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.