon as being of sexual -origin and due to repression as in hysteria. After the unpleasant -idea is repressed, however, the mechanism is different. Instead of -converting the concept into a bodily symbol, a defense reaction -displaces the affect from the painful thought, connecting it with some -entirely disinterested and innocuous idea. This process he spoke of as -substitution. This transference, as in hysteria, takes place in the -subconscious and is not recognized by the patient as having anything to -do with his peculiar symptoms. Compulsive ideas prevent the recurrence -in thought, of the repressed etiological factor. It must be conceded -that these mechanisms are exceedingly interesting from a psychological -point of view. Freud's theories have, however, met with a great deal -of opposition, due apparently to the fact that all of his conceptions -are based almost exclusively on the influence of the sexual life on -the human mind. The characteristic and entirely consistent Freudian -answer to this objection is that it is a "defense reaction." Without -attempting to determine the exact basis of the psychoneuroses the -fact remains that their importance from a psychiatric point of view -cannot be questioned. They constitute in a large measure the field -of observation covered by the out-patient clinics and psychopathic -hospitals. They played an exceedingly important part in the psychiatry -of the late war. - -Leaving out of consideration the mental mechanisms involved, the -American Psychiatric Association has endeavored to collect statistical -data relating to the various psychoneuroses generally recognized, as is -shown by the suggestions regarding their delimitation, in the manual:— - -"The psychoneurosis group includes those disorders in which mental -forces or ideas of which the subject is either aware (conscious) or -unaware (unconscious) bring about various mental and physical symptoms; -in other words these disorders are essentially psychogenic in nature. - -"The term neurosis is now generally used synonymously with -psychoneurosis, although it has been applied to certain disorders in -which, while the symptoms are both mental and physical, the primary -cause is thought to be essentially physical. In most instances, -however, both psychogenic and physical causes are operative and we can -assign only a relative weight to the one or the other. - -"The following types are sufficiently well defined clinically to be -specified: - -"(a) Hysterical type: Episodic mental attacks in the form of delirium, -stupor or dream states during which repressed wishes, mental conflicts -or emotional experiences detached from ordinary consciousness break -through and temporarily dominate the mind. The attack is followed by -partial or complete amnesia. Various physical disturbances (sensory -and motor) occur in hysteria, and these represent a conversion of the -affect of the repressed disturbing complexes into bodily symptoms -or, according to another formulation, there is a dissociation of -consciousness relating to some physical function. - -"(b) Psychasthenic type: This includes the compulsive and obsessional -neuroses of some writers. The main clinical characteristics are -phobias, obsessions, morbid doubts and impulsions, feelings of -insufficiency, nervous tension and anxiety. Episodes of marked -depression and agitation may occur. There is no disturbance of -consciousness or amnesia as in hysteria. - -"(c) Neurasthenic type: This should designate the fatigue neuroses in -which physical as well as mental causes evidently figure; characterized -essentially by mental and motor fatigability and irritability; also -various hyperesthesias and paresthesias; hypochondriasis and varying -degrees of depression. - -"(d) Anxiety neuroses: A clinical type in which morbid anxiety or fear -is the most prominent feature. A general nervous irritability (or -excitability) is regularly associated with the anxious expectation or -dread; in addition there are numerous physical symptoms which may be -regarded as the bodily accompaniments of fear, particularly cardiac and -vasomotor disturbances; the heart's action is increased, often there is -irregularity and palpitation; there may be sweating, nausea, vomiting, -diarrhea, suffocative feelings, dizziness, trembling, shaking, -difficulty in locomotion, etc. Fluctuations occur in the intensity of -the symptoms, and acute exacerbations constituting the "anxiety attack." - -"(e) Other types." - -The psychoneuroses occur very infrequently in institutions for mental -diseases. In 49,640 first admissions to the New York state hospitals -during a period of eight years, only 671 cases were reported as -neuroses or psychoneuroses, constituting 1.35 per cent of the total. -Of this number 29.97 per cent were of the hysterical type, 37.35 -of the psychasthenic, 30.27 of the neurasthenic form, and 2.41 per -cent were anxiety psychoses. In the Massachusetts hospitals during -the year 1919, thirty-six, or 1.19 per cent, of the 3,011 admissions -reported were neuroses or psychoneuroses. Of these, 44.83 per cent -were of the hysterical, 24.14 of the psychasthenic, and 18.39 per -cent of the neurasthenic forms. On analyzing 18,336 admissions to -twenty-one hospitals in other states we find 297 cases of neurosis or -psychoneuroses, 1.63 per cent of the total. Of these, 44.11 per cent -were cases of hysteria, 28.28 of psychasthenia, 22.90 of neurasthenia -and 4.71 per cent of anxiety psychoses. The neuroses or psychoneuroses -constituted 1.42 per cent of over seventy thousand admissions to all -institutions. Of the 1,048 psychoneuroses reported, 35.20 per cent were -cases of hysteria, 33.68 of psychasthenia, 29.19 of neurasthenia, and -3.91 per cent of anxiety psychoses. - - - - -CHAPTER XVII - -THE PSYCHOSES WITH PSYCHOPATHIC PERSONALITY - - -The introduction of the term psychopathic personality is probably to be -attributed to the description of "Die Psychische Minderwertigkeiten" -by Koch in 1893. These were referred to by Morel[337] as "Psychopathic -Depreciations," a group in which he says Koch included "a very large -number of these psychical manifestations, so varied in their nature -and intensity which, without belonging to the class of mental diseases -proper, cannot, nevertheless, be reconciled with the idea of perfect -mental sanity." These were described as being either congenital or -acquired and including psychopathic predisposition, psychopathic -defect and degeneration. To congenital defects were attributed the -"Eccentrics, disequilebrated, overscrupulous and capricious persons, -foolish, misanthropes, redressers of wrong, reformers of society, -etc." In the degenerative processes he included mental deficiencies -both intellectual and moral. Meyer,[338] who based his conception of -"constitutional inferiority" largely on the work of Koch, says that -the latter by "Psychische Minderwertigkeiten" "meant those little -defects which constitute the inferiority of the individual in the whole -strife of life, that inferiority which does not allow him to come up -to an actually efficient balance in the struggle of life.... They -were oddities, peculiar nicks in the personalities of the various -people, and he designated those as constitutionally inferior." Koch -in this grouping unfortunately included hysteria, psychasthenia and -neurasthenia. Meyer eliminated these: "I wanted to do justice to the -hysterias and psychasthenias which I could define as such, but I knew -there was a whole group of cases in which the definition could not -be pushed. I also knew that it was difficult to give the definition -in the downward line towards imbecility, and since it was so very -hard to give the definition in the individual cases, I thought that -the least trouble would arise from making a relatively large group -of 'inferiorities not sufficiently differentiated' and let those be -entered under the heading of 'constitutional inferiority.'" - -The original conception of this group was that it included intellectual -defects which have subsequently been classified with the mental -deficiencies, leaving only those cases showing purely psychopathic -taints of a constitutional origin. There have been numerous other -descriptions of these conditions. Ziehen[339] included under the -psychopathic constitution "chronic, psychopathic conditions, which -in their symptomatology and course not only involve defect of the -affectivity but also of the intelligence, even though pronounced -psychopathic symptoms, such as delusions, hallucinations, etc., do not -intrude for any extended period. Where hallucinations and analogous -symptoms do appear they are solitary and the patient retains insight -into the condition." Ziehen's psychopathic constitution covers a very -wide field, including not only hysteria and neurasthenia but epilepsy. - -The psychopathic personalities as described today represent only -a modern interpretation of conditions which have been given -ample consideration in the psychiatric literature of the past. -An early illustration of this fact is Pritchard's definition of -"moral insanity" in 1835:—"A morbid perversion of the feelings, -affections and active powers, without any illusion or erroneous -conviction impressed upon the understanding; it sometimes coexists -with an apparently unimpaired state of intellectual faculties." -The psychopathic states were undoubtedly fully covered in Morel's -description of the insanity of degeneracy in 1860. This he divided -into cases arising from constitutional nervous temperaments, moral -insanity, the feebleminded with or without morbid impulses, and those -with criminal tendencies. This conception was well summarized by -Diefendorf[340]:—"The disharmony of the intellectual and the moral -faculties is one of the most striking features of degeneracy. As in -the defects of the intellectual development, so in the moral sphere, -the condition varies from a complete arrest of moral development to -all forms of moral perversion and even to an abnormal development of -the moral and emotional susceptibility. All of these conditions may -exist, with a perfect development of the intellectual faculties.... The -professional criminals should also, without doubt, be included in this -class, as they present all possible varieties of moral perversions and -anomalies, all of which may exist with preservation of the intellect -and even with intellectual keenness." - -Magnan described compulsions, impulsions and contrary sexual instincts -as episodes of the insanity of degeneracy. The psychopaths were -undoubtedly the "déséquilibrés" or ill-balanced individuals of -Régis,[341] whose work on "Mental Medicine" included an exceedingly -elaborate discussion of the so-called "borderline" conditions. -"After maturity they are complex beings, heterogeneous, made up of -disproportioned elements, contradictory qualities and defects, and -as over-endowed in some directions as they are deficient in others. -Intellectually, they often possess in a very high degree, the faculties -of imagination, of invention, and of expression, that is to say, the -gifts of speech, the arts, and poetry; on the moral side, they possess -a singular emotivity, or rather, sensibility. What they lack, more or -less completely, is good judgment, the moral sense, and especially -continuity or logical consecutiveness, a unity of direction in -intellectual production and the actions of life. It follows, that in -spite of their often superior qualities, these persons are incapable -of conducting themselves in a rational manner, of following regularly -the exercise of a profession that seems well beneath their capacity, of -looking after their interests or those of their families, of carrying -on business prosperously or of directing the education of their -children; their existence, therefore, constantly recommencing, is one -long contradiction between the apparent wealth of means and poverty -of results. They are the utopians, the theorists, the dreamers, who -are enamored with the best things but accomplish nothing. The public -which sees only the brilliant exterior looks upon these individuals as -artists and superior beings. The medal is reversed, however, to those -who are compelled to associate with them and share their existence; -they see their defects, their incapacities and evil tendencies, of -which they are not merely the witnesses, but also the victims. Aside -from their lack of mental poise these individuals also display an -excessive emotional sensibility and an enfeeblement of psychic energy -that reveals itself by a noticeable predominance of spontaneity over -reflection and volition. Hence their inability, their instability, -and their irresolution; hence also their alternations of apathy and -activity, of excitement and torpor, their violent attacks of passion -and their cries of despair for the most trivial and slightest reasons." -Régis divided the "psychic discordances" or disharmonies into the -ill-balanced, the original and the eccentric. These were all included -in the degeneracies of evolution. Clouston covers this same ground -fully and in a somewhat similar manner in his "Unsoundness of Mind" -(1911). - -The insanities of degeneracy have also been given considerable space by -such Italian writers as Lombroso, Bianchi, etc. Lombroso in "The Man -of Genius" (1888) discussed this subject as follows:—"A theory, which -has for some years flourished in the psychiatric world, admits that -a large proportion of mental and physical affections are the result -of degeneration, of the action, that is, of heredity in the children -of the inebriate, the syphilitic, the insane, the consumptive, etc.; -or of accidental causes, such as lesions of the head or the action of -mercury, which profoundly change the tissues, perpetuate neuroses or -other diseases in the patient, and, which is worse, aggravate them in -his descendants, until the march of degeneration, constantly growing -more rapid and fatal, is only stopped by complete idiocy or sterility. -Alienists have noted certain characteristics which very frequently, -though not constantly, accompany these fatal degenerations. Such are, -on the moral side, apathy, loss of moral sense, frequent tendencies -to impulsiveness or doubt, psychical inequalities owing to the excess -of some faculty (memory, aesthetic taste, etc.) or defect of other -qualities (calculation, for example), exaggerated mutism or verbosity, -morbid vanity, excessive originality, and excessive preoccupation with -self, the tendency to put mystical interpretations on the simplest -facts, the abuse of symbolism and of special words which are used as an -almost exclusive mode of expression." - -Several other very elaborate works have been published on the subject -of degeneracy. One of the better known of these perhaps is that of -Max Nordau on "Degeneration" (1894). The book of Grasset[342] on the -"Demifous et Demiresponables" has been translated into English and -constitutes one of our most valuable contributions on this subject. -Grasset credits Trélat with making the first comprehensive study of the -semi-insane in his "La Folie Lucide," etc., in 1861. His classification -of these conditions included imbeciles, the feebleminded, satyrists, -nymphomaniacs, monomaniacs, erotomaniacs, jealous individuals, -dipsomaniacs, spendthrifts, adventurers, the conceited or boastful, -evildoers, kleptomaniacs, suicides and the inert and lucid manias. -Grasset gives some interesting illustrations of the psychopathic traits -of various men of genius. Tolstoï fell sixteen feet as a result of -attempting to fly when eight years old, and whipped himself with ropes -to become accustomed to pain. In school he chose a course in Oriental -languages because everyone else was interested in law. Not being able -to finish a college career in two years, he decided to go to a desert -and live a purely animal life. It was necessary for him to resort to -devices of various kinds to prevent suicide. Rousseau was at various -times a clockmaker, music master, painter and servant in addition to -studying medicine, music, theology, and botany. He dedicated a pamphlet -"to all Frenchmen who were friends of justice" and distributed it on -the streets. One of his acts was to write a letter "to God Almighty" -and place it under the altar of Notre Dame. Persecutory ideas were -entertained by him for years. Emile Zola was evidently a psychasthenic -as well as a psychopath. He counted the gas jets on the street, the -numbers on the doors, and the cabs passing by. These were added -together. "For a long time the multiples of three seemed to him of -good omen, then the multiples of seven were reassuring." "For a long -time he was afraid he would not succeed in any proceeding on which he -was about to enter if he did not leave the house with his left foot -first." Balzac had an ambulatory mania and could not be found when -called for military service. It is said that on one occasion "when he -had put on a handsome new dressing gown he wanted to go out into the -street with it on with a lamp in his hand to excite the admiration of -the public." His father is said to have stayed in bed for twenty years -without any reason for so doing, suddenly resuming his former mode of -life at the end of that time. Schopenhauer broke a hotel proprietor's -arm because he heard him talking outside of his room. He refused to pay -a legitimate account because his name was spelled with two p's instead -of one, on the bill. He often burned his beard instead of shaving and -wrote his notes in Greek, Latin and Sanskrit for fear someone would -read them. In his will he left all of his possessions to soldiers and -to his dog. Goethe alternated between great joy and extreme depression -and had unjustifiable attacks of anger. Frederick II had such a -dislike for changing his coat that he had only two or three during the -course of his life. When Schiller wanted to meditate he had a habit of -putting his feet on ice and sniffing the aroma of fermenting apples. -Nordau says "that Richard Wagner is accused of having a greater degree -of degeneracy than all the degenerates that we have thus far seen -put together." Mozart played the harpsichord at three years of age, -composed concertos at five and made a concert tour at the age of six. -He was extremely nervous and fell in love at fifteen with a girl of -twenty-five. In the last months of his life he was obsessed with the -idea that he had to prepare his own funeral mass. Lombroso's theory -is that "genius is a true degenerative psychosis, belonging to the -group of moral insanities which may temporarily spring from other -psychoses and take their form, but always conserving certain special -characteristics which distinguish it from the others." Although his -conclusions may not be warranted it must be admitted that many men of -genius have been psychopaths. - -Kraepelin[343] in discussing the influence of heredity on psychoses and -personalities, says, "Hence we may, perhaps, discriminate between -congenital states of disease and morbid personalities, according as the -disturbances are apparently the expression of the morbid conditions of -past generations, or seem to be purely personal abnormalities, although -it is certainly impossible to make any sharp distinction." In 1915, in -the fourth volume of his eighth edition, Kraepelin devoted nearly one -hundred and fifty pages to the subject of psychopathic personalities. -These he divides into the excitable, the unstable, the impulsive, -the eccentric, the liars and swindlers, the antisocial or enemies of -society, and the quarrelsome. - -A study of the "excitable" psychopaths in Kraepelin's[344] clinic -showed the intellectual standard of these individuals to be above the -average. Apprehension and judgment were unimpaired even when mental -inferiority was not entirely lacking. Some complained of poor memory -or absentmindedness, others of a feeling of fatigue. A definite mental -activity was noted, usually of a happy mood, but occasionally with -depressive tendencies. The characteristic feature was an emotional -excitement, associated often with violent rages, without any adequate -reason. The emotional reaction changed quickly to one of despair, -anxiety, irritability or inaccessibility. The mood in a large number of -cases was depressed and tearful, while others were cheerful and elated, -laughing and joking, or erotic. Often without any apparent cause, -irritability, pessimism, unsociability, weariness of life and thoughts -of suicide appeared—more particularly during menstrual periods. The -emotional state as a rule was kind, affable, good-natured, tractable, -often religious, sensitive or sympathetic. The patients are often -spoken of as well-liked, industrious, honest and substantial citizens. -Some are timid, bashful or gloomy in disposition. Others are conceited, -overbearing, tyrannical, rude, unsociable and quarrelsome. Many are -childish, foolish or eccentric, highstrung and affected or untruthful. -Some are unsteady, restless and over-occupied, full of schemes, rash, -talkative, gossiping, and assuming striking mannerisms. Occasionally -they are disinclined to any regular occupation, neglect their work, -loaf around and are supported by their relatives. In sixty-two per cent -of these cases the patients were brought to the clinic on account of -suicidal tendencies. This was due to reduced circumstances in nearly -fifty per cent of the men and in seventy-one per cent of the women. In -the men marital troubles and love affairs were more common; sometimes -loss of position, or death in the family, etc. Spurious attempts at -suicide of a theatrical type were frequently reported. Next to suicidal -inclinations as a cause for being brought to the clinic there were -assaults, attacks of rage and outbursts of despair. In any stress or -anger over a disagreeable occurrence these individuals are likely to -become abusive, shout, scream, run around, strike the head against -the wall, tear their clothes off, pull out their hair, etc. Some -rush around all night in the streets in a senseless rage, improperly -clothed. Occasionally they attack others unjustifiably and for no -apparent reason. They are exceedingly susceptible to alcohol. During -their excitements, consciousness may be clouded. Afterwards they say -they were confused, not themselves, in a dream as it were, etc. Some -have no recollection whatever as to what was done. These excitements -rarely last more than a few hours. Thirty-two per cent of the men and -less than ten per cent of the women were convicted of crime, usually -for disturbing the peace, or criminal assaults, but occasionally for -much more serious offenses. As a rule alcohol is a factor in these -cases. The relations between the sexes are characterized by jealousy -and quarreling. The women are particularly likely to have delusions of -infidelity. Genuine hysterical attacks occur in a certain number of -cases. They often see visions and may have dizzy spells or syncopes. -Somnambulism may occur. Nervous symptoms often appear—headaches, -unpleasant dreams, palpitations, tremors, increased reflexes, -tics, etc. The excitable cases constituted nearly one-third of the -psychopaths admitted at Kraepelin's clinic. Sixty per cent of these -were women. The majority of cases were between fifteen and twenty-five -years of age. Heredity appeared to be a factor in forty-seven per -cent and many showed physical defects. Fifty per cent of the men were -intemperate. - -The "unstable" psychopaths are characterized by a dominating weakness -of the will. In nearly one-half of the cases the intellectual -endowment is normal, some having a surprising power of comprehension -and ability to take up new things, with accurate observation of their -surroundings and keen discrimination. These persons have no great -persistence and do not exert themselves, are inattentive, tire easily -and are distractible. They never go into things deeply and have only a -superficial knowledge of events. They learn readily and forget quickly. -The memory is poor and unreliable. The imagination is usually very -active, with a tendency to exaggerate, dream of the impossible and -relate great stories. There is an inclination to boast and fabricate, -telling of wonderful but wholly imaginary deeds and accomplishments. -They often represent themselves to be important personages. Some show -artistic talent, write plays or fantastic poetry and discuss literary -and dramatic problems. They are strongly inclined to become actors. The -higher intellectual development is uniformly defective. Comprehension -is not clear and judgment is immature and short-sighted. Their -interests are devoted to frivolous matters without much attention to -more important questions. They sometimes show great prospects in school -but do not fulfill them later. The mood is cheerful and conceited, with -a very high opinion of themselves and great ambitions. They blame their -relatives for their lack of success and claim they are not understood -or appreciated. Sometimes the emotional trend is more sad and gloomy. -They complain of being unlucky, everything goes wrong. Occasionally -anxieties appear, with a feeling of oppression, fear of being alone, of -mental troubles or suicide. These feelings are, however, superficial -in character, usually disappearing in a short time, to be followed by -excitement, outbursts of anger or anxiety. They are often quarrelsome. -The characteristic disturbance, however, is that of the will. They are -entirely lacking in the capacity to stick to any one occupation. They -are not punctual, are interfered with in innumerable ways and often -change their work, looking for something more suitable. Hypochondriacal -notions hamper their activities. Senseless journeys and trips are often -undertaken. Some become vagabonds and tramps. They are much inclined -to bad company and resort to immoderate use of tea, coffee, drugs and -alcohol. Sixty-four per cent of Kraepelin's male cases and twenty per -cent of the women were intemperate. The sexual habits are very often -irregular and venereal diseases to be expected. Kraepelin found either -gonorrhea or syphilis in twenty-two per cent of the women examined. -Some exhibited homosexual tendencies. Many become spendthrifts, making -extravagant and foolish purchases. They are inclined to speculate -unwisely. Fifty-four per cent of the men and nearly a third of the -women as a result of their moral deterioration come into conflict -with the courts on account of thefts, assaults, quarrels, vagrancy, -etc. Suicidal tendencies were shown in forty-eight per cent of the -men and sixty-five per cent of the women in Kraepelin's clinic. In -many cases these were induced by alcoholism, in other instances by -family quarrels, etc. Often the reasons given were foolish. Hysterical -attacks appear in a certain percentage of cases in the women. Some had -hallucinations and confusional attacks or syncopes. Tremors, headaches, -increased reflexes and other neurological symptoms occasionally -appeared. The "unstable" group included about one-fifth of the -psychopaths observed by Kraepelin. Thirty-six per cent of these were -women. The majority of those admitted were between the ages of fifteen -and twenty-five. Heredity was a factor in forty-nine per cent of the -cases. - -The "impulsive" psychopaths are characterized by a domination of -the conduct by emotional impulses. The intellectual makeup of these -individuals is usually good. They often have a special bent for art, -music, poetry, etc. They frequently show a considerable mental activity -and versatility. They express themselves well, make witty remarks and -appear brilliant, although they may complain of absentmindedness or -fatigability. They are always conceited, born to greater things and -have a great future. There is an almost unbounded egotism in some -cases. The emotional tone is good-natured, easygoing and accessible. -Many are sensitive and visionary; others obstinate, inconsiderate, -pretentious or quarrelsome. The mood is usually high-spirited and -confident but variable. The patients are often depressed and hopeless, -complaining of their luck. At other times they are sullen, surly, -irritable and faultfinding. Many exhibit suicidal tendencies. An -emotional irritability is exceedingly common, with violent outbursts -of anger. Often they refuse to associate with others for a time and -will speak to no one. The three common types are the spendthrift, the -wanderer and the dipsomaniac. The spendthrifts usually indulge in -alcohol and naturally soon contract enormous debts. They frequently -have little insight into their condition or blame someone else -for it. Many become wanderers and go aimlessly from one place to -another—wherever their inclination leads them. The memory for these -events is good. Some inadequate reason is always offered. These -wanderers usually are children between the ages of ten and fifteen. -The impulsive alcoholics may have attacks very rarely, sometimes only -once a year. Debauches are preceded by restless and moody conduct. -After constant drinking for days or weeks they sometimes have suicidal -impulses. Sexual excitements may occur. They always show psychopathic -traits between attacks. They are unsteady, unreliable, make sudden -resolutions, change their occupations and residence and lead a wild -existence with surprising adventures. Some have hysterical attacks, -fainting spells, or even convulsions. The impulsive psychopaths -constituted only two or three per cent of Kraepelin's cases. -Practically all were over twenty-five years of age. There was a -hereditary taint in seventy-one per cent of the cases. - -The "eccentric" psychopaths are characterized by a lack of uniformity -and consistency in the mental makeup. The intellectual endowment of -these individuals is usually normal. They are often absentminded, -forgetful and show a variation in productivity. Some are artists -or devote themselves to inventions. Judgment is impaired and -reasoning becomes distorted and onesided. There is a tendency towards -exaggeration and extravagance in their viewpoints, with a leaning -towards queer notions. They are often quickwitted, versatile and write -long and wordy documents. Their mode of expression is bombastic and -labored, and the content of speech or writing, verbose, desultory, -flighty and full of meaningless expressions. They show a certain -shrewdness and cunning, dissimulate, resort to all kinds of evasions, -and are conspicuous in their conduct. Occasionally there is a tendency -towards delusional ideas of a mild form. As a rule the mood is -cheerful, although often depressed, suspicious or irritable. They are -opinionated, boastful and better than others. Usually there is an -emotional excitability. The patients are sensitive and irritated by -small things, scold and complain. Sometimes they are sentimental and -dreamy, with extravagant language. They often take sudden dislikes to -brothers, sisters or other members of the family. They are capricious, -quarrelsome, and faultfinding. Their conduct is aimless, contrary -and incomprehensible. They lose all capacity for judgment of real -conditions. They cannot proceed in any orderly way in things which they -are really fitted for. They do not stick to anything long, changing -plans and occupations frequently. They often go about at night talking, -arguing and drinking. It is not unusual for them to quarrel with -their wives or even commit assaults. The majority of these eccentric -psychopaths were men over thirty-five and of degenerate families. This -group constitutes only a small number of cases. - -The "liars and swindlers" are characterized by an excitability of -the imaginative faculties and a variable and uncertain will power. -At first these individuals are likely to appear as unusually gifted -persons. They are good-natured, present an excellent appearance and are -apparently well informed on almost all subjects. They have a faculty -for quoting foreign languages and sometimes are familiar with many -tongues. Often they are brilliant conversationalists. On investigation -their actual knowledge is found to be very superficial. They are -inclined to art, poetry and literature. Many become interested in -hypnotism or spiritualism. They are inclined to join religious sects -or attach themselves to the Salvation Army. These individuals learn -quickly but do not stick to things long. Their mental powers are not -orderly or consistent. They have an extraordinary imagination but -accomplish nothing. They are liars from birth, the falsifications -usually being entirely useless. Many are anonymous letter writers. -They are often unable to discriminate, themselves, between the true -and the false in their own stories. These fabrications appear to be -an emotional product, the imaginary occurrence practically always -relating to the individual himself. They boast of their superiority in -literary and scientific accomplishments and claim to be theologians, -mathematicians, jurists, chemists, etc. In their imaginations and -fabrications the patients always better themselves. In many instances -they assume pretentious titles, represent themselves as counts, -princes, etc. Sometimes they strongly suggest paranoia. In a small -number of cases self-accusations appear and they confess to all kinds -of imaginary crimes. As a rule they are elated and optimistic, but -often affected and theatrical. Occasionally suicidal attempts are -made. At times general depressions or anxious states appear. Some are -coarse and deceitful. They are usually uncertain and capricious in -everything. Some become spendthrifts. They are naturally cheats and -swindlers; occasionally thieves. The swindling schemes resorted to are -innumerable. The use of false names and assuming of uniforms and titles -of various kinds is the most common. They make purchases of all kinds -without any ability to pay or any intention of doing so. Many refuse -to pay bills without any excuse whatever. Others attempt to marry rich -women by deceitful means and misrepresentations. Some practice medicine -without a license; others claim damages for imaginary injuries. -Sexual offenses are common. If arrested they are often inclined to -claim amnesia for the period of time when the act was committed. They -occasionally have genuine psychoses and hysterical attacks. These -simulate various diseases. The group of liars and swindlers constituted -from six to seven per cent of the psychopaths in Kraepelin's clinic. -Seventy-one per cent of the men were accused of crimes. The majority -of cases were under twenty-five years of age. Heredity was a very -important factor. - -The "antisocial" psychopaths or enemies of society are characterized -by a blunting of the moral elements of their makeup and a lack of -adjustment to their environment. Kraepelin found that forty per cent -of his cases were persons who had done well in school. They have a -strong dislike for regular occupations and avoid them in every possible -way. Their behavior is variable, with a tendency to be industrious -occasionally and more often lazy. Frequently they appear queer, -abstracted, inattentive, dreamy, sleepy or dull. When at their best -they are not bright mentally and have no ambition or far reaching -interest. They learn quickly and forget as rapidly. Their store of -knowledge is very limited. They have no capacity for going into things -thoroughly and cannot acquire a higher education. They are lacking -in judgment, foresight and discrimination. Many have a weakness for -cheap stories of adventure, pictures of crime, etc. In expression they -are usually quick as well as verbose. A characteristic is their lack -of truthfulness. They are liars and braggarts. The mood is usually -cheerful and confident; sometimes arrogant, surly, moody, irritable and -occasionally depressed or anxious. They change unexpectedly from one -mood to the other. Irritability, with outbursts of anger, is common. -They often become threatening and destructive. Eighteen per cent of -Kraepelin's cases attempted suicide. At least one-third of these were -theatrical attempts on account of fear of punishment. Childish vanity -and conceit is a very common symptom, with boastful tendencies. A -prominent feature is the lack of any deep emotional reactions. They -do not react normally and properly to their surroundings. Another -characteristic defect is their entire lack of sympathy for anyone else. -They are likely to be cruel to animals as well as persons. They show -little affection for parents, children or relatives and are lacking -in a sense of decency and personal cleanliness. As children they -are exceedingly troublesome in school. Some have to go to custodial -institutions for care. Many are truants at school and run away from -home, becoming wanderers and vagabonds. They are inclined to sexual -excitement, irregularities and crimes of various sorts. Seventy per -cent of Kraepelin's cases were thieves, beginning to steal as children; -twenty per cent were embezzlers and twelve per cent guilty of fraud -or forgery. Practically every variety of crime was represented. They -exhibit an extraordinary tendency to revert to criminal habits. Prison -life makes some submissive but starts others in a war against society. -They often attempt violence or make passive resistance to the law. They -occasionally develop hypochondriacal tendencies. Friendly advances are -greeted with mistrust. Some are stubborn, sulky, unrepentant and have -nothing to say, or lie and explain by putting the blame on others. Thus -an opposition to all organized society develops. They often look upon -themselves as martyrs. Others take the situation lightly and minimize -the gravity of their position. Some seem to really see the error of -their ways. The antisocial individuals sooner or later, like other -psychopaths, are very prone to hysterical attacks, fainting spells, -or even convulsions. Anesthesias and hyperesthesias may be noted. -Some patients complain of headache, disturbed sleep, dreams, etc. The -antisocial in Kraepelin's clinic constituted less than ten per cent of -the psychopaths, of which seventy per cent were men. Half of the women -were prostitutes. Over eighty per cent of the cases were under twenty -years of age. - -The intellectual makeup of the "quarrelsome" psychopath is usually -fairly good. As a rule these persons show a narrowing of the -intellectual sphere, with, however, a well-defined shrewdness which -enables them to take advantage of others. Some show a tendency to -pedantry and hair-splitting arguments. Memory is good but distorted -by an emotional coloring. Judgment is warped and unreliable. They -are credulous and accept statements without proof, but they look -with suspicion on anything not in accord with their own ideas. The -influence of these factors leads to an emotional excitability. They -are always passionate, sensitive individuals who become excited over -trivial matters. This is complicated by a marked self-confidence, -minimizing their own failings. Quarrels are the inevitable consequence. -Everything is exaggerated in importance. The conclusion is reached that -the neighbors and others are all organized against them. Sometimes -the feeling of enmity is transferred from one individual to another. -The patient is constantly in trouble with someone. They are almost -invariably of the male sex and usually of middle age or older when they -come under observation. - -For statistical purposes the differentiation of the psychopathic -personalities has been described by the Association's committee as -follows:— - -"Under the designation of psychopathic personality is brought together -a large group of pathological personalities whose abnormality of makeup -is expressed mainly in the character and intensity of their emotional -and volitional reactions. To meet the demands of current usage, the -term for this group has been shortened from the older one "psychoses -with constitutional psychopathic inferiority" with which it is -synonymous. Individuals with an intellectual defect (feeblemindedness) -are not to be included in this group. - -"Several of the preceding groups, in fact all of the so-called -constitutional psychoses, manic-depressive, dementia praecox, paranoia, -psychoneuroses, etc., may be considered as arising on a basis of -psychopathic inferiority or constitution because the previous mental -makeup in these conditions shows more or less clearly abnormalities in -the emotional and volitional spheres. These reactions are apparently -related to special forms of psychopathic makeup now fairly well -differentiated, and the associated psychoses also have their own -distinctive features. - -"There remain, however, various other less well differentiated types -of psychopathic personalities, and in these the psychotic reactions -(psychoses) also differ from those already specified in the preceding -groups. - -"It is these less well differentiated types of emotional and volitional -deviation which are to be designated, at least for statistical -purposes, as psychopathic personality. The type of behavior disorder, -the social reactions, the trends of interests, etc., which psychopathic -personalities may show give special features to many cases, _e.g._, -criminal traits, moral deficiency, tramp life, sexual perversions and -various temperamental peculiarities. - -"The pronounced mental disturbances or psychoses which develop in -psychopathic personalities and bring about their commitment are varied -in their clinical form and are usually of an episodic character. Most -frequent are attacks of irritability, excitement, depression, paranoid -episodes, transient confused states, etc. True prison psychoses belong -in this group. - -"In accordance with the standpoint developed above, a psychopathic -personality with a manic-depressive attack should be classed in the -manic-depressive group, and likewise a psychopathic personality with a -schizophrenic psychosis should go in the dementia praecox group. - -"Psychopathic personalities without an episodic mental attack or any -psychotic symptoms should be placed in the _without psychosis_ group -under the appropriate subheading." - -Unfortunately there are no statistics which show the incidence of -psychopathic personalities in the community. A study of 70,987 first -admissions to state hospitals shows that the psychoses associated with -this condition constituted only 1.12 per cent of the total number. On -the other hand, the reports of the Phipps Psychiatric Clinic show an -admission rate for psychopaths of over six per cent during a five-year -period. When they reach a state hospital it is usually owing to the -development of manic-depressive insanity or some other well-defined -psychosis. The important and troublesome cases from a social point of -view are those that do not reach hospitals. A much larger percentage is -to be found in institutions of the correctional and penal type. There -is no greater problem today than the attitude of the state towards -the psychopathic criminal. The influence of these individuals on the -community at large is something that we have no means of estimating at -the present time. - - - - -CHAPTER XVIII - -THE PSYCHOSES WITH MENTAL DEFICIENCY - - -The literature of mental deficiency is almost as old as that of -medicine. Imbecility was studied at some length by Plato and Galen -and was recognized by Felix Plater, who has been accredited with the -first classification of mental diseases known (seventeenth century). -Fitzherbert[345] in his "Natura Brevium" in 1652 included the following -interesting definition of idiocy: "He that shall be said to be a sot -and idiot from his birth, is such a person who cannot count or number -twenty pence, nor tell who was his father or mother, nor how old he is, -so as it may appear that he hath no understanding or reason what shall -be for his profit, or what for his loss; but, if he have sufficient -understanding to know and understand his letters, and to read by -teaching or information, then it seems he is not an idiot." One of -the first medical writers to discuss mental defects at any length was -Esquirol. In differentiating them from mental diseases he said: "Idiocy -is not a disease, but a condition in which the intellectual faculties -are never manifested; or have never been developed sufficiently to -enable the idiot to acquire such an amount of knowledge as persons of -his own age, and placed in similar circumstances with himself, are -capable of receiving. Idiocy commences with life, or at that age which -precedes the development of the intellectual and affective faculties, -which are from the first, what they are doomed to be during the whole -period of existence." ... "A man in a state of Dementia is deprived -of advantages which he formerly enjoyed. He was a rich man, who has -become poor. The idiot, on the contrary, has always been in a state of -want and misery." An elaborate treatise on the subject of cretinism was -published by Fodéré in 1792. - -Tredgold,[346] in discussing the etiology of mental deficiency, divides -the causes into factors indicative of, or producing, a variation of the -germ plasm and those acting directly upon the offspring. The former -include neuropathic inheritance, alcoholism, tuberculosis, syphilis, -consanguinity and the age of the parents. Among the latter are abnormal -mental and physical conditions of the mother during pregnancy, or -injury to the fœtus; abnormalities of labor, primogeniture and -premature delivery; and after birth—traumatic, toxic, convulsive and -nutritional factors. He found neuropathic inheritance in over eighty -per cent of the cases studied. In 64.5 per cent the heredity took -the form of mental defects, insanity or epilepsy, and in eighteen -per cent paralysis, cerebral hemorrhage, neuroses of various kinds, -or psychoses. There was a history of alcoholism in 46.5 per cent of -the series investigated. Tuberculosis occurred in the families of -thirty-four per cent, syphilis in 2.5 per cent, consanguinity in five -per cent, and a marked disparity in the ages of the parents in four -per cent. Factors acting directly on the offspring, either before, -during or after birth, were found to be present in sixty-five per cent. -Goddard[347] in a study of 327 cases found a history of inherited mental -deficiency in fifty-four per cent, probable heredity in 11.3 per cent, -neuropathic ancestry in twelve per cent, accidents of various kinds in -nineteen per cent, and no ascertainable cause of any kind in 2.6 per -cent of the total number. - -The definition of a feebleminded person, proposed by the Royal -College of Physicians of London, and subsequently adopted by the -English Royal Commission, reads as follows:—"One who is capable of -earning a living under favorable circumstances, but is incapable, -from mental defect existing from birth, or from an early age, (a) of -competing on equal terms with his normal fellows; or (b) of managing -himself and his affairs with ordinary prudence." The English Mental -Deficiency Act of 1913 included the following definition:—"Persons -in whose case there exists from birth or from an early age mental -defectiveness not amounting to imbecility, yet so pronounced that -they require care, supervision, and control for their own protection -or for the protection of others, or, in the case of children, that -they, by reason of such defectiveness, appear to be permanently -incapable of receiving proper benefit from the instruction in ordinary -schools." It will be noted that imbeciles and idiots do not come -within the scope of these definitions. This is due to the fact that -the term feeblemindedness as used in England includes only the High -Grade Amentia of Tredgold or the Morons as defined by Goddard. The -classification of the latter is as follows: - -1. High Grade Morons—Those that can do fairly complicated work, with -only occasional or no supervision, run simple machinery or take care of -animals, but are unable to plan. - -2. Middle Grade—Those capable of doing routine institution work only. - -3. Low Grade—Those who are only capable of running errands, doing -light work, making beds, scrubbing or caring for rooms—if there is no -great complexity of furniture. - -Tredgold describes imbecility as Medium Grade Amentia and idiocy as Low -Grade Amentia. - -The Mental Deficiency Act of England defines idiots as "persons so -deeply defective in mind from birth, or from an early age, as to be -unable to guard themselves against common physical dangers." It also -refers to moral imbeciles as "persons who from an early age display -some permanent mental defect coupled with strong vicious or criminal -propensities on which punishment has had little or no deterrent -effect." The imbecile as defined by the Royal Commission of England -is "one who by reason of mental defect existing from birth or from an -early age is incapable of earning his own living, but is capable of -guarding himself against common physical dangers." - -Tredgold classifies either feeblemindedness, imbecility or idiocy -if due to pathological germinal variations (caused by alcoholism, -tuberculosis, syphilis, etc., and manifested by amentia, insanity, -epilepsy, etc.) as being either simple, microcephalic, or Mongolian. -He describes those which represent somatic modifications due to -gross cerebral lesions as syphilitic, amaurotic, hydrocephalic, -porencephalic, sclerotic, paralytic and other toxic, inflammatory or -vascular forms. The somatic modifications due to defective cerebral -nutrition he divides into epilepsy, cretinism, nutritional forms and -isolation (sense deprivation). - -The classification of mental defects used by Fernald at the -Massachusetts School for the Feebleminded and based on mental ages -is as follows:—Idiot,—low grade, less than one year; middle grade, -one year or more; high grade, two years. Imbecile,—low grade, three -and four years; middle grade, five years; high grade, six and seven -years. Moron,—low grade, eight and nine years; middle grade, ten -years; high grade, eleven and twelve years. Fernald calls attention -to the fact that the diagnosis cannot be based on the mental age -alone. The intelligence quotient must be taken into consideration. -This is determined by dividing the mental by the physical age. It is a -comparison of the average intelligence of the child, using the normal -as a standard. The diagnosis cannot be definitely made until the age of -sixteen, or until the probable mental age at sixteen is determined. - -The following definitions are used by the American Association for -the Study of the Feebleminded:—"An idiot is a mentally defective -person having a mental age of not more than 35 months, or, if a child, -an intelligence quotient of less than 25. An imbecile is a mentally -defective person having a mental age between 36 months and 83 months -inclusive, or, if a child, an intelligence quotient between 25 and 49. -A moron is a mentally defective person having a mental age between -84 months and 144 months inclusive, or, if a child, an intelligence -quotient between 50 and 74." - -Tredgold expresses the opinion that "the insanity of the feebleminded -and high grade imbeciles does not, on the whole, differ from that -occurring in ordinary persons." In sixty-two cases under his -observation he found the following forms:—Mania, thirty-two; -melancholia, sixteen; alternating mania and melancholia, six; stupor, -one; delusional insanity, one; and juvenile general paresis, six. He -also speaks of epileptic insanity and terminal dementia in his cases. - -Kraepelin[348] describes certain characteristics as applying very -generally to the mental deficiency group which he prefers to speak -of as "Oligophrenia." Sense perception is often interfered with -by defective vision, opacities of the lens and cornea, errors of -refraction, optic atrophy or deafness. The apprehension of external -impressions may be prevented to a certain extent also by disturbances -of attention. Only the sharper and stronger stimuli reach the patients -as a rule and these impressions are retarded. Many occurrences escape -their notice entirely and their sense perceptions are poor and scanty -at best. Disturbances of attention are shown by the attitude, facial -expression, carriage and conduct, so that they have an appearance -of apathy and indifference when their real feelings are entirely -different. An increased effort cannot be produced by an exertion of the -will, nor can the fatigue which such attempts result in, be overcome. -Repeated tests of various kinds show a marked decrease in the power -of apprehension. In profound idiocy it is difficult to determine -whether any impression can be made on the sense organs or not. When the -patients react to a severe pin prick it is only after a considerable -delay, apprehension and attention being equally impaired. Schlesinger -found fifty-five per cent of his cases lacking in interest, thirty-five -per cent were distractible and ten per cent showed an increased -fatigability. An evidence of the lack of attention is the fact that the -weakminded as a rule are not susceptible to hypnotism. - -The apprehension of colors, form and dimensions is uncertain and -difficult. The patients learn to distinguish colors very late usually. -They can form no clear conception as to the outlines, surface or -contents of objects. They have considerable difficulty in putting -syllables and sentences together. They recognize the details but -not the significance of pictures. In the elaboration of impressions -they are unable to distinguish between the real and the accidental -or nonessential. This gives rise to a confusion of ideas. Changes in -size, color, shape, etc, always annoy them. Their lack of observation -and discrimination explains the absence of timidity in the presence -of strangers which characterizes normal children. There is also a -defective apprehension of auditory impressions and they are unable to -understand very familiar sounds. Ley showed that they were often unable -to identify letters they heard pronounced. There is a marked inability -to grasp the meaning of ordinary words. The sense of taste and smell -is comparatively much less impaired. Very defective children object at -once to quinine when it is placed on the tongue. Nevertheless, many do -not notice unpleasant odors or even the taste of excreta, etc.,—things -which are exceedingly offensive to normal individuals,—and are -entirely indifferent as to the quality of their food. Sensory -disturbances of the skin are not very marked. In a series of -esthesiometric tests, however, Ley obtained unsatisfactory "automatic" -responses in eighteen cases, meaningless answers in forty-eight, and -intelligent responses in eleven of 127 mental defectives examined. The -application of the sense of touch in recognizing articles is acquired -with difficulty. Pain sensations are somewhat diminished also and some -defectives are apparently insensible to blows, etc. That the sense of -position and location is not well developed is often shown by coarse, -awkward movements. The sense of weight and motion is lacking. Demoor -found that the feebleminded usually pointed out the larger article -as being the heavier even when lighter in weight. Claparede found -this characteristic present in one per cent of ninety-seven pupils -rejected as a result of mental tests, in eight per cent of the mildly -weakminded, and in sixty-five per cent of the markedly defective -cases. Memory is always involved. Superficial impressions are easily -lost. Johnson subjected seventy-two defective children to retention -tests. Seventy could correctly repeat only three numbers; sixty-six -only four; fifty-one only five; twenty-seven only six; fourteen only -seven, and four only eight. Ranchburg's tests showed them to be very -susceptible to suggestion. Some defectives, on the other hand, have a -peculiar faculty for remembering dates, numbers, performing feats of -arithmetic, etc. The memory defect is usually shown more especially -by the inability to take advantage of the experience of the past. The -patients learn with difficulty, read little and forget what they are -taught. The events of life leave few traces and make only a superficial -impression on them. The intellectual horizon for this reason is very -limited. Their thoughts are confined largely to the matter of clothing, -food, etc. - -The fundamental obstacle in the mental progress of the defectives is -the inadequate elaboration of general impressions and conceptions. -There is an absence of any understanding of the importance of time, -events, numbers, etc. They often have no idea whatever as to the -significance of money. Dates mean nothing usually and they are often -unable to determine the time of day. The train of thought as shown -by tests made by Buccola is delayed. Their poverty of thought is -shown by the fact that defective children can think of only about -one-fourth as many words during a given time as suggest themselves -to the normal child—a test suggested by Binet. Tests reported by -Sommer, Nathan, Binet and others show a marked delay in association -time and an impoverished mental capacity. They frequently repeat the -test word or give entirely meaningless replies. Associations do not -become fixed on repeated tests as they do with normal individuals -(Wreschner). It is not easy for them to repeat numbers, the months of -the year or days of the week backwards. They cannot supply omitted -words or syllables in sentences (Ebbinghaus test). It is hard for them -to assemble picture puzzles or pieces of cards. Revesz found that it -was more difficult for them to learn to divide than to subtract or -add. Multiplication he found to be most easily acquired. They did not -do well in tests requiring any reason or judgment. They are entirely -incapable of defining or explaining abstract conceptions of any kind. -They cannot explain the meaning of fables and have no appreciation of -irony. Nor can they correct the most obvious faults in test sentences. -They have no insight into their own condition and no grasp on either -past or present events. Their capacity for efficient occupation and -employment is much diminished. Their ability to acquire an education -is also limited. Of 286 cases examined in school Schlesinger found -only fifteen per cent to be industrious in their habits. Nine per cent -failed in writing, eighteen in reading and twenty-four per cent in -arithmetic tests. - -The emotional life is also much impoverished and unstable. There is -no sense of shame and no feeling of family pride or patriotism. There -is often a tendency to commit criminal acts. As a rule the mood is -indifferent and apathetic—in strange surroundings they are sometimes -timid and anxious. Some feel ashamed of their speech defects and -awkwardness. Others show a childish cheerfulness, or satisfaction -and self-confidence. There is a tendency to uncontrollable laughter, -attacks of anxiety, angry excitement, or childish despair with -hysterical manifestations which disappear quickly. Usually the patients -are inoffensive, manageable and well behaved, but easily susceptible to -bad influences. Often they are queer, whimsical, capricious, obstinate -and childish. Henneberg, who examined a large series of cases, -described 33.8 per cent as anxious, timid, sensitive and inclined to -weep; 15.7 per cent as apathetic, dreamy, sluggish and seclusive; 12.6 -per cent as quiet, serious, good-natured, sociable and pleasant; 18.7 -as active, cheerful, shallow, playful and talkative; and nineteen per -cent as rude, malicious, obstinate, irritable and bad-tempered. The -sexual life is sometimes undeveloped or may show actual perversions. -Bonhöffer found six idiots and fifty-three feebleminded persons in -an examination of 190 prostitutes. The volitional expressions of the -defective are very largely impulsive. They act without reflection or -regard to consequences and are easily induced to do improper acts. -The inhibition of will is shown by the defective control of ordinary -movements in responding to commands. They are always slow in learning -to walk. The childish inability to perform finer and more precise -movements does not disappear later as it does in the course of normal -development. This is shown in their gait, awkward movements, etc. -Kraepelin interprets the tendency to bedwetting as an evidence of -volitional disturbance, also the stereotyped, rhythmical movements of -the idiot. Laser found that forty per cent of his cases had the habit -of biting the finger nails. - -Dependent upon the inhibition of volitional impulses, two clinical -groups of the feebleminded have been described by Kraepelin,—the -excitable and the apathetic or dull. The excited forms are much -more common. Schlesinger, however, found thirty-one per cent of his -cases of the apathetic variety; twenty-nine per cent were excitable; -twenty-eight per cent had simple mental defects, and the remainder -showed antisocial tendencies. In the apathetic or dull form there is -a marked disturbance of the attention; the patient takes no interest -in his surroundings, appears sluggish, awkward, emotionally dull, and -devoid of any voluntary impulse, often doing only what he is urged -to do. They are usually good-natured, contented, and do simple work -under direction, in a slow and mechanical way. The lighter grades -are of a dull, weak-willed, readily influenced type. They are timid, -unconcerned and agreeable. The excitable variety, on the other hand, -show a purposeless, mercurial variability. Their attention is easily -distracted from one thing to another. They cannot sit still, are -restless and constantly on the go. Occasionally they are violent. - -The defective control of motor impulses by the will is also shown in -defectives by the disturbance of speech and writing. Crailsheimer found -speech disturbances in 36.3 per cent of his cases, Schlesinger in -thirty per cent, and Leubuscher in fifty per cent. They can often hear -although mute, sometimes recovering their speech during an attack of -excitement. Ley reported stammering in twelve per cent of his cases and -stuttering in thirteen per cent. Agrammatism and akataphasia sometimes -occur. Word-blindness is also referred to as a symptom and various -disturbances of reading and writing have been observed. - -According to Kraepelin, the important developmental landmarks in -the life of the young are the acquisition of speech (one year), the -beginning of the school life (six years), the appearance (fourteen -years) and the completion (eighteen years) of sexual development. The -first and second periods represent the relative levels of low and high -grade idiocy, the third imbecility and the fourth feeblemindedness. -This classification is somewhat similar to that of Weygandt. The -education ordinarily acquired by the higher grade of the feebleminded -is somewhat limited. They may even excel in certain occasional lines -of work, for example, in music, art, etc. They are usually poor in -mathematics and lack interest and application as a rule. Difficult -apprehension and mental fatigability are to be expected. They have -to go over things repeatedly, as their memory is not good. Their -education is often ample in some directions and very lacking in others. -Their judgment is onesided, their viewpoint narrow and their worldly -knowledge childish. What they acquire at school is soon forgotten. -They take no interest in religion, politics or current events of -importance, and very impractical ideas are expressed on all questions. -The emotional manifestations vary. Some are agreeable, cheerful, -tractable; others timid, tenderhearted, sensitive, slightly emotional -or anxious. They are more likely to be obstinate, stubborn, unruly, -rude, irritable, unsociable and violent-tempered. Some have periods -of active excitement and become threatening, abusive and violent. -Occasionally suicidal attempts are made, although they are usually not -genuine. Some are addicted to sexual excesses, lying or swindling. -Sexual perversions also occur in some cases. They are usually incapable -of any continuous occupation and drift from one thing to another. As -a rule they have little conception of the value of money and spend -it recklessly. They are very susceptible to alcoholism and often -commit petty crimes. Occasionally hysterical manifestations—syncopes, -seizures, etc.—appear. Clouded and confused states have been -observed. Frequently impulsive tendencies are noted. In some instances -psychopathic traits are very striking. Excitable, unstable, impulsive, -quarrelsome and antisocial types appear as well as liars and swindlers. -Periodical excitements and depressions suggest manic-depressive forms. - -Considerable confusion has been occasioned by the relation thought -by some to exist between mental deficiency and dementia praecox. -Kraepelin[349] has spoken of an engrafted hebephrenia, as shown by the -following quotation from his eighth edition:—"I made the suggestion -a long time ago that certain, not very frequent, forms of idiocy with -well developed mannerisms and stereotypies were an early expression -of dementia praecox." He is of the opinion that "the affected manners -of certain idiots, as well as the associated stereotypies of attitude -and movement in addition to the negativistic impulses and the -permanent obstinate inaccessibility to all attempts at approach, show -no relation whatever to ordinary childish peculiarities and belong -on the contrary to the well-known picture of dementia praecox." He -interprets the "demenza precocissima" of Sante de Sanctis and the -"dementia infantilis" of Heller as belonging to dementia praecox rather -than the mental deficiency group. He further makes the suggestion -that "weakmindedness existing from youth without focal symptoms, and -later leading to deterioration, is as a rule to be looked upon as -pfropfhebephrenia, if epilepsy and cerebral syphilis can be excluded, -the former by the absence of seizures, the latter by the results of -the Wassermann reaction." Engrafted hebephrenia or "pfropfhebephrenia" -has been studied by various observers. After an analysis of ten cases -Wasner reached the conclusion that feeblemindedness predisposes to -dementia praecox. Weygandt and various other writers are not in accord -with Kraepelin on this subject. It is, however, generally conceded that -the occurrence of manic-depressive and other affective psychoses in -mental defectives is not at all infrequent. - -As special types Kraepelin described microcephalic varieties, the -tuberous sclerosis of Hartdegen and Bourneville (1880), vascular and -other cerebral defects, infantilismus, dysadenoid and other endocrine -conditions, Mongolian idiocy, hydrocephalus, encephalitic forms, -etc. Alzheimer, Hammarberg, and Bourneville have made pathological -classifications of the mental deficiencies. - -Psychoses which render the commitment of mental defectives to hospitals -for mental diseases necessary are comparatively infrequent, as is -shown by statistics. In the words of the statistical manual, "the most -common mental disturbances are episodes of excitement or irritability, -depressions, paranoid trends, hallucinatory attacks, etc." Cases -diagnosed as showing manic-depressive psychoses or dementia praecox -are not shown in the mental defective group. Three and forty-eight -hundredths per cent of the admissions to the Massachusetts hospitals -during 1919 were diagnosed as psychoses with mental deficiency. During -a period of eight years the admission rate to the New York hospitals -amounted to 2.8 per cent. The admissions to twenty-one institutions in -other states constituted 4.33 per cent of the whole number reported. -In 70,987 admissions to forty-eight hospitals in sixteen states the -psychoses with mental deficiency amounted to 3.22 per cent of all first -admissions. - - - - -INDEX - - - Abbot, E. Stanley, 248 - - Abraham, Karl, 419 - - Abrahamson, Isador, 341 - - Acute chorea, 338 - - Acute hemorrhagic polioencephalitis superior, 356, 357 - - Administration and legislation, 50 - - Adrenal diseases, 214 - - Adrenal stigmata, 204 - - Adrenals, lesions of, 214 - - Agnew, D. Hayes, 34 - - Albany Hospital, 107 - - Albrecht, 436 - - Alcoholic psychoses, 344 - acute hallucinosis, 356 - acute intoxication, 348 - alcoholic deterioration, 350, 351 - alcoholic paralysis, 357 - chronic hallucinosis, 357 - chronic intoxication, 349 - delirium tremens, 352 - delimitation, 358 - history, 344 - Korsakow's psychosis, 354 - pathological intoxication, 349 - pathology, 356 - statistics, 360, 361 - - Aliens in hospitals, 160 - - Alzheimer, A., 225, 286, 302, 303, 304, 325, 354, 356, 485, 486, 536 - - Alzheimer's disease, 274 - - Amentia, 401 - - American Institute of Criminal Law, 176 - - American Psychiatric Association, 173, 231, 234, 245, 247, 263, 276, 291, - 307, 320, 325, 331, 358, 390, 405, 421, 438, 453, 473, 487, 501, 521 - - Anderson, Victor V., 178 - - Anxiety neuroses, 501 - - Appropriations, hospital, 26 - - Aretaeus, 234, 409 - - Arnold, 142 - - Arsenic psychoses, 373 - - Arteriosclerosis, cerebral, 280 - apoplectiform attacks, 288 - delimitation of psychoses, 291 - depressions, 287 - deterioration, 287, 288 - epileptiform attacks, 287, 288 - excitements, 287, 288 - pathology, 281, 282, 285, 286 - statistics, 292 - - Aschaffenburg, G., 398 - - Aurelianus, 235, 409 - - - Babcock, J. W., 379 - - Babinski, J., 494 - - Bailey, Pearce, 188 - - Baillarger, J., 411 - - Ball, Jau Don, 32 - - Ballet, G., 197 - - Barker, Lewellys F., 282, 309, 310, 364, 383 - - Barrett, Albert M., 115, 248 - - Baths, continuous, 98 - - Bayle, A. L., 221, 293 - - Beers, Clifford W., 121, 122, 123, 124, 127, 129 - - Bellevue Hospital, 106 - - Bianchi, L., 384 - - Billigheimer, E., 211 - - Binswanger, Otto, 191 - - Birnbaum, K., 197 - - Bleuler, E., 130, 145, 275, 436, 444, 445, 446, 447, 471 - - Bloomingdale Hospital, 38 - - Blumer, G. Alder, 46, 124 - - Blumgarten, A. S., 203, 205 - - Boards of Charities and Corrections, 52 - - Boards of control, 52 - - Boards of managers, 51 - - Boards of trustees, 51 - - Bonhöffer, K., 188, 347, 352, 353 - - Boston Police Act, 64 - - Boston State Hospital, 43 - - Boveri, Piero, 341 - - Brachet, J. L., 490 - - Brain or nervous diseases, psychoses with, 332 - acute chorea, 338 - cerebral embolism, 332 - cerebral hemorrhage, 332 - cerebral thrombosis, 332 - encephalitis lethargica, 339 - meningitis, tubercular, 336 - multiple sclerosis, 336 - paralysis agitans, 334 - statistics, 343 - tabes dorsalis, 337 - - Brain lesions, symptoms due to, 282, 283 - - Brain tumors, 326 - frequency, 327 - psychoses, 328, 329, 330, 331 - statistics, of psychoses, 331 - symptoms, 327 - - Brattleboro Retreat, 43 - - Breuer, 494, 495 - - Briggs, L. Vernon, 248 - - Briquet, 490 - - British Association, 240 - - Bromide psychoses, 371 - - Buckley, A. C., 422, 453 - - Bucknill, J. C., 234, 393, 394 - - Bumke, 436 - - Burnham, Wm. H., 131 - - Burr, C. W., 338 - - Buzzard, E. F., 340 - - - Cabot, Richard C., 20 - - Calmeil, J. L., 221, 293 - - Camp, Carl D., 334 - - Campbell, C. Macfie, 115, 132, 248, 497 - - Casamajor, Louis, 371, 373 - - Case rate, general diseases, 18 - - Causes of death, 17, 18 - - Celsus, 139, 234, 253 - - Central neuritis, 437 - - Cerebral embolism, 332 - - Cerebral hemorrhage, 332 - - Cerebral syphilis, 308 - delimitation of psychoses, 320 - gummatous, 310 - meningeal, 309 - pathology, 309 - salvarsan therapy, 319 - statistics, 321, 322 - symptomatology, 311 - treponema in inactive cases, 320 - vascular, 310 - - Cerebral thrombosis, 332 - - Cerebropathica psychica toxaemica, 404 - - Chloral hydrate, 370 - - Chorea, acute, 338 - - Civil war psychoses, 186 - - Clark, L. Pierce, 478, 479, 480 - - Classification of mental diseases, 234 - American Psychiatric Association, 248, 249, 250 - Aretaeus, 234 - Aurelianus, 235 - British Association, 240 - Celsus, 234 - Cullen, 235 - Esquirol, 236 - Flemming, 236, 237, 238 - Galen, 235 - Griesinger, 239 - Hippocrates, 234 - Kraepelin, 242 - Krafft-Ebing, 240 - Linnaeus, 235 - Maudsley, 239 - Pinel, 236 - Plater, 235 - Pritchard, 236, 239 - Régis, 240 - Roman, 235 - Sauvages, 235 - Vogel, 235 - - Clouston, T. S., 7, 8, 140, 144, 266, 304, 346, 508 - - Cobb, Stanley, 133 - - Cocaine psychoses, 367 - - Colajanni, 178 - - Collapse delirium, 400 - - Columbia State Hospital, 41 - - Columbus State Hospital, 43 - - Commitment, methods of, 58 - - Communicable diseases, 23 - - Compression of brain, 253 - - Concord State Hospital, 43 - - Concussion of brain, 253 - - Continuous baths, 98 - - Copp, Owen, 67, 81, 131 - - Cramer, 463 - - Criminal responsibility, 169 - - Criminal responsibility, laws relating to, 172 - - Criminals, psychoses in, 180, 181, 182 - - Crowbar case, 254 - - Cullen, William, 235, 490 - - Curtin, Roland G., 35 - - Cushing, Harvey, 326, 327 - - - DaCosta, J. C., 253 - - Davenport, Chas. B., 146 - - Davis, Thomas K., 210 - - Death rate: - diseases of the nervous system, 18 - mental diseases, 19 - registration area, 17 - state hospitals, 28 - - Definition of insanity, legal, 172 - - DeFursac, J. R., 197 - - Delirium: - acute, 400 - collapse, 400 - exhaustion, 403 - febrile, 396 - infection, 395 - initial, 398 - tremens, 352 - - Dementia praecox, 440 - delimitation, 453, 454, 455 - hebephrenia, 441 - history, 440 - katatonia, 441 - Kraepelin's views, 450, 451, 452, 453 - mental mechanisms, 442, 443 - schizophrenia, 444, 445 - statistics, 455, 456, 457 - - Diagnosis, errors in, 20 - - Dickens, Charles, 43 - - Diefendorf, A. R., 229, 324, 422, 429, 455, 492, 506 - - Diem, 149 - - Diseases, communicable, 23 - - Diseases, general case rate, 18 - - Diseases, general, cause of death, 17 - - Diseases, mental, social and economic importance of, 15 - - Dix, Dorothea, 47, 48, 123, 126 - - Dreyfus, G, L., 429 - - Drugs and other exogenous poisons, 363 - arsenic, 373 - bromides, 371 - chloral hydrate, 370 - cocaine, 367 - gases, 374 - lead, 372 - mercury, 374 - morphine, 363, 364 - silver, 374 - statistics, 375 - - Drusen, senile, 273 - - Dublin, Louis I., 21 - - Dunlap, Chas. B., 309, 337 - - - Earle, Pliny, 106 - - Eastern State Hospital, Ky., 40 - - Eastern State Hospital, Va., 36 - - Economic loss on account of mental diseases, 28 - - Economo, C. von, 339 - - Eder, Montague D., 196 - - Edsall, David L., 372, 374 - - Embolism, cerebral, 332 - - Emerson, H., 210 - - Encephalitis lethargica, 339 - - Endocrinology and psychiatry, 202 - - Epilepsy, 475 - delimitation of psychoses, 487 - epileptic delirium, 483 - epileptic deterioration, 485 - epileptic dream states, 482 - epileptic ill-humor, 481 - etiology, 478, 479, 480 - pathology of, 485 - statistics, 488 - - Epileptic personality, 478 - - Epileptics, institutions for, 29 - - Erlenmeyer, A., 365, 367 - - Errors in diagnosis, 20 - - Esquirol, J. E. D. 142, 236, 293, 524 - - Etiology of mental diseases, 138, 154 - alcoholism, 152 - arteriosclerosis, 152 - brain tumor, 152 - cerebral syphilis, 152 - epilepsy, 152 - heredity, 145 - other factors, 153 - pellagra, 152 - psychic traumata, 152 - senility, 152 - traumatism, 152 - - Evolution of the modern hospital, 34 - - Exhaustion delirium, 403 - - Expenditures, hospital, 26 - - - Falret, J., 411 - - Falta, Wm., 203, 206, 207, 208 - - Farrar, Clarence B., 122, 189 - - Febrile delirium, 396 - - Fernald, Walter E., 527 - - Ferri, E., 177 - - Feuchertsleben, E. von, 141, 394, 462, 489 - - Flemming, C. F., 236, 237, 238, 346, 410, 461 - - Focal symptoms due to brain lesions, 282, 283 - - Foreign born in hospitals, 160 - - Fracastoro, 293 - - Franz, S. I., 372 - - Friedreich, J. B., 394, 395 - - Freud, S., 130, 145, 225, 226, 448, 472, 473, 494, 495, 496, 497, 498, - 499, 500, 501 - - Furbush, Edith M., 27, 29, 248 - - - Galen, 235, 253, 409 - - Garofalo, 178 - - Garretson, W. V. P., 206 - - Gases, 374 - - General diseases: - case rate, 18 - cause of death, 17 - - General paralysis, 293 - delimitation, 307 - etiology, 294 - history, 293 - juvenile form, 304 - pathology, 303 - physical signs, 301 - statistics, 306, 307 - types, 298 - - Georgia State Sanitarium, 51 - - Gesell, Arnold, 131 - - Goddard, H. H., 525 - - Goldberger, J., 381, 382 - - Gonadal stigmata, 205 - - Grasset, Joseph, 509 - - Gregor, A., 386 - - Griesinger, W., 105, 142, 239, 260, 383, 411, 462 - - - Hamilton, A. S., 324 - - Handcock, Thos., 39 - - Harlow, John M., 254 - - Harrisburg State Hospital, 48 - - Hartford Retreat, 40 - - Hartung, M. U., 200 - - Haslam, J., 293, 344 - - Hecker, E., 222, 241, 440, 441 - - Heinroth, J., 104, 239, 394, 395, 462 - - Hemorrhage, cerebral, 332 - - Henderson, D. K., 336 - - Heredity, Mendelian, 145 - - Heredity in mental diseases, 145, 150 - - Heubner, 310 - - Hippocrates, 138, 253, 344, 392, 409, 461, 475 - - History-taking, 85 - - Hitzig, 105 - - Hoch, Aug., 115, 198, 234, 248, 372, 422, 445, 446, 448 - - Holmes, Oliver Wendell, 230 - - Hospitals: - Albany, 107 - Bellevue, 106 - Bloomingdale, 38 - Boston Psychopathic, 108 - Boston State, 43 - Brattleboro Retreat, 43 - Columbia State, 41 - Columbus State, 43 - Concord State, 43 - Eastern State, Ky., 40 - Eastern State, Va., 36 - Georgia State Sanitarium, 51 - Harrisburg State, 48 - Hartford Retreat, 40 - Maryland, 37 - McLean, 39 - New York, 38 - Pennsylvania, 35 - Philadelphia, 34 - Sheppard and Enoch Pratt, 48 - Spring Grove State, 38 - St. Elizabeths, 48 - Trenton State, 47 - Utica State, 46 - Worcester State, 42 - - Hospital social service, 113 - - Hospital treatment, 84 - - Hübner, 435 - - Hunt, J. Ramsey, 284 - - Huntington, Geo., 323 - - Huntington's chorea, 323 - classification, 325 - mental symptoms, 324, 325 - statistics, 326 - - Hurst, A. F., 200 - - Huss, Magnus, 345 - - Hydrotherapy, 97 - - Hysteria, 493 - - - Idiocy, 527, 528, 529 - - Imbecility, 527 - - Immigration and mental diseases, 155 - - Immigration laws, 164 - - Incidence of mental diseases, 25 - - Infantilismus, 211 - - Infection delirium, 395 - - Insanity, legal definition of, 172 - - Institutions for mental defectives, 29 - - Institutions for mental diseases, 25 - - Involution melancholia, 427 - (see Melancholia) - - Ireland, M. W., 200 - - - Janet, Pierre, 222, 493, 494, 500 - - Jelliffe, S. E., 235, 236, 293, 461 - - Jung, C. G., 145, 225, 448, 484, 497 - - - Kahlbaum, K. 222, 412, 440, 441 - - Kaplan, D. M., 206 - - Karpas, M. J., 347 - - Kehrer, F., 434, 435, 436 - - Kempf, E. J. 245 - - Kirby, Geo. H., 84, 115, 248, 342, 430 - - Kirkbride, Thos., 71 - - Kline, Geo. M., 56, 67 - - Knapp, P. C., 329 - - Knauer, A., 211, 405 - - Koch, 504, 505 - - Koch, M. L., 380 - - Koller, 149 - - Köppen, M., 256, 258 - - Koren, John, 51 - - Korsakow's psychosis, 354, 357, 358 - - Kraepelin, E., 106, 149, 151, 211, 214, 224, 229, 242, 260, 267, 274, - 286, 288, 290, 298, 300, 316, 324, 329, 334, 337, 348, 353, 365, 369, - 395, 398, 415, 419, 431, 434, 440, 450, 453, 467, 470, 481, 484, 492, - 511, 518, 520, 521, 528, 532 - - Krafft-Ebing, R. von, 240, 296, 335, 346, 364, 368, 412, 463, 464, 465, - 491 - - - Lambert, C. I., 281, 282 - - Laws, immigration, 164 - - Laws, Massachusetts, 63, 64, 65, 66 - - Laws, New York, 61 - - Laws relating to criminal responsibility, 172 - - Laws relating to mental diseases, 57, 61 - - Lead psychoses, 372 - - Legal definition of insanity, 172 - - Legislation and administration, 50 - - Lesions of the adrenals, 214 - - Lhermitte, J., 284 - - Life insurance statistics, 21 - - Linnaeus, 235 - - Local boards of control, 52 - - Locomotor ataxia, 337 - - Lombroso, C., 177, 379, 508 - - Louis, Pierre, 230 - - Lust, F., 199 - - - MacCurdy, J. T., 199 - - Magnan, V., 466, 506 - - Manic-depressive psychoses, 409 - delimitation, 421 - depressed type, 417 - history, 409 - manic type, 416 - mixed type, 417 - psychological mechanisms, 419 - statistics, 422, 423, 424, 425, 426 - - Mannheim, Paul, 363 - - Maryland Hospital, 37 - - Massachusetts legislation, 64, 65, 66 - - Massachusetts temporary care laws, 63 - - Maudsley, H., 239, 476 - - McCarthy, D. J., 323, 335, 338 - - McLean Hospital, 39 - - McNaughton case, 171 - - Melancholia, involution, 427 - delimitation, 438 - history, 427 - statistics, 439 - - Mendel, E., 463 - - Mendel, G., 145 - - Mendelian heredity, 145 - - Meningitis, tubercular, 336 - - Mental cases in jails, 63 - - Mental deficiency, 524 - criminals, 179 - etiology, 525 - history, 524 - institutions for, 29 - pfropfhebephrenia, 535 - statistics, 536 - types, 526, 527 - - Mental diseases: - appropriations for, 26 - classification, 234 - criminal responsibility, 169, 172 - death rate, 19 - economic loss, 28 - expenditures for, 26 - heredity in, 145, 150 - history-taking, 85 - hospital treatment, 84 - incidence of, 25 - institutional care of, 25 - laws relating to, 57, 61 - mental examination, 93 - military problems, 188 - physical examination, 88 - social and economic importance, 15 - state care of, 79 - - Mental hygiene movement, the, 121 - Canadian committee, 128 - French society, 129 - history, 122, 123, 124, 125 - National Committee, 124 - objects and purposes, 127 - state societies, 126 - - Mercury psychoses, 374 - - Methods of commitment, 67 - - Methods of control, 67 - - Metropolitan Life Insurance statistics, 21 - - Meyer, Adolf, 84, 106, 115, 116, 122, 130, 251, 346, 427, 452, 463, 471, - 504, 505 - - Meyer, E., 198 - - Meynert, Th., 401 - - Miliary plaques, 273 - - Military problems, 188 - - Misaurus, 393 - - Mitchell, S. Weir, 80 - - Möbius, 493 - - Modern hospital, evolution of the, 34 - - Modern progress of psychiatry, 217 - - Mongeri, L., 384 - - Morel, Jules, 177, 504 - - Morgagni, G. B., 142, 410 - - Morons, 526 - - Morphine psychoses, 364, 365 - - Mortality statistics, 16 - - Mortality statistics, wage earners, 22 - - Mott, Frederick W., 195, 196, 215, 302 - - Multiple sclerosis, 336 - - Murray, J. H., 489 - - - National Committee for Mental Hygiene, 54, 124 - - Neubürger, 210 - - Neurasthenia, 498 - - Neuritis, central, 437 - - Neuroses, 489 - - New York Hospital, 38 - - New York laws, 61 - - Niles, G. M., 378 - - Nissl, F., 225, 269, 302, 303, 325, 354, 356, 370, 392, 398, 486 - - Nolan, Wm. J., 180, 459 - - Nonne, Max, 190 - - Norbury, Frank P., 67 - - Nordau, Max, 178, 508 - - Nothnagel's syndrome, 283 - - Nurses, training schools for, 74 - - - Observation wards, 106 - - Occupational therapy, 100 - - Occupations, 32 - - O'Malley, Mary, 372, 374, 375 - - Opium, use of, 376 - - Oppenheim, H., 190, 208, 308 - - Orton, Samuel T., 248 - - Osler, Wm., 280 - - Out-patient clinics, 77, 78 - - - Paralysis agitans, 334 - - Paranoia and paranoid conditions, 461 - delimitation, 473 - history, 461 - statistics, 474 - - Parant, 335 - - Paraphrenia, 468, 469 - - Parathyroid stigmata, 204 - - Pathologists, 75 - - Paton, S., 228 364, 422 - - Pavilion F., Albany Hospital, 107 - - Pellagra, 378 - classification, 390 - etiology, 378, 380 - history, 378 - psychoses, 387, 388, 389 - statistics, 390 - symptoms, 383 - - Pennsylvania Hospital, 35 - - Pfropfhebephrenia, 535 - - Philadelphia Hospital, 34 - - Phipps Clinic, 115 - - Physical examination, 88 - - Pilgrim, Chas. W., 67 - - Pineal stigmata, 205 - - Pinel, 142, 219, 220, 223, 236 - - Pituitary stigmata, 204 - - Plater, Felix, 235 - - Plato, 138 - - Plocquet, 236 - - Pollock, Horatio M., 27, 29, 248, 360, 361, 456, 458, 459 - - Portal, 222 - - Post-infectious psychoses, 402, 403 - - Post-rheumatic psychoses, 404 - - Pritchard, J. C., 236, 239, 410, 462, 506 - - Procopiu, G., 385 - - Psychasthenia, 500 - - Psychiatric Institute, N. Y., 106 - - Psychiatry, modern progress of, 217 - - Psychiatry of the war, 185 - - Psychoneuroses and neuroses, 489 - classification, 501 - history, 489 - hysteria, 493 - neurasthenia, 498 - psychasthenia, 500 - statistics, 503 - - Psychopathic Hospital, Boston, 108 - - Psychopathic Hospital, development of the, 104 - - Psychopathic Hospital, University of Michigan, 107 - - Psychopathic hospitals, 108, 110, 111, 112, 113, 114, 115 - - Psychopathic personality, 504 - classification, 521, 522 - statistics, 522 - the antisocial, 519 - the eccentric, 516 - the excitable, 511 - the impulsive, 515 - the quarrelsome, 521 - the unstable, 513 - - Psychoses: - alcoholic, 344 - arteriosclerotic, 280 - dementia praecox, 440 - due to drugs and other exogenous poisons, 363 - epileptic, 475 - general paralysis, 293 - involution melancholia, 427 - manic-depressive, 409 - of criminals, 181 - of different races, 163 - of recruits, 188 - of the civil war, 186 - of the Russo-Japanese war, 187 - paranoia and paranoid conditions, 461 - psychoneuroses and neuroses, 489 - senile, 266 - traumatic, 253 - with brain tumor, 326 - with cerebral syphilis, 308 - with Huntington's chorea, 323 - with mental deficiency, 524 - with other brain and nervous diseases, 332 - with other somatic diseases, 392 - with pellagra, 378 - with psychopathic personality, 504 - - - Quincke, 295 - - - Races of patients, 162 - - Races, psychoses of, 163 - - Raeder, O. J., 209, 319 - - Ray, Isaac, 169, 170 - - Rayner, H., 373 - - Régis, E., 240, 266, 296, 384, 506, 507 - - Rehm, 435 - - Richards, R. L., 187 - - Roberts, S. R., 382 - - Roman classification, 235 - - Rosanoff, A. J., 147, 148 - - Rush, Benjamin, 141, 218, 219, 220 - - Russell, Wm. L., 127 - - - Sachs, 337 - - Salmon, Thos. W., 54, 124, 156, 157, 160, 165, 192, 193, 194, 195, 201 - - Salvarsan therapy, 319 - - Sandy, Wm. A., 388, 389 - - Sankey, W. H., 414 - - Sauvages, 235 - - Savage, G. H., 240, 241 - - Schaudinn, 218 - - Schizophrenia, 444, 445, 446, 447 - - Schläger, 260 - - Scholz, 105 - - Schüle, H., 415, 442, 480 - - Schuster, 329 - - Seelert, 436 - - Senile drusen, 273 - - Senile psychoses, 266 - Alzheimer's disease, 274 - delimitation, 276 - delirious and confused states, 272 - depressed and agitated types, 272 - errors in diagnosis, 279 - - Senile psychoses, paranoid forms, 272 - pathology, 273, 274 - presbyophrenia, 272 - presenile conditions, 267, 268, 269 - senile deterioration, 271 - statistics, 275, 277, 278 - - Shadwell, A., 360 - - Shell shock, 189 - - Sheppard and Enoch Pratt Hospital, 48 - - Sibbald, J., 105 - - Silver psychoses, 374 - - Simon, T. W., 229 - - Singer, H. Douglas, 387 - - Sinkler, Wharton, 338 - - Smith, Frank R., 105 - - Social and economic importance of mental diseases, 15 - - Social service, hospital, 113 - - Somatic diseases with psychoses, 392 - acute delirium, 400 - amentia, 401 - classification, 405 - collapse delirium, 400 - febrile delirium, 396 - history, 392 - infection delirium, 395 - infectious exhaustions, 403 - initial delirium, 398 - post-infectious psychoses, 402, 403 - post-rheumatic psychoses, 404 - statistics, 407 - types, 395 - - Southard, E. E., 115, 117, 134, 245, 246, 279 - - Specht, 435 - - Spratling, Wm. P., 477 - - Spring Grove State Hospital, 38 - - St. Elizabeths Hospital, 48 - - State care of mental diseases, 79 - - State hospitals: - construction, 70 - death rate, 28 - location, 69 - management of, 73 - number of, 49 - organization and functions, 68 - reception buildings, 72 - statistics, 27, 76 - - Statistics: - case rate, general diseases, 17 - communicable diseases, 23 - death rate and psychoses, 19 - death rate, mental diseases, 19 - epileptics, 29 - errors in diagnosis, 20 - hospitals for mental diseases, 25 - incidence of mental diseases, 25 - mental defectives, 29 - mortality, 16 - psychopathic hospitals, 108, 110, 111, 112, 113, 114, 115 - psychoses: - alcoholic, 360 - dementia praecox, 455 - epileptic, 488 - general paralysis, 306 - manic-depressive, 422 - melancholia, involution, 439 - paranoia or paranoid conditions, 474 - psychoneuroses and neuroses, 503 - senile, 275 - traumatic, 264 - with brain or nervous diseases, 343 - with brain tumor, 331 - with cerebral arteriosclerosis, 292 - with cerebral syphilis, 321 - with drugs or other exogenous poisons, 375 - with Huntington's chorea, 326 - with mental deficiency, 536 - with pellagra, 390 - with psychopathic personality, 522 - with somatic diseases, 407 - wage earners, 22 - - Stigmata: - adrenal, 204 - gonadal, 205 - parathyroid, 204 - pineal, 205 - pituitary, 204 - thymus, 205 - thyroid, 203 - - Stöcker, Wm., 347 - - Stransky, 435, 443 - - Straus, S. G., 210 - - Striatum syndrome, 284, 285 - - Sutton, Thos., 352 - - Sydenham, 409 - - Symptoms due to brain lesions, 282, 283 - - Syphilis, cerebral, 308 - - - Tabes, 337 - - Tanzi, 385 - - Temporary care laws, 63 - - Thalmic syndrome, 284 - - Thomas, Henry M., 332, 333 - - Thymus stigmata, 205 - - Thymus subinvolution, 215 - - Thyroid stigmata, 203 - - Thrombosis, cerebral, 332 - - Timme, Walter, 215, 216 - - Training schools for nurses, 74 - - Traumatic psychoses, 253 - compression, 253, 260 - concussion, 253, 260 - delimitation, 263 - Friedmann's complex, 255 - mental enfeeblement, 262 - Meyer's classification, 257 - statistics, 264, 265 - traumatic constitution, 254 - traumatic neuroses, 256 - - Tredgold, A. F., 525 - - Trenton State Hospital, 47 - - Treponema pallidum, 295 - - Tubercular meningitis, 336 - - Tuke, D. Hack, 138, 171, 234, 235, 344, 409, 411, 475 - - Turner, 437 - - Turro, R., 211 - - - Ullman, A. E., 229 - - Utica State Hospital, 46 - - - Verrücktheit, 467 - - Voegtlin, Karl, 380 - - Vogel, 235 - - Vogt, Cecile and Oskar, 284 - - Voluntary patients, 62 - - - Wage earners, mortality statistics, 20 - - Wahnsinn, 467 - - War psychoses, 185 - - Warthin, Alfred S., 320 - - Wassermann reaction, 295 - - Waters, C. O., 323 - - Weber-Gubler syndrome, 283 - - Weber, Hermann, 400 - - Wernicke, C., 224, 356, 444 - - Westphal, A., 316 - - Weygandt, Wm., 187 - - White, Wm. A., 130, 148, 227, 297, 339, 364, 420, 431, 448 - - Widal, 295 - - Williams, Frankwood E., 67, 248 - - Willis, Thos., 140, 410 - - Wilson, J. C., 371 - - Wilson, S. A. K., 284 - - Wilson's syndrome, 284 - - Wolfsohn, Julian M., 191 - - Worcester, Dean A., 189 - - Worcester State Hospital, 42 - - Wright, R. B., 97 - - - Ziehen, Th., 240, 266, 415, 506 - - -FOOTNOTES: - -[1] Cabot, Richard C.: Diagnostic Pitfalls Identified During a Study of -3000 Autopsies. Journal of the American Medical Association. December -28, 1912. - -[2] Dublin, Louis I.: Mortality Statistics of Insured Wage Earners and -Their Families. 1919. - -[3] Statistical Directory of State Institutions, Department of -Commerce, Bureau of the Census, 1919. - -[4] Pollock, Horatio M., and Furbush, Edith M.: Patients with Mental -Disease, Mental Defects, etc., in Institutions of the United States. -Mental Hygiene, January, 1921. - -[5] Ibid. - -[6] Pollock, Horatio M., and Furbush, Edith M.: Patients with Mental -Disease, Mental Defects, etc., in Institutions of the United States. -Mental Hygiene, January, 1921. - -[7] Ball, Jau Don: The Correlation of Neurology, Psychiatry, Psychology -and General Medicine as Scientific Aids to Industrial Efficiency. The -American Journal of Insanity, April, 1919. - -[8] Nineteenth Annual Report of the State Commission in Lunacy, N. Y., -1908. - -[9] Curtin, Roland G.: The Philadelphia General Hospital. Philadelphia -General Hospital Reports Vol. VIII, 1910. - -[10] The Institutional Care of the Insane in the United States and -Canada, Vol. III, 1916. - -[11] Ibid. - -[12] Ibid. - -[13] Friends' Asylum for the Insane, Frankford, Pa. Annual Report, 1853. - -[14] The Institutional Care of the Insane in the United States and -Canada, Vol. II, 1916. - -[15] Ibid. - -[16] The Institutional Care of the Insane in the United States and -Canada, Vol. II, 1916. - -[17] Reports and other documents relating to the State Hospital at -Worcester, Mass. Published by order of the Senate, Boston, 1837. - -[18] Reports and other documents relating to the state Hospital at -Worcester, Mass. 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Vol. 3, 1913. - -[289] Kehrer, F.: Die Psychosen des Um- und Rückbildungsalters. -Zentralblatt für die gesamte Neurologie und Psychiatrie, April 1, 1921. - -[290] Kehrer, F.: Die Psychosen des Um- und Rückbildungsalters. -Zentralblatt für die gesamte Neurologie und Psychiatrie, April 1, 1921. - -[291] Kehrer, F.: Die Psychosen des Um- und Rückbildungsalters. -Zentralblatt für die gesamte Neurologie und Psychiatrie, April 1, 1921. - -[292] Meyer, Adolf: Insanity: General Pathology. Reference Handbook of -the Medical Sciences. 1909. - -[293] Meyer, Adolf: Insanity: General Pathology. Reference Handbook of -the Medical Sciences. 1909. - -[294] Kraepelin, E.: Psychiatrie. Eighth edition, Vol. 3, 1913. - -[295] Bleuler, E.: Lehrbuch der Psychiatrie. Second edition, 1918. - -[296] Ibid. - -[297] Hoch, August: Review of Bleuler's "Schizophrenia." New York State -Hospitals Bulletin, August 15, 1912. - -[298] Bleuler, E.: Lehrbuch der Psychiatrie. 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Eighth edition, Vol. 3, 1913. - -[312] Pollock, Horatio M., and Nolan, William J.: Sex, Age, and -Nativity of Dementia Praecox First Admissions to the New York State -Hospitals, 1912-1918. The State Hospital Quarterly, August, 1919. - -[313] Pollock, Horatio M.: Dementia Praecox as a Social Problem. The -State Hospital Quarterly, August, 1918. - -[314] Jelliffe, S. E.: A Summary of Origins, Transformation and -Present-Day Trend of the Paranoia Concept. New York Medical Record, -April 5, 1913. - -[315] Flemming, C. F.: Ueber Classification die Seelenstörungen. -Allgemeine Zeitschrift für Psychiatrie. 1844. - -[316] Quoted by Cramer. Abgreugung und Differenzial-Diagnose der -Paranoia. Allgemeine Zeitschrift für Psychiatrie. 1894. - -[317] Krafft-Ebing, R. von: A Text-book of Insanity. Translated by C. -G. Chaddock. 1905. - -[318] Krafft-Ebing, R. von: A Text-book of Insanity. Translated by C. -G. Chaddock. 1905. - -[319] Kraepelin, E.: Psychiatrie. Sixth edition. 1899. 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Vol. 3, 1913. - - - - - - -End of the Project Gutenberg EBook of Mental diseases; a public health -problem, by James Vance May - -*** END OF THIS PROJECT GUTENBERG EBOOK MENTAL DISEASES *** - -***** This file should be named 54611-0.txt or 54611-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/4/6/1/54611/ - -Produced by MWS, Ralph, Bryan Ness and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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