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Title: Mental diseases; a public health problem
Author: May, James Vance
Language: English
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                            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. Published by order of the Senate, Boston, 1837.

[19] The Institutional Care of the Insane in the United States and
Canada, Vol. III, 1916.

[20] Dickens, Charles: American Notes, 1842.

[21] The Institutional Care of the Insane in the United states and
Canada, Vol. III, 1916.

[22] The Institutional Care of the Insane in the United States and
Canada, Vol. III, 1916.

[23] Koren, John: Summaries of State Laws Relating to the Insane.
National Committee for Mental Hygiene, New York, 1917.

[24] Koren, John: Summaries of State Laws Relating to the Insane.
National Committee for Mental Hygiene, New York, 1917.

[25] Salmon, Thomas W.: The State Care of the Insane under State Boards
of Control. State Hospital Bulletin, February 15, 1915.

[26] Kline, George M.: Proposed Reorganization and Correlation of State
Institutions in Massachusetts. American Journal of Insanity, January,
1920.

[27] Thirteenth Annual Report, New York State Hospital Commission.
Albany, 1919.

[28] Fourth Annual Report of the Massachusetts Commission on Mental
Diseases. Boston, 1920.

[29] Mitchell, S. Weir: Address before the Fiftieth Annual Meeting of
the American Medico-Psychological Association. Transactions, 1894.

[30] Copp, Owen: Barriers to the Treatment of Mental Patients. Mental
Hygiene, April, 1918.

[31] Kirby, G. H.: Guides for History Taking and Clinical Examination
of Psychiatric Cases. 1921.

[32] Wright, R. B.: Medical Staff Manual—Hydrotherapy. Boston State
Hospital. 1920.

[33] Sibbald, John: Psychiatry in General Hospitals. Review of
Neurology and Psychiatry. January, 1903.

[34] Smith, Frank R.: Extracts from the Writings of Wilhelm Griesinger,
a Prophet of the Newer Psychiatry. American Journal of Insanity, July,
1903.

[35] Earle, Pliny: The Psychopathic Hospital of the Future. Address at
the laying of the corner stone of the General Hospital for the Insane
of the State of Connecticut, June 20, 1867. Utica, 1867.

[36] Meyer, Adolf: The Aims of a Psychiatric Clinic. Proceedings of
the Mental Hygiene Conference at the College of the City of New York,
November, 1912.

[37] Ibid.

[38] Beers, Clifford W.: A Mind That Found Itself, 1908.

[39] Notes and Comments. The American Journal of Insanity, July, 1908.

[40] Farrar, Clarence B.: The Autopathography of C. W. Beers. American
Journal of Insanity, July, 1908.

[41] Notes and Comments. The American Journal of Insanity, July, 1908.

[42] Beers, Clifford W.: A Mind That Found Itself. Revised. Fourth
edition, 1917.

[43] Beers, Clifford W.: A Mind That Found Itself. Revised. Fourth
edition, 1917.

[44] Ibid.

[45] Russell, William L.: Community Responsibilities in the Treatment
of Mental Disorders. Mental Hygiene, July, 1918.

[46] Notes and Comments. Mental Hygiene, July, 1920.

[47] Ibid., October, 1920.

[48] White, William A.: Childhood: the Golden Period for Mental
Hygiene. Mental Hygiene, April, 1920.

[49] Copp, Owen: The Duty of the State and the Physician to the Mental
Patient. The Pennsylvania Medical Journal, December, 1919.

[50] Burnham, William H.: The Scope and Aim of Mental Hygiene. Boston
Medical and Surgical Journal, December 19, 1918.

[51] Gesell, Arnold: Mental Hygiene and the Public School. Mental
Hygiene, January, 1919.

[52] Campbell, C. Macfie: The Responsibilities of the Universities in
Promoting Mental Hygiene. Mental Hygiene, April, 1919.

[53] Cobb, Stanley: Applications of Psychiatry to Industrial Hygiene.
The Journal of Industrial Hygiene, November, 1919.

[54] Ibid.

[55] Southard, Elmer E.: Notes and Comments. Mental Hygiene. January,
1921.

[56] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[57] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[58] Clouston, T. S.: Unsoundness of Mind. 1911.

[59] Morgagni, G. B.: De Sedibus et Causis Morborum per Anatomem
Indegatis. 1761.

[60] Journal of Mental Science. January, 1870.

[61] Clouston, T. S.: Unsoundness of Mind. 1911.

[62] Mendel, Gregor J.: Versuche über Pflanzen Hybriden. 1865.

[63] Davenport, Charles B.: Heredity in Relation to Eugenics. 1911.

[64] Rosanoff, A. J., and Orr, Florence: A Study of Heredity in the
Light of the Mendelian Theory. American Journal of Insanity, October,
1911.

[65] Rosanoff, A. J.: On the Inheritance of the Neuropathic
Constitution. New York State Hospitals Bulletin, August 15, 1912.

[66] White, William A.: Outlines of Psychiatry. 1919.

[67] Kraepelin, Emil: Psychiatrie. Eighth edition. Vol. 1. 1909.

[68] Ibid.

[69] Kraepelin, Emil: Psychiatrie. Eighth edition. Vol. 1. 1909.

[70] Kraepelin, Emil: Psychiatrie. Eighth edition. Vol. 1. 1909.

[71] Salmon, Thomas W.: Immigration and the Mixture of Races in
Relation to the Mental Health of the Nation. Modern Treatment of
Nervous and Mental Diseases. White and Jelliffe. Vol. 1, 1913.

[72] Salmon, Thomas W.: Immigration and the Mixture of Races in
Relation to the Mental Health of the Nation. Modern Treatment of
Nervous and Mental Diseases. White and Jelliffe. Vol. 1, 1913.

[73] Twenty-fifth Annual Report of the State Hospital Commission.
Albany, 1914.

[74] Salmon, Thomas W.: Immigration and the Mixture of Races in
Relation to the Mental Health of the Nation. Modern Treatment of
Nervous and Mental Diseases. White and Jelliffe. Vol. I, 1913.

[75] Thirtieth Annual Report of the State Hospital Commission. Albany,
1919.

[76] Thirty-first Annual Report of the State Hospital Commission.
Albany, 1920.

[77] Salmon, Thomas W.: Immigration and the Mixture of Races in
Relation to the Mental Health of the Nation. Modern Treatment of
Nervous and Mental Diseases. White and Jelliffe. Vol. I, 1913.

[78] Ray, Isaac: A Treatise on the Medical Jurisprudence of Insanity.
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[79] Ray, Isaac: A Treatise on the Medical Jurisprudence of Insanity.
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[80] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[81] Report of the Committee on Medical Expert Testimony. Transactions
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[82] Anderson, Victor V.: Mental Disease and Delinquency. Mental
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[83] May, James V.: Mental Diseases and Criminal Responsibility. New
York State Hospitals Bulletin, November, 1912.

[84] Nolan, William J.: Some Characteristics of the Criminal Insane.
The State Hospital Quarterly, May, 1920.

[85] Medical and Surgical History of the War of the Rebellion. Part
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[86] Weygandt, W.: Psychiatry in the Field. Medizinische Klinik.
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[87] Richards, R. L.: Nervous and Mental Disorders in their Military
Relations. Modern Treatment of Nervous and Mental Disease. White and
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[88] Physical Examination of the First Million Draft Recruits. Bulletin
No. 11, War Department, Burgeon General, 1919.

[89] Bailey, Pearce: Reconstruction in Nervous and Mental Diseases,
Medical Record, June 16, 1919.

[90] Farrar, Clarence B.: The Problem of Mental Diseases in the
Canadian Army. Mental Hygiene, July, 1917.

[91] Oppenheim, H.: The War and the Traumatic Neuroses. Berlin klin.
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[92] Nonne, Max: Shall War Injuries Still Be Diagnosed as Traumatic
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of the American Medical Association. Sept. 18, 1915.

[93] Binswanger, Otto: Hystero-somatic Symptoms in War Hysteria. Monat.
für Psych. u. Neurol., Berlin, July and August, 1915. Abstract of War
Work Committee of the National Committee for Mental Hygiene, 1918.

[94] Wolfsohn, Julian M.: The Predisposing Factors of War
Psychoneuroses. Lancet, London, Feb. 2, 1918.

[95] Salmon, Thomas W.: The Care and Treatment of Mental Diseases and
War Neuroses (Shell Shock) in the British Army. War Work Committee of
the National Committee for Mental Hygiene, 1917.

[96] Mott, Frederick W.: Effects of High Explosives upon the Central
Nervous System. Lancet, London, February 26, 1916.

[97] Mott, Frederick W.: The Brain in Shell Shock. Brit. Med. Journal,
November 10, 1917.

[98] Eder, Montague D.: War Shock: the Psychoneuroses in War.
Psychology and Treatment. 1917.

[99] Ballet, Gilbert, and de Fursac, Rogues J.: The Concussion
Psychoses: Psychoses from Nervous "Commotion" or Emotional Shock.
Paris Méd., January 1, 1916. Abstract of the War Work Committee of the
National Committee for Mental Hygiene. 1918.

[100] Lust, F.: War Neuroses and Prisoners. München Med. Woch., Dec.
26, 1916. Abstract of the Journal of the American Medical Association.
Feb. 24, 1917.

[101] MacCurdy, John T.: War Neuroses. Psychiatric Bulletin, July, 1917.

[102] Hartung, M. U.: German Experiences of War Neuroses. Zeitschrift
für d. ges. Neur. u. Psych., 1918. Abstract of the Journal of Nervous
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[103] Hurst, A. F.: Observations of the Etiology and Treatment of War
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Journal of Nervous and Mental Diseases. Oct., 1919.

[104] Ireland, Merritte W.: Care of the Army's Mental Defectives.
Journal of Nervous and Mental Diseases, December, 1920.

[105] Salmon, Thomas W.: The Insane Veteran and a Nation's Honor. The
American Legion Weekly, January 28, 1921.

[106] Falta, Wilhelm: The Ductless Glandular Diseases. Trans. by Milton
K. Meyers. 1916.

[107] Blumgarten, A. S.: The Rôle of the Endocrine System in Internal
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[108] Kaplan, D. M.: Internal Secretions. New York Medical Journal,
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[109] Garretson, William V. P.: The Dominance of the Endocrines. New
York Medical Journal, May 17, 1921.

[110] Falta, Wilhelm: The Ductless Glandular Diseases. Trans. by Milton
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[111] Raeder, Oscar J.: Endocrine Imbalance in the Feebleminded.
Journal of the American Medical Association, August 21, 1920.

[112] Neubürger: Arch. für Psychiatrie. Vol. 55. Abstract of,
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[113] Walter and Krumbach: Zeitschrift f. d. g. Neurologie und
Psychiatrie. Vol. 28. Abstract of, Psychiatric Bulletin, January, 1916.

[114] Emerson, H.: A Note on the Incidence of Status Lymphaticus in
Dementia Praecox. Arch. Int. Medicine, December, 1914.

[115] Davis, Thomas K.: Status Lymphaticus; Its Occurrence and
Significance in the War Neuroses. Arch. of Neurology and Psychiatry,
October, 1919.

[116] Straus, S. G.: Thyroidal Constipation. New York Medical Journal,
February 14, 1920.

[117] Turro, R.: Emotions and Endocrine Functions. Abstract of Journal
of the American Medical Association, December 13, 1919.

[118] Knauer, A., and Billigheimer, E.: Concerning Organic and
Functional Disturbances of the Vegetative Nervous System with Special
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[119] Kraepelin, E.: Psychiatrie. Vol. 4, 1915.

[120] Kraepelin, E.: Psychiatrie. Vol. 4, 1915.

[121] Mott, Frederick W.: British Medical Journal, November, 1919.

[122] Timme, Walter: Clinical Endocrinology. Neurological Bulletin,
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[123] White, William A.: Outlines of Psychiatry. Seventh edition, 1919.

[124] Paton, Stewart: Psychiatry. 1905.

[125] Diefendorf, A. Ross: Clinical Psychiatry. 1918.

[126] Simon, T. W.: The Occurrence of Convulsions in Dementia Praecox,
Manic-Depressive Insanity and the Allied Groups. The State Hospital
Bulletin, November 15, 1914.

[127] Ullman, A. E.: Proceedings of the Inter-hospital Meeting at the
Central Islip State Hospital. The State Hospital Bulletin, November 15,
1914.

[128] Kraepelin, E.: Psychiatrie. Vol. 3, 1913.

[129] Thirty-first Annual Report of the New York State Hospital
Commission. 1918.

[130] Bucknill, J. C., and Tuke, D. H.: A Manual of Psychological
Medicine. 1879.

[131] Bucknill, J. C., and Tuke, D. H.: A Manual of Psychological
Medicine. 1879.

[132] Ibid.

[133] Jolliffe, S. E.: A Summary of the Origins, Transformations and
Present-day Trends of the Paranoia Concept. The Medical Record, April
5, 1913.

[134] Bucknill, J. C., and Tuke, D. H.: A Manual of Psychological
Medicine. 1879.

[135] Pritchard, J. C.: A Treatise on Diseases of the Nervous System.
1822.

[136] Flemming, C. F.: Ueber Classification der Seelenstörungen, etc.
Allgemeine Zeitschrift für Psychiatrie. 1844.

[137] Pritchard, J. C.: A Treatise on Insanity. 1835.

[138] Griesinger, W.: Die Pathologie und Therapie der psychischen
Krankheiten. 1845.

[139] Krafft-Ebing, R. v.: Lehrbuch der Psychiatrie. Third edition.
1888.

[140] Ziehen, Th.: Psychiatrie, 1894.

[141] Savage, G. H.: Insanity and Allied Neuroses. Fourth edition. 1907.

[142] Savage, G. H.: Insanity and Allied Neuroses. Fourth Edition. 1907.

[143] Kempf, E. J.: The Mechanistic Classification of Neuroses and
Psychoses Produced by Distortion of Anatomic-Affective Functions. The
Journal of Nervous and Mental Diseases. August, 1919.

[144] Southard, E. E.: A Key to the Practical Grouping of Mental
Diseases. Journal of Nervous and Mental Diseases. January, 1918.

[145] Southard, E. E.: Recent American Classification of Mental
Diseases. Transactions, American Medico-Psychological Association, 1918.

[146] Southard, E. E.: A Key to the Practical Grouping of Mental
Diseases. Journal of Nervous and Mental Diseases. January, 1918.

[147] DaCosta, J. C.: Modern Surgery. Seventh edition. 1918.

[148] Ibid.

[149] Harlow, John M.: Recovery from the Passage of an Iron Bar through
the Head. Boston, 1868.

[150] Witmer, Lightner: Brain: Functions of the Cerebral Cortex.
Reference Handbook of the Medical Sciences. 1899.

[151] Meyer, Adolf: The Anatomical Facts and Clinical Varieties of
Traumatic Insanity. Transactions of the American Medico-Psychological
Association, 1903.

[152] Meyer, Adolf: The Anatomical Facts and Clinical Varieties of
Traumatic Insanity. Transactions of the American Medico-Psychological
Association, 1903.

[153] Meyer, Adolf: The Anatomical Facts and Clinical Varieties of
Traumatic Insanity. Transactions of the American Medico-Psychological
Association, 1903.

[154] Griesinger, W.: Mental Pathology and Therapeutics. Translated by
C. L. Robertson and James Rutherford. 1867.

[155] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2. 1910.

[156] Clouston, T. S.: Unsoundness of Mind. 1911.

[157] Ziehen, Th.: Psychiatrie. 1894.

[158] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[159] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[160] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[161] Bleuler, E.: Lehrbuch der Psychiatrie, 1918.

[162] Southard, E. E.: Anatomical Findings in Senile Dementia, etc.
Transactions of the American Medico-Psychological Association, 1909.

[163] Lambert, Charles I.: A Clinical-Anatomical Classification of the
Senile and Arteriosclerotic Disorders. Transactions of the American
Medico-Psychological Association. 1910.

[164] Ibid.

[165] Barker, Lewellys F.: Monographic Medicine. Vol. 4, 1916.

[166] Lhermitte, J.: The Anatomical and Clinical Syndromes of the
Corpus Striatum. Translated by J. H. Huddleson and W. M. Kraus. The
Neurological Bulletin. May, 1921.

[167] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[168] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[169] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[170] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[171] Krafft-Ebing, R. v.: Lehrbuch der Psychiatrie. 1888.

[172] Régis, E.: A Practical Manual of Mental Medicine. Translated by
H. M. Bannister. 1894.

[173] White, William A.: Outlines of Psychiatry. 1919.

[174] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[175] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[176] May, James V.: A Résumé of the Work of the Pathological
Laboratory of the Binghamton State Hospital. July 1, 1911.

[177] Ibid.

[178] May, James V.: A Review of the Recent Studies of General Paresis.
American Journal of Insanity. April, 1910.

[179] Mott, F. W.: Oliver-Sharpey Lectures on the Cerebro-Spinal Fluid.
Lancet, July 2 and 10, 1910.

[180] Alzheimer, Alois: Histologische Studien zur Differentialdiagnose
des Progres s. Paralyse. Hist. und Histopath. Arbeiten. 1904.

[181] Movimiento de la Casa de Orates de Santiago, 1920.

[182] Oppenheim H.: Diseases of the Nervous System. Translated by
Edward E. Mayer, 1900.

[183] Barker, Lewellys F.: Monographic Medicine. Vol, 4, 1916.

[184] Dunlap, Charles B.: Anatomical Borderline between the So-called
Syphilitic and Metasyphilitic Disorders in the Brain and Spinal Cord.
American Journal of Insanity, April, 1913.

[185] Barker, Lewellys F.: Monographic Medicine. Vol. 4, 1916.

[186] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[187] Raeder, Oscar J.: Interim Report of the Neurosyphilis
Investigation of the Massachusetts Commission on Mental Diseases.
Transactions of the American Medico-Psychological Association, 1919.

[188] Warthin, Alfred S.: The Persistence of Active Lesions in the
Tissue of Clinically Inactive or "Cured" Syphilis. American Journal of
Medical Sciences. October, 1916.

[189] McCarthy, Daniel J.: Paralysis Agitans, Chorea, etc. Modern
Medicine, Osler and McCrae. 1915.

[190] Hamilton, Arthur S.: A Report of Twenty-seven Cases of Chronic
Progressive Chorea. American Journal of Insanity. January, 1908.

[191] Diefendorf, A. Ross: Neurographs. May, 1908.

[192] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[193] Cushing, Harvey. Tumors of the Brain and Meninges. Modern
Medicine, Osier and McCrae. 1915.

[194] Redlich, E. The Pathogenesis of Psychic Disturbances in Brain
Tumors. Reviewed by Morris J. Karpas. State Hospitals Bulletin, June,
1911.

[195] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[196] Thomas, Henry M.: Diseases of the Cerebral Bloodvessels. Modern
Medicine, Osler and McCrae. 1915.

[197] Thomas, Henry M.: Diseases of the Cerebral Bloodvessels. Modern
Medicine. Osler and McCrae. 1915.

[198] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[199] Camp, Carl D.: Paralysis Agitans and Multiple Sclerosis and Their
Treatment. Modern Treatment of Nervous and Mental Diseases. White and
Jelliffe. 1913.

[200] McCarthy, Daniel J.: Paralysis Agitans, Chorea, etc. Modern
Medicine. Osler and McCrae. 1915.

[201] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[202] Henderson, D. K.: Disseminated Sclerosis with Psychosis. State
Hospitals Bulletin. March, 1910.

[203] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[204] Sachs, Bernard: Syphilitic Diseases of the Central Nervous
System. Modern Medicine, Osler and McCrae. 1915.

[205] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[206] McCarthy, Daniel J.: Paralysis Agitans, Chorea, etc. Modern
Medicine, Osler and McCrae. 1915.

[207] White, William A.: Outlines of Psychiatry. 1919.

[208] Economo, C. von: Wien Klin. Wochenschrift. July 26, 1917.

[209] Buzzard, E., Farquhar, and Greenfield, J. G.: Lethargic
Encephalitis Brain, 1919.

[210] Boveri, Piero: The Cerebrospinal Fluid in Epidemic Encephalitis.
Journal of Nervous and Mental Diseases. October, 1920.

[211] Abrahamson, Isador: Mental Disturbances in Lethargic
Encephalitis. Journal of Nervous and Mental Diseases. September, 1920.

[212] Kirby, George H., and Davis, Thomas K.: Psychotic Aspects of
Epidemic Encephalitis. Archives of Neurology and Psychiatry. May, 1921.

[213] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[214] Tuke, D. Hack: Alcohol, Use of, as a Beverage in Asylums. A
Dictionary of Psychological Medicine. 1892.

[215] Flemming, C. F.: Ueber Classification die Seelenstörungen.
Allgemeine Zeitschrift für Psychiatrie. 1844.

[216] Clousten, T. S.: Clinical Lectures on Mental Diseases. 1898.

[217] Krafft-Ebing, R. von: Text book of Insanity. Translated by C. G.
Chaddock. 1905.

[218] Meyer, Adolf: Modern Psychiatry: Its Possibilities and
Responsibilities. New York State Hospitals Bulletin. September, 1909.

[219] Stöcker, Wilhelm: Klinischer Beitrag zur Frage der
Alkoholpsychosen. Jena, 1910. Abstract of Morris J. Karpas in State
Hospitals Bulletin, December, 1910.

[220] Ibid.

[221] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[222] Shadwell, A.: Article on Temperance. The Encyclopedia Britannica,
Vol. 26, 1911.

[223] Pollock, H. M.: A Statistical Study of 1739 Patients with
Alcoholic Psychoses. State Hospital Bulletin. August, 1914.

[224] Krafft-Ebing, R. von: Text-book of Insanity. Translated by C. G.
Chaddock. 1905.

[225] Paton, Stewart: Psychiatry. 1905.

[226] Barker, Lewellys F.: Monographic Medicine, Vol. 4, 1916.

[227] White, William A.: Outlines of Psychiatry. 1919.

[228] Erlenmeyer, A.: Die Morphiumsucht und ihre Behandlung. 1887.

[229] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[230] Mannheim, Paul: Ueber das Cocain und seine Gefahren, etc.
Zeitschrift für klinische Medicin. 1891.

[231] Erlenmeyer, A.: Cocainsucht. 1886. Abstract in Zentralblatt für
Nervenheilkunde, Psychiatrie, etc., by Goldstein. November, 1887.

[232] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[233] Wilson, James C.: The Opium Habit and Kindred Affections. System
of Medicine. Pepper. 1886.

[234] Casamajor, Louis: Bromide Intolerance and Bromide Poisoning.
Journal of Nervous and Mental Diseases. June, 1911.

[235] Hoch, August: A Study of Some Cases of Delirium Produced by
Drugs. Review of Neurology and Psychiatry. February, 1906.

[236] O'Malley, Mary, and Franz, Shepherd Ivory: A Case of Delirium
Produced by Bromides. Bulletin No. 1. Government Hospital for the
Insane. Washington, 1909.

[237] Edsall, David L.: Chronic Lead, Arsenic and Other Forms of
Poisoning. Modern Medicine. Osler and McCrae. Vol. 2, 1914.

[238] Rayner, H.: Journal of Mental Science. 1880.

[239] Edsall, David L.: Chronic Lead, Arsenic and Other Forms of
Poisoning. Modern Medicine. Osler and McCrae. Vol. 2, 1914.

[240] O'Malley, Mary: A Psychosis Following Carbon-Monoxide Poisoning
with Complete Recovery. American Journal of the Medical Sciences. June,
1913.

[241] Drug Addiction in the United States. Journal of Nervous and
Mental Diseases. August, 1920.

[242] Niles, George M.: Pellagra. 1912.

[243] Babcock, J. W.: The Prevalence and Psychology of Pellagra.
Transactions of the American Medico-Psychological Association, 1910.

[244] Studies in Pellagra. U. S. Treasury Department. Hygienic
Bulletin. No. 106. January, 1917.

[245] Voegtlin, Carl: The Treatment of Pellagra. Journal of the
American Medical Association. September 26, 1914.

[246] Koch, M. L., and Voegtlin, Carl: Chemical Changes in the Central
Nervous System in Pellagra. Hygienic Laboratory Bulletin No. 103,
February, 1916.

[247] Goldberger, J.: Pellagra: Causation and a Method of Prevention:
A Summary of Some of the Recent Studies of the Public Health Service.
Journal of the American Medical Association, February 12, 1916.

[248] Goldberger, J., Wheeler, G. A., and Sydenstricker, Edgar: A Study
of the Diet of Nonpellagrous and of Pellagrous Households. Journal of
the American Medical Association. September 21, 1918.

[249] Roberts, Stewart R.: Types and Treatment of Pellagra. Journal of
the American Medical Association, July 3, 1920.

[250] Barker, Lewellys F.: Monographic Medicine, Vol. 4, 1916.

[251] Babcock, J. W.: The Prevalence and Psychology of Pellagra.
Transactions of the American Medico-Psychological Association, 1910.

[252] Griesinger, W.: Pathology and Therapeutics of Mental Diseases.
1887.

[253] Mongeri, L.: Malattie Mentali. Milan, 228. Quoted by Babcock.

[254] Bianchi, Leonardo: A Textbook of Psychiatry. Translated by James
H. Macdonald. 1906. Quoted by Babcock.

[255] Régis, E.: Precis de Psychiatrie. 1909. Quoted by Babcock.

[256] Procopiu, G.: La Pellagre. Paris. 1903. Quoted by Babcock.

[257] Tanzi, Eugenio: Textbook of Mental Diseases. Translated by
Robertson. 1909.

[258] Gregor, A.: Jahrb. Psychiat. Neurol. Leipsig, 1907

[259] Singer, H. Douglas: Mental and Nervous Disorders Associated with
Pellagra. Archives of Internal Medicine. January, 1915.

[260] Sandy, William A.: Psychiatric Aspects of Pellagra. Transactions
of the American Medico-Psychological Association. 1916.

[261] Bucknill, J. C., and Tuke, D. Hack: A Manual of Psychological
Medicine. 1879.

[262] Bucknill, J. C., and Tuke, D. Hack: A Manual of Psychological
Medicine. 1879.

[263] Feuchtersleben, E. von: Lehrbuch der Aerzlichen Seelenkunde.
1845. Translated by H. E. Lloyd. 1847.

[264] Friedreich, J. B.: Historisch kritische Darstellung der Theorieen
über den Wahnsinn. 1839. Quoted by von Feuchtersleben.

[265] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[266] Knauer, A.: The Psychoses Occurring as a Result of Acute
Articular Rheumatism. Zeitschrift f. d. ges. Neurol. u. Psychiatrie.
Vol. 21, 1916.

[267] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[268] Ibid.

[269] Ibid.

[270] Pritchard, James C.: A Treatise on Insanity and Other Disorders
Affecting the Mind. 1835.

[271] Flemming, C. F.: Ueber Classification der Seelenstörungen.
Allgemeine Zeitschrift für Psychiatrie. 1844.

[272] Griesinger, Wilhelm: Die Pathologie und Therapie der psychischen
Krankheiten. 1845.

[273] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[274] Sankey, W. H. O.: Lectures on Mental Disease. 1884.

[275] Schüle, Heinrich: Klinishe Psychiatrie. Third edition. 1886.

[276] Ziehen, Th.: Psychiatrie. 1894.

[277] Kraepelin, E.: Psychiatrie. Sixth edition. 1899.

[278] White, William A.: Outlines of Psychiatry. 1919.

[279] Diefendorf, A. Ross: Clinical Psychiatry. 1918.

[280] Buckley, Albert C.: The Basis of Psychiatry. 1920.

[281] Paton, Stewart: Psychiatry. 1905.

[282] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 3, 1913.

[283] Diefendorf, A. Ross: Clinical Psychiatry. 1918.

[284] Dreyfus, G. L.: Die Melancholia ein Zustanbild des
Manisch-Depressiven Irreseins. 1907. Reviewed by Dr. George H. Kirby.
The State Hospitals Bulletin, December 1, 1908.

[285] Dreyfus, G. L.: Die Melancholia ein Zustandbild des
Manisch-Depressiven Irreseins. 1907. Review by Dr. George H. Kirby. The
State Hospitals Bulletin, December 1, 1908.

[286] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[287] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 2, 1910.

[288] Kraepelin, E.: Psychiatrie. Eighth edition. 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. Second edition, 1918.

[299] Hoch, August: Review of Bleuler's "Schizophrenia." New York State
Hospitals Bulletin, August 15, 1912.

[300] Bleuler, E.: Lehrbuch der Psychiatrie. Second edition, 1918.

[301] Meyer, Adolf: Fundamental Conceptions of Dementia Praecox.
British Medical Journal, September, 1906.

[302] Hoch, August: Constitutional Factors in the Dementia Praecox
Group. Review of Neurology and Psychiatry, August, 1910.

[303] Jung, C. G.: The Psychology of Dementia Praecox. 1909.

[304] White, William A.: Outlines of Psychiatry. 1919.

[305] Kraepelin, E.: Psychiatrie. Eighth edition, Vol. 3, 1913.

[306] Ibid.

[307] Meyer, Adolf: The Nature and Conception of Dementia Praecox. The
Journal of Abnormal Psychology. Dec., 1910, Jan., 1911.

[308] Buckley, Alfred C.: The Basis of Psychiatry. 1920.

[309] Diefendorf, A. Ross: Clinical Psychiatry. 1918.

[310] Kraepelin, E.: Psychiatrie. Eighth Edition, Vol. 3, 1913.

[311] Kraepelin, E.: Psychiatrie. 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. Book Review,
American Journal of Insanity. July, 1900.

[320] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 3, 1913.

[321] Kraepelin, E.: Die Erscheinungsformen des Irreseins. Zeitschrift
für die gesamte Neurologie und Psychiatrie. December, 1920.

[322] Bleuler, E.: Affectivität, Suggestibilität, Paranoia. Translated
by Charles S. Ricksher. New York State Hospitals Bulletin. February,
1912.

[323] Meyer, Adolf: Paranoia and Paranoid States. The Modern Treatment
of Nervous and Mental Diseases. White and Jelliffe. 1913.

[324] Meyer, Adolf: Paranoia and Paranoid States. The Modern Treatment
of Nervous and Mental Diseases. White and Jelliffe. 1913.

[325] Tuke, D. Hack: A Dictionary of Psychological Medicine. 1892.

[326] Spratling, William P.: Epilepsy and its Treatment. 1904.

[327] Clark, L. Pierce: Clinical Studies in Epilepsy. Psychiatric
Bulletin. January, 1916.

[328] Clark, L. Pierce; Clinical Studies in Epilepsy. Psychiatric
Bulletin. January, 1916.

[329] Clark, L. Pierce: Clinical Studies in Epilepsy (Concluded).
Psychiatric Bulletin. January, 1917.

[330] Clark, L. Pierce: A Further Study of Mental Content in Epilepsy.
Psychiatric Bulletin, October, 1917.

[331] Kraepelin, E.: Psychiatrie. Eighth edition, Vol. 3, 1913.

[332] Murray, James A. H.: A New English Dictionary. 1888.

[333] Brachet, J. L.: Traité de l'hysteria. 1847.

[334] Krafft-Ebing, R. von: Lehrbuch der Psychiatrie. Translated by C.
G. Chaddock. 1905.

[335] Janet, Pierre: État mental des hystériques. Translated by C. R.
Corson. 1901.

[336] Freud, Sigmund: Sammlungen kleiner Schriften zur Neurosenlehre.
1906 and 1909. Translated by A. A. Brill. 1909.

[337] Morel, Jules: The Treatment of Degenerative Psychoses.
International Congress of Charities, etc., Chicago, 1893.

[338] Meyer, Adolf: Constitutional Abnormality. C. P. Obendorf.
Discussion. State Hospitals Bulletin, March, 1910.

[339] Ziehen, Th.: Psychiatrie. 1911. Quoted by Hickson. Report of the
Psychopathic Laboratory, etc., Chicago, 1917.

[340] Diefendorf, A. Ross: Degenerative Insanity. Reference Handbook of
the Medical Sciences. 1909.

[341] Régis, E.: A Practical Manual of Mental Medicine. Translation of
H. M. Bannister, 1894.

[342] Grasset, Joseph: The Semi-Insane and the Semi-Responsible.
Translated by Smith Ely Jelliffe. 1907.

[343] Kraepelin, E.: Clinical Psychiatry. Translated by Thomas
Johnstone. 1906.

[344] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 4, 1915.

[345] Bucknill, J. C., and Tuke, D. Hack: Psychological Medicine.
Fourth edition. 1879.

[346] Tredgold, A. F.: Mental Deficiency, 1915.

[347] Goddard, H. H.: Feeblemindedness. 1914.

[348] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 4, 1915.

[349] Kraepelin, E.: Psychiatrie. Eighth edition. Vol. 3, 1913.





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