PART I — часть 6

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.