T H E COLLOID CHEMISTRY O F INSASITY.
11*
BY WILDER D . BAKCROFT AND J. E . RUTZLER, .JR.**
So far as we can learn, the theories of insanity vary all the way from the purely pathological to the purely psychological. C. Stanford Read' says in regard to insanity. "This term ordinarily connotes more or less severe unsoundness of mind. Though its loose usage is almost synonymous with mental disease, scientifically the term should only be applied to the mental condition of an individual who, through socially inefficient conduct, has to be placed under supervision and control. The mind is the mechanism by means of which we adapt adequately to our environment and when, through its derangement, conduct is exhibited which the community looks upon as evidence of disease and as implying irresponsibility, the individual concerned is said to be insane and the law steps in to certify him as such. Strictly speaking, then, insanit,y is really a social and legal term and not medical. Mental illness is a broad concept which may include very efficient members of society. No satisfactory definition can therefore be arrived at, since it would be necessary to define what we mean by sanity, which would involve us in equal difficulties. "It is unnecessary to dwell upon the mystical conceptions of insanity which were held in the middle ages, and it will be sufficient to note that it was only towards the close of the eighteenth century that this sphere of mental disorder was scientifically studied. This was a period in which materialism flourished and research devoted to the anatomy and physiology of the brain gave the workers reason to believe that the nature and cause of insanity would before long be discovered, since the advance of knowledge in the structure and functioning of the central nervous system was progressing at a rapid rate. A school of thought therefore held sway which founded insanity on a physiological basis and endeavoured to base all pathology in terms of organic change in the brain. Although the great value of this method cannot be gainsaid, there is ample evidence that other aspects of approaching the problem of insanity are essentially necessary. Of late years another school has advanced the belief that the majority of cases of insanity are psychogenic in origin and that, even where gross physical disease has been the exciting factor, the symptoms can only be adequately understood at the psychological level. Others, again, prefer to take a wider view-point still and regard insanity in the light of biological or psycho-biological reactions. *This work is done under the programme now being carried out a t Cornell University and supported in part by a grant from the Heckscher Foundation for the Advancement of Research established by August Heckscher a t Cornel1 University. "'Eli Lilly Fellow. Encyclopaedia Britannica, 12, 383 (1929).
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Modern psychological knowledge would lead us to believe that the understanding of much of the subject is made clearer when we regard it in the light of instinctive forces conflicting with environment and resulting in a failure of adjustment. The mental symptoms cannot be rightly spoken of as a disease but as t,ypes of reaction through the effort on the part of the individual to meet conditions. . . The materialistic school would hold that, though in many states of insanity no observable structural changes are found, they exist all the same, only they are such that our imperfect methods cannot detect t,hem, and in time they will be discovered. At present we have insane conditions divided into those that are regarded as functional and those that are organic. In the former we have mania, melancholia and paranoia, and some would include dementia praecox. The psychogenic school would argue that, though mental disease may arise secondarily to physical disorder, the symptoms are psychological reverberations of that disorder and the body of an individual must be regarded as environmental to the ego. I n an integrated organism, though the basis of the wrong functioning lies in the physical sphere, some of the effects are manifested a t the psychological level. The symptoms, then, are expressions of the personalit,y, and however much we may stress the bodily aspect, that can in no way explain the content of a delusion or a hallucination. The fact that some individuals may take alcohol to the extent of producing severe physical disease without affecting the mind, and others will fall victims to insanity through its use, proves that psychic factors canriot, be left out of the calculation. The many structural changes which are found in certain forms of insanity should be reviewed as probably secondary to a perverted mentality. The bodily effects of emotion are well known and it can easily be surmised that long-continued emotional stress should in time be followed by organic change. During the TVorld War we had ample evidence of this. As McDougall says, ‘mind has a nature and a structure and functions of its own which cannot be fully and adequately described in terms of structure of the brain and its processes.’ If this be true, as he thinks, it does not seem logically impossible that the nature of the mind itself may be disordered or impaired or defective. I t seems, then, that we must steer clear of belonging to one or other of the extreme camps when we view the nature of insanity, but take a very wide vista which will embrace the study of the individual, his personal and racial history, his environment, and his physical and mental structure.” In a presidential address before the American Psychiatric Association, Dr. W.A. White’ of Saint Elizabeth’s Hospital in Washington has presented the case for the psychiatrist in an admirably clear manner. “Since the advent of psychoanalysis we for the first time have our vision directed to where the real trouble has taken place, and our interests centered upon the actual mechanisms that are producing the symptoms. K e understand that the deflection of our vision to the body or to the infectious organism are but examples of that mechanism of projection with which we have
.
1
Am. J. Psychiatry, 5 ,
I
(192 jj.
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become so familiar, and that it was because of the emotional necessity for seeing causes otherwise than in ourselves that we for so many centuries have been unable to face the facts of our own mental life. The tendency to refer all mental diseases to either an exclusively somatic or infectious etiology is, I believe, a regressive tendency in psychiatry. Of course I do not want to be understood as saying that physical disease or infection plays no part in the etiology of the psychoses, although I am not at all sure that such a thesis might not be entertained. Still we are hardly ready for such an extreme position as yet. But the very fact that there are organs that should be removed in whole or in part makes it all the more difficult to discover and to overcome the compromises with tradition and superstition which are hidden behind the concepts of infection or the enucleating operations of surgery. The emphasis is undoubtedly for the first time where it belongs. and when I said that perhaps a thesis could be maintained that would eliminate the consideration of the soma or the pathogenic organism as etiological factors in mental disease I had in mind that one of the results of this new point of view has been, I will not say the development, because matters have not gone far enough perhaps to warrant such a phrase, but Lhe beginning of the development, at least, of a theory of disease, speaking in the large, which for the first time looks as if we might be able to compass the understanding of what we have heretofore spoken of as pathological and abnormal, two terms which have always carried an implication that the things to which they refer were in some way outside of the natural order of things.” At the ot’her extreme from Dr. White is Dr. Henry A. Cotton’ of the New Jersey State Hospital at Trenton. His book was written before Dr. White’s presidential address. “For years we have been content to consider mental disorders in two large groups, designated as ‘organic’ and ‘functional.’ This division was based on the fact that in the first group pathological changes in the brain tissue, which would account for the ‘mental disease’ were demonstrable, while in the so-called functional group, for a long time, investigations, owing to inadequate methods, failed to reveal changes in the brain which could account for the mental symptoms. “This led to the erroneous viewpoint that certain mental disorders could occur independently of any changes in the brain. From this view we unhesitatingly dissent. A too literal interpretation of T’irchow’s cellular hypothesis had led to the hasty and erroneous conclusion that because the cell looked normal in arrangement and outline it was necessarily normal in function. Among others, the English physiologist, Haldane, has recently called attention to the gross error of this view. This erroneous hypothesis that the mind is independent of the brain, was further support’ed by the fact that no recognizable physical disease was formerly known to exist in these patients. By exclusion, therefore, mental factors came to be accepted “The Defective, Delinquent and Insane,”
11-15,
16-18, 22-27,
120-122 (1921).
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as the sole cause operating in this group. I t followed that if mental factors caused ‘mental diseases’ necessarily mental treatment was the only method which could promise a cure. “That such a conception is erroneous can be demonstrated by the entire lack of success in such treatment of this type of disease in the last fifty years, during which time the mental picture has been subjected to the closest analysis, and every possible form of psychic treatment has been tried and proved useless. This is evident also from the fact that the percentages of recoveries of this class of patients have decreased rather than increased in the last few years and that at present we have an ever-growing net annual increase in our insane population. In Massachusetts, for instance, the proportion of recoveries to admissions is only 6.9 percent and if improved cases are included the ratio is only 24 percent. I t is conservative to state that not over 2 j percent of the patients admitted to state hospitals throughout the country are sufficiently improved to leave the institutions permanently. This rate is due entirely to spontaneous recovery, not to any definite therapy, either psychoanalytical or otherwise.” “One has only to turn to works on modern medicine for condemnation of this misinterpretation of the relation of function to structure. Hewlett has recently stated: ‘It is true that in the last analysis all disturbances of function must be capable of explanation in terms of physical or chemical changes in the body, cells and fluids.’ Anatomical investigations have repeatedly shown that conditions which have been classed among the functional diseases possess, in reality, an anatomical basis.” “Conklin states: ‘The mind is related to the body as function is to structure.’ Also, ‘Any cell may be functionally modified in a thousand different ways without any change being evident to the human eye.’ This is entirely in accord with the view of many surgeons who have found that the functional disorders of the stomach and other organs reflexly caused by the appendix have been relieved by the removal of appendices which showed neither gross nor microscopic lesions. The explanation of this relief is that the epithelial cells of the appendix have undergone invisible but extensive biochemical alterations, permitting the passages into the lymphatics of bacteria and toxins which it was their function to prevent but which alterations, either for lack of time or for other reasons, failed to cause distinctly visible changes. “While psychiatrists, in the past, have held the non-biological view of the nature of the so-called mental disturbances, the biologists have produced evidence regarding function and structure which when applied to mental disorders will, undoubtedly, modify these traditional ideas. The biologists are definite in the assertion that there can be no function without structure. This being true it would also be true that there can be no abnormal function without a correspondingly abnormal structure. Medical men have been willing to admit this fundamental law so far as it related to other organs in the body but there has been some hesitancy in accepting this truth when applied to the brain and the mind. If we could conceive of a mental state
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independent of the brain, and all known facts refute such a belief, then we could believe that certain forms of insanity were diseases of the mind and not diseases of the brain. “Conklin is emphatic in his opinion that the mind as well as the body develops out’ of the germ. I t cannot be considered apart from the body. Every known scientific fact’ substantiates this viewpoint. When the brain tissue is affected or destroyed the patient becomes deteriorated or demented and finally there is no evidence of functioning of the mind. When the brain is congenitally abnormal and does not develop properly, as in idiocy and imbecility, the mind is either retarded in development or entirely absent. “Investigations, in certain types of insanity, as our technique for conducting them has developed, have shown conclusively t,hat a disturbance in the anatomical structure of the brain accompanies the mental symptoms. Thus, in paresis, there are now always demonstrable distinct changes in the brain as a result of the invasion of the brain tissue by the organism of syphilis and finally in such cases the mind ceases to function. I n senile dementia, the insanit’y of old age, it has been found that the disease is a result of definite dest,ructive changes in the brain t,issue. In arterio-sclerotic brain disease a similar condition is found, due to the diseases of the arteries and disturbances of the brain tissue. The deterioration in dementia praecox can also be cited as a similar example. In alcoholic mental disorders, on the other hand, while the effect of the poisoning by alcohol is clinically evident, and while the withdrawal of the alcohol and the elimination of the poison from the system causes the mental symptoms to disappear, the transient changes in the brain cells may or may not cause visible lesions. “With these known facts as a basis one might well inquire why the other types which formerly have been designated as functional and of unknown origin should be considered so entirely different from the types which investigation has shown to bear out the law that function is dependent upon structure. Success in the treatment and prevention of this large group of mental disorders depends upon the establishment of a definite relation between the mental symptoms and pathological conditions in the brain tissue; and while this may be difficult to demonstrate conclusively, sufficient data are at hand to prove that such a relation does exist and that the abnormal mental symptoms disappear when the abnormal brain conditions are corrected.” “It should be said that the primary lesion which determines the abnormal mental state is most frequently not to be found in the brain itself. The brain cells are constantly influenced by abnormal conditions in other parts of the body through the circulation. Anatomical lesions of other organs of the body are known to change the metabolism, contaminating the blood with abnormal products, which in turn disturb the chemical exchange and nutrition of the cells of the brain. Thus, frequently, there is a direct action on the cerebral elements by the morbid agents carried directly through the circulation. The result may be coarse and extensive lesions, such as result from a large hemorrhage, or fine, diffuse, and frequently invisible lesions; either one of these may be the result of the action of various toxins. Or, the brain
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tissue itself, by the invasion of micro-organisms, such as those responsible for syphilis, may be in part destroyed, leaving instead of the normal nerve cells non-nervous replacements, a condition which actually occurs in paresis. The effect of toxins of any origin, whether produced by alcohol or by bacterial Infection, may be temporary or permanent. Thus, in delirium tremens, the result of alcohol poisoning, we have a profound mental disturbance. This, however, may disappear within twenty-four hours after the alcohol is withdrawn and the patient has had a good night’s sleep. X o lesion may be found in the brain. I n other forms of alcoholic mental disturbance the symptoms may not be so profound, in fact they may be mild when compared to delirium tremens, still the degree of poisoning may be so severe and of such long duration that a withdrawal of the alcohol will not alleviate mental symptoms and In such caSes brain cell changes may be found. “In other words, the changes in the brain, the result of poisoning, may have reached such a stage that repair is no longer possible, even after the toxin is eliminated. They are permanent and often visible. It is logical to assume that these conditions hold good in other types of mental disorders, the result of bacterial toxemias. This explains why a certain percentage of patients among the manias and melancholias recover spontaneously, even when the symptoms exhibited are very profound and severe, while in other types, such as dementia praecox, in which the toxemia is chronic, continuous, and of long duration, the patients will go on to rapid deterioration, in many cases showing no tendency towards a spontaneous recovery. “From the fact that certain serious mental disturbances do permit of spontaneous recovery it has been argued that the brain itself could not have been affected, but this is not necessarily true as we have already seen, on bio-chemical evidence, as well 3s clinically in delirium tremens. I n this condition we know that the brain has been seriously affected but with the removal of the alcohol it becomes perfectly normal again. Therefore, it cannot be argued that because of recoveries in the acute psychoses the brain has not been affected. Moreover we have seen many recoveries among the acute psychoses occur in a day or two after the removal of the chronic foci of infection. “It is evident from these considerations that the interpretation of the socalled functional mental disorders is following the course already taken in functional diseases of other organs, Le., that we hate to recognzze the physzcal nature of the dzsturbance.” “The traditional attitude of psychiatrists that mental disorders were in fact diseases of the mind and not, as we are forced to believe today, disorders of the brain, has led students of the subject to concentrate their attention exclusively upon the psychogenic or mental factors, ascribing to them and to heredity the most important role in the causation of these diseases. No attempt is made to eliminate entirely the importance of the mental factors in producing a psychosis for they have their proper place. They are, however, of secondary importance t o the toxic factors about to be described.
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“It is idle to deny that worry, grief, shock, mental overwork and other factors have a distinct role in this mechanism. They undoubtedly occur in a large number of patients, but, on the other hand, in a number of cases they are absent. Is it not fatuous to suppose that because present in some cases they must be present’ in all, even when a thorough investigation fails to disclose them? The relative importance of the psychogenic factors diminishes in proportion as they are found to be absent. “Of what practical value is it to strive to see things that cannot be demonstrated? We are not in accord with the extreme Freudian who wants to account for all psychoses on a sexual basis. Such dogmatic reasoning has led to the conclusion that mental disorders could be cured only by mental therapy and we know that such treatment has been in general very disappointing. “Mental factors are contributory in the mechanism of the psychoses. Such factors undoubtedly lower the patient’s vitality-lower the immunity to infection and produce profound physical disturbances. The loss of appetite, disturbance of nutrition, loss of sleep,-the result of these psychogenic factors-will cause latent infections, which may have existed for years, to become active and virulent. “It is probable that the emotional reactions, having a profound effect upon the ductless glands, lower the resistance sufficiently to allow the latent infection to become active. I t must be admitted that the exact mechanism is not known. Further investigations will help to decide the relation of emotional disturbances to the pathology of the ductless glands and infection. “No matter what the outcome of such investigations may be, we do know that the infections should be considered far more important in the production of mental disease than heredity, mental factors, environmental defects, personality, and improper training, because they can be directly controlled. “Many cases occur in which such causes as love affairs, disappointment. in love, domestic difficulties, conjugal disharmony, financial reverses,-to mention only a very few,-are considered to be the only cause of the psychosis. I n these cases we have never failed to find serious and often extensive local foci of infection. Following the removal of this infection, if the disease has not been of too long duration, the mental disturbance is very apt to adjust itself. Often these patients have to return to the same environment and their domestic difficulties cannot be disposed of as they should be for the comfort of the patient. “But, in spite of these unfortunate situations, many of our detoxicated and recovered patients have been able to weather the storms and to go through difficulties which would have sent them back to the hospital in former days. One history should be cited to show the effect of detoxication by the removal of focal infection, not only in restoring the patient to a normal mental state, after a period of ten years of almost constant hospital residence, without normal intervals, but also to show how she met and conquered real domestic difficulties after her return to her home.
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“This patient had suffered from depression with intervals of slight’ improvement, during which efforts had been made to keep her at home, but having on two occasions made attempts a t suicide she had to be returned to a private hospital. During this time she had no thought for her husband as she was too self-centered and took no interest in his affairs. As a result the husband became interested in other women. Three months after admission to the State Hospital, she recovered, following the removal of her infected tonsils, her infected teeth having been extracted on admission. The change was most’ pronounced. When admitted, she was thin, emaciated, and spent her time standing in the corner of her room taking no interest. in her surroundings, whining and crying. She gained rapidly in weight and her appearance changed from a very pitiful sight to one of great attractiveness. (When she recovered the husband was reluctant to take her home. She found a very unpleasant condition of affairs. Her husband was infatuated with another woman of ill-repute, and did everything he could to get her back to the hospital, even threatening her with divorce and bringing this woman to live with the patient’s children. Our sympathy was aroused and on investigating the circumstances we found her statement correct and not delusional, as her husband would have had us believe. She accepted a position in the hospital for the time being, hoping that matters would improve. Finally, she returned home and after a year or more of extremely bitter experience, the situation adjusted itself and there is no further trouble. She recovered in the fall of 1918 and in spite of this harrowing experience she never had any return of her former depression, although, according to those who place so much stress upon the psychogenic factors, there was ample cause. I t is significant to note that at the time of the onset of her trouble no psychogenic factors were present, at’ least not to the extent following her recovery and return home. I t is also important to note that the psychosis was of ten years’ duration and recovery followed removal of the tonsils. “There can be no doubt that the endocrin system plays an important role in the mechanism of mental disorders. The ductless glands, notably the thyroid, thymus, pituitary, adrenals, and sex glands, when they are functioning normally, furnish very definite and specific secretions, which are necessary to the proper development and functioning of the various activities of the entire organism. The activities of these glands are very closely related; disturbance of one undoubtedly causes disturbances in the others. Their function may be inhibitory or stimulating, thus maintaining a proper equilibrium in the body. “The nervous system is very sensitive to disturbances of the ductless glands and we know definitely that the thyroid exerts a specific influence on it as well as on the sex glands. Cannon and other physiologists have shown that an infinitesimal portion of a grain of the internal secretion of the adrenal gland will cause an amazing reaction in the bodily metabolism. “Likewise, the absence of thyroid secretion causes a mental condition known as cretinism, in which the patient has all the appearance of an imbecile. If extract of the thyroid gland is fed to these patients, early enough,
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WILDER D. BANCROFT AND J. E. RUTZLER, JR.
the mental disease may be arrested. There are also other conditions in the adult, known as myxoedema, and caused by lack of thyroid secretion, which can also be relieved by feeding thyroid extract. An excess of secretion by these glands, or an abnormal secretion, may also exert a toxic influence on the whole body, especially on the nervous system. “The treatment of conditions due to hyperactivity of the glands is much easier than treatment directed to supplying a deficient secretion. In the former case very often the glands can be partially removed by surgical means and thus rid the system of the excess secretion. This is especially true of the thyroid, a large proportion of which can be removed without danger to the patient. The other glands are not so easily removed. “It is not altogether clear what factors are concerned in producing these disturbances of the ductless glands. I t has been demonstrated that anger, fear, and other emotional disturbances, acting through the sympathetic system, will materially, but transiently, affect the secretions of these glands. Psychogenic factors, then, existing over prolonged periods, may well cause extensive disturbance in the ductless glands, producing a t first an abnormal hypersecretion, often followed by a distinct, permanent, structural char?ge. I t is possible that such disturbances occur independent of chronic infection, but we have found that these disturbances of the ductless glands are closely related to infection. “Our experience is entirely in accord with that of Billings, Barker and others, namely that t,he chronic infections have a direct secondary influence upon the ductless glands. These observers are of the opinion that it is possible to restore the function of the ductless glands by removing chronic foci of infection. For instance, an enlarged thyroid will frequently return to normal, following the removal of infected teeth and tonsils. This restoration, however, is proportionate to the amount of damage caused in the thyroid gland by the circulating toxin. If this damage has gone beyond the point of repair, as is frequently the case, then the abnormal condition can be remedied only by excision of the gland. Very few of our patients were benefitted by efforts to correct conditions in the ductless glands, without first eliminating the infection and toxemia. Consequently, we are inclined to believe that infection and toxemia are the primary factors in the majority of cases, and that the disturbance of the ductless glands is secondary. “Further investigation in this field is necessary before final and definite conclusion regarding the role of the ductless glands in the mechanism of ment’al disorders can be reached. Enough is known, however, to make certain that the first step in the treatment is to remove the chronic foci of infection, then, if disturbances of the ductless glands persist, and it can be determined that the failure of the patient to recover is due to such disturbances, measures directed toward this secondary condition should be instituted. It is highly probable that, in a small number of our unsuccessful cases the failure is due to the persistance of these disturbances. Much work yet remains to be done in this most important field.
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[‘From the discussion of the factors involved in the production of a psychosis it can be seen that the causes vary in different individuals. I n some cases hereditary influences may produce a distinct susceptibility and create a more fertile soil for the development of a psychosis. Emphasis, however, must be laid on the fact that while this influence may favor such a development it is not essential to its production. Furthermore, while psychogenic factors, when present, also exert an important influence, these may be absent and yet a psychosis may develop. The most important and constant factor is the toxemia resulting from chronic infections. “In the majority of mental cases there is undoubtedly a combination of the factors already discussed and all should be taken into careful consideration in the effort to restore the patient to a normal mental condition. In some instances the hereditary and psychogenic factors may appear to be most prominent and in others the infections and disturbances of the ductless glands. I n the treatment of mental disorder it must be realized that hereditary influences cannot be changed. The attack then should be directed upon the factors which can be eliminated from the patient’s system, which, in the present state of our knowledge, is limited to the chronic infection referred to above.” “Unfortunately for the many chronic patients confined in hospitals for the insane today, their disease has progressed to the stage where remedial therapy is entirely unsuccessful. There are at the State Hospital at Trenton 900 cases of dementia praecox, none of whom will ever recover. I t has been difficult to impress this fact upon the friends and relatives of the chronic patients who apply for admission to the State Hospital. To this class of patients, and especially their friends, undoubtedly the publicity given to this work has been most unfortunate. I t has arcused hope for treatment in these cases when as we have explained none can be expected. “We have stated repeatedly that nothing can be done for the chronic patients, especially dementia praecox in the terminal stage. But, in spite of all this, the idea persists that these methods are applicable to all stages of the disease. Elimination of infection to be effective in arresting the mental symptoms must be instituted early, otherwise no favorable outcome can be expected. The reason for this is that the brain tissue has probably become permanently affected as a result of the long-standing toxemia and no repair is possible, even with the elimination of the original infection. But, the situation, in the early stages of the chronic mental disorders, is quite different. When treatment is instituted early it has proven successful in arresting the mental symptoms whether diagnosed as dementia praecoxthe deteriorating type of psychosis,-or manic depressive insanity which tends toward spontaneous recovery. This statement is supported by the fact that the chronic cases in the State Hospital have not increased in the last three years, in fact there has been actually a decrease and not an accumulation of those patients as was formerly the invariable rule. Over j0 percent of the permanent residents belong to the dementia praecox group. Practically all of these cases could not only have been prevented but their symptoms arrested after
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WILDER D. BANCROFT AND J. E. RUTZLER, JR
the onset, if the methods of eliminating chronic infection had been applied. There can be no excuse for failure to treat such cases in early stages now that the cause is known. S o stronger plea could be offered for the prosecution of the work outlined in these pages than the effect it has had in arrest,ing the ever-increasing number of human derelicts, now consigned, for the rest of their years, t,o mental obscurity and darkness. “The ‘do-nothing’ policy of those who continue to oppose any form of treatment, because they are convinced that insanity is the result of hereditary causes and constitutional defects and, therefore, inevitable and incurable, is beyond comprehension. However, for these afflicted individuals there is the prospect of the dawning of a better day. These relics of medical superstition and barbarism will be supplanted by modern biological conceptions based upon the proper recognition of the true relation of structure to function.” Bolton’ is on the side of the biologists; but he does not like toxaemia which is the whole thing to Cotton, and it is not absolutely clear to the layman what happens to the cortical neurones and why. At the time this book was published ( 1 9 1 4 ) ~its author was apparently Professor of Mental Diseases at the University of Leeds and Medical Director of the West Riding Asylum. The preface was written at the West Riding Asylum in Wakefield. “For reasons which will appear in subsequent chapters, I subdivide all cases of mental disease into two categories, namely: (I) cases which, from the macroscopic post-mortem aspect, exhibit abnormal, no abnormal, no morbid, or slight morbid appearances; and ( 2 ) cases which exhibit morbid signs of any higher grade of intensity, and, in some instances, abnormal appearances also. “The former group, from the clinical aspect, I class under the term Amentia, which I employ to connote the mental condition of patients suffering from dejicient neuronic development; and the latter under the term Dementia, which I employ to signify the mental condition of patients who suffer f r o m a permanent psychic disability due to neuronic degeneration following i n s u f i c i e n t durability. “The subjects of amentia, therefore, as I shall suggest from the macroscopic and prove from the microscopic aspect, sufferfi.om a more or less inarked grade of snb-evolution of the cerebrum. The chief clinical varieties of amentia are low-grade amentia, or idiocy and imbecility of all grades with or without epilepsy, and high-grade amentia, which includes moral, unstable and excited cases, together with cranks and asylum curiosities, recurrent cases of all types, hysteria, epileptic insanity, and true paranoia and allied cases.” “The subjects of dementia, as I shall indicate both macroscopically and microscopically, suffer f r o m a nioye or less marked grade of i n z d u t i o n or dissolut,ion of the cerebrum. I group all such cases into a primarily neuronic class composed of senile, presenile, mature and premature types; into a progressive and secondary class which includes senile and presenile dementia associated “The Brain in Health and Disease,”
j,6 , 162 i1914).
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with gross degeneration of the cerebral vessels, and general paralysis and kindred pathological conditions; and into a class of special varieties following sense deprivation, epilepsy and cerebral lesions. “This generalisation of amentia and dementia is a gross one, and, as I shall indicate, is based on the fact that cases of mental disease exhibit, a lesion of the cortex of the prefrontal region of the cerebrum, which lesion, in the case of amentia, is of the nature of a true sub-evolution, and, in the case of dementia, is of the nature of a true involution or dissolution. “The existence of amentia does not preclude the onset of dementia, the milder grades of which may in fact be regarded as the normal result of cerebral senility in all persons, sane or insane, who survive to the necessary age-period, which, however, varies great’ly in accordance with their individual personal cerebral durability. In many idiots, for example, cerebral senility occurs before the age of forty years, and in some normal persons indications of its onset are absent, at the age of eighty. “The necessity precursor of dementia, whether this be severe or mild, of a rapid or of slow development, is a more or less severe grade of Mental Confusion, which term I employ to connote, in the broadest sense, the mental symptoms occurring in association with certain pathological states of the cortical neurones, which m a y be followed by the?-ecouery, or by a more or less extensire dissolution of these elements. I n the former case, in which the symptomatology is incited by temporary or removable causes-e.g. alcoholic excess-complete recovery often occurs. In the latter, a more or less severe grade of dementia ensues. Further, certain clinical indications are frequently, though not constantly present which enable a prognosis to be made as to whether a given case which exhibits mental confusion is recoverable or will develop dementia. Again, it is certain that recoverable mental confusion may occur in persons possessing normal cerebra. Lastly, mental confusion followed by dementia more commonly occurs in cases with cerebra of normal or relatively normal development, though probably of deficient neuronic durability, than in cases with cerebra which exhibit some grade of sub-evolution. The generalisation may in fact be made that the greater t,he grade of amentia the less is the tendency to dementia, not through a more normal durability of the cortical neurones of the former, but owing to the fact that cases of amentia so readily suffer from symptoms of mental alienation under any form of stress that as a rule little or no irreparable damage to the cortical neurones results from its influence.” “I hope that recognition of the fact t,hat,mental disease consists in essence of a large group of cases with varying degrees and types of cerebral degeneracy and of another larger group with varying degrees and types of cerebral dissolution will be of value at a time when, with the object of elucidating the aetiology of insanity with a view to its prevention, even a bacterial origin of mental alienation has been seriously discussed. If the views expressed in the present volume receive credence, I trust that future attempts to deal seriously with the incidence of mental disease will treat the subject, not as a branch of infectious disease or at any rate a toxaemia, but as the greatest of the de-
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generacies; and that an endeavour will be made on the one hand to discover and to minimise the causes which lead to cerebral degeneracy and on the other to diminish the ‘stress’ (in the widest sense) to which actual degenerates are subjected, with the object of decreasing the degree and the frequency of cerebral dissolution.” Bolton’s. views are not necessarily inconsistent with those of Cotton though Bolton thinks they are. Bolton is interested primarily in the anatomical structure and not. in the causes that produce it. Cotton is interested primarily in the toxic effects which produce anatomical changes in the brain. Bolton would undoubtedly accept Cotton’s dictum that there can be no abnormal function without a corresponding abnormal structure. AS chemists it is our duty to hold fast to this dictum until it is definitely proved wrong in some cases. While it is conceivable that there may be conditions under which one may have insanity with a normal brain, it is hopelessly unprofitable to make such an assumption unnecessarily. Paton‘ takes a sane, intermediate view. “There is no department of medicine in which the investigator needs to be in more intimate touch with the advances of modern science than in psychiatry. The problems to be solved by it are mainly of general, not special, interest. I t not only forms a branch of general medicine, but should be classed with other biological studies. Science has demonstrated that the anomalies in thought, action, volition, and emotion, popularly referred to as fornis of insanity, are the expression of a disordered functioning of the central nervous system. Gradually we are awakening to an appreciation of the fact that the same general methods of investigation that are applicable in the study of all biological sciences may be successfully adopted in attacking the problems connected with mental diseases. “Let us consider very briefly the methods which the alienist may employ in dealing with psychic phenomena. The problems to be solved can be approached from several stand-points which for the sake of convenience can be described as psychological, clinical, chemico-physical, and anatomicopathological. A word may here be said regarding the attitude of the alienist towards the study of mental phenomena or the functions of the cerebral cortex. Instead of contenting himself with a nai’ve psychology founded upon theory and speculation, he has been taught to rely upon the basis of steady, painstaking observation, substantiating his results whenever possible by experiment. And by these methods alone will it become possible to attain a comprehensive rational understanding of the nature of insanity. The point of view of the modern physiologist, that organic processes are referable to physico-chemical changes, offers another vantage ground, since physiology also teaches that material changes in any organ give rise t o disorders of function. The brain is no exception to this rule. Changes in consciousness, anomalies in t,he emotional life, impairment of volition, are merely expressions of a disturbance in equilibrium of the functions of the brain. In this country, 1
“Psychiatry,”
2 (190jj.
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particularly, the alienist is singularly indebted to the physiologist and to the psychologist, not only for keeping alive and stimulating interest in the study of mental phenomena, but also for valuable contributions that have been made by both to our knowledge of the functions of the central nervous system, So little is known, so much still remains to be found out, and the speculative tendency in certain quarters is so strong, that the temptation to substitute theory for observation and experiment has to be met and resisted a t every turn. The relation of body and mind is still an enticing theme for the philosopher, but to spend valuable time in theorizing as to the manner in which the ultimate solution of this problem will be effected belongs only to those who live in a realm that is far afield from the path of the clinician. New points of view are always desirable, if they ultimately lead to the discovery of additional facts; but psychiatry cannot afford to build upon shifting sands. The theories of psycho-physic parallelism and of neo-vitalism may afford useful working hypotheses to many investigators, but their adoption as philosophical creeds should be a matter of no concern to the alienist. The attempt to establish a ‘psychological basis’ for the study of mental disease is quite as undesirable as would be the attempt to limit clinical medicine to the mere study of symptoms. The psychological method is a useful aid to investigation, but to consider its scope and methods as the end-all of modern psychiatry shows no appreciation of the advances that have already been made. Great as has been the stimulus derived from psychological studies, the alienist fully appreciates that his line of investigation differs essentially from that of the psychologist. “But before pointing out more in detail the positive advantages derived from the new psychology a word of caution is necessary. The facts derived from observation and experiment have thwarted the attempts of those who have tried to transform the useful working hypotheses expressed in the theory of psycho-physic parallelism into dogmas. Even those who were formerly the most ardent supporters of this doctrine are now willing to admit that, while the parallelism may hold in the case of the simpler sensations, it cannot be applied to the more complicated psychic phenomena. Even in the analysis of the simpler mental phenomena it is impossible to correlate the so-called mental and physical events. In all the cerebral processes, from the simplest sensations to the most complex psychic phenomena, there is a series of physicochemical changes that take place, and these, so far as is known, have no immediate correlates in the mental sphere. A series of ether vibrations strikes the ear and the individual may become conscious of a musical note. How is each event in this physical chain to be correlated with those comprising thp psychic phenomenon? And, in fact, do not the teachings of modern science demonstrate the futility of such an attempt? According to the psychophysical theory the individual events in one place are not contrasted with those in the other, but what is actually attempted is the establishment of a parallelism between a whole series of events on the physical side with those in the mental sphere.
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WILDER D. BANCROFT A N D J. E. RUTZLER, JR.
“But it may be asked, Who shall determine exactly the two series of events that are to be contrasted? What is to be called physical and what mental; and what censor shall decide the question for us? The careful analysis of the cerebral functions has resulted in the destruction of the artificial barriers that were supposed to separate them from each other. The differences of gradation but not of quality are recognized. The power of discrimination between violet and yellow, heat and cold, pleasure and pain, represents to each sentient individual important distinctions, but by what right do we assume that in the final analysis these differences are not referable to physical processes that vary only in degree and intensity? For all that we know to the contrary there are no abrupt divisions or chasms to be crossed. The cerebral processes vary, but they do so by degrees, by shading off into each other without gap and without break in continuity. “It would be superfluous to emphasize the necessity of far more active cooperation in America between psychologist and psychiatrist were there not abundant evidence of the lack of communism of interests. Two facts have contributed to this unfortunate condition. In the first place, too many students of normal mental phenomena start with philosophical speculation and make exact observation and the recording of facts of merely secondary importance. This attitude in a measure accounts for the widespread and not unjustifiable scepticism abroad as to the true merit of many of the so-called psychological investigations. And again, when a recognized leader in the modern school of psychology has actually admitted defeat and declared that his specialty never can become a science, is it to be expected that the wares he offers for sale are to be taken at more than their appraised value? But, happily, although he may have succeeded in demonstrating the inefficiency of his own methods, he has failed signally in the attempt to pr, ve that all others are equally untrustworthy. More hopeful investigators-and, fortunately, they represent the large majority of psychologists-still have faith in the efficacy of patient and well directed observation. The end is not yet in view, but a bright and brilliant page is being written, and even in the face of what seem to be insuperable difficulties the investigator, in the light of the advances that have been made since Herbart’s day, finds reason to take courage and begin the attack anew. Observation, whether it be introspective in character or be applied to the study of mental phenomena noted in others, is being carried on with more rigorous exactitude than ever before. This is still the period of critical analysis. The period of synthesis will come as soon as the methods of introspection, of observation of the normal and abnormal mental processes, and of experiment stand the crucial tests applied to them.” At Cornell the general theory of Claude Bernard in regard to anesthesia has been developed to the point that the next step beyond the position of Cotton has been taken,‘ in that we are able to specify what the abnormal changes in the brain are in incipient insanity, at any rate in the simple cases. From the literature it is evident that there are two general types of insanity, Bancroft and Richter: R o c . Nat. Acad. Sci., 17, 294;J. Phys. Chem., 35, 1606 (1931)
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one in which the brain colloids are slightly over-coagulated or puckered, and the other in which the brain colloids are slightly over-peptized or mushy. These changes may be so slight that there would be no possibility of detecting them microscopically. Consequently, we must resort to indirect methods if we are going to prove our point. I t was shown in the first paper that the abnormal symptoms of the coagulated type should be alleviated by treatment with suitable peptizing agents, while the abnormal symptoms of the peptized type should be alleviated by treatment with suitable coagulating agents. While there is evidence to that effect in the literature, it is purely haphazard evidence. The investigators did not know that there were two types of insanity, and they used specific drugs without knowing that these belonged either to the class of peptizing or coagulating agents. Since nobody tried both peptizing and coagulating agents even accidentally, nobody knew what the failures were due to, and there were failures. It seemed desirable, therefore, to have tests made on a considerable number of insane patients, starting with the simplest cat3eF: and testing them both with coagulating agents and with peptizing agents. I n this way it would be possible to tell to what extent it is possible to divide insane patients sharply into two classes, one of which is helped by peptizing agents and is made worse by coagulating agents, while the other class is helped by coagulating agents and made worse by peptizing agents. As coagulating agent sodium amytal was obviously one to try because good results had previously been obtained' with it. Previous investigators had used sodium bromide2 without knowing that it was a peptizing agent; but we are in a position to predict that sodium rhodanate, NaSCN, will be much better. We3 are using the German term, rhodanate, in the future, because we find that biologists, medical men and newspaper men confuse the terms sodium thiocyanate or sodium sulphocyanide with sodium thiosulphate or sodium cyanide. Since this compound is likely to be used more frequently by medical men in the future than in the past, it seems wiser to adopt an arbitrary but less misleading name for it. By feeding sodium and potassium rhodanate for several weeks Borg' has developed insanity in certain patients who were supposed to be suffering only from high blood pressure; but this was only a disturbing incident to him and he failed to see the real significance of his experiments. As was pointed out in a previous paper, sodium iodide, though a good peptizing agent for proteins, cannot be used because of the specific action of the iodide ion. Dr. Lang5of the Willard State Hospital has run tests with sodium rhodanate and sodium amytal on forty-six patients suffering from functional psychoses. These tests were continued for a week or until it was fairly certain whether the patient was or was not made better or worse. In some cases the results were very clear-cut. Case I had suffered from dementia praecox cataLorenz: Psychiatric Quarterly, 4, 9 j (1930). *Wright: Am. J. Psychiatry, 5 , 365 (1926). Bsncroft and Rutzler: J. Phys. Chem., 35, 3036, (1931). Minnesota Medicine, 13, 281 (1930). Lang and Paterson: J. Phys. Chem., 35, 3425 (1931).
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WILDER D. BANCROFT AND J. E. RUTZLER, JR.
tonia for five years. His ordinary characteristics were: stupor, seclusive, untidy, refused to care for personal needs. After oral administration of sodium amytal, there was a slow and steady improvement. He asked for work; assisted in cleaning and polishing; kept his clothes neat and himself clean; was in good contact with surroundings. After oral administration of sodium rhodanate, there was a confused stupor reaction. He was very pale, sat with his head bowed and made no response; was untidy and dirty. After stopping the sodium rhodanate, he went back to the state before the experiment began. There is a marked improvement with sodium amytal and a marked deterioration with sodium rhodanate. The man is obviously of the dispersion type. Dr. Lang uses the term schizoid instead of dispersion and cycloid instead of agglomerated or coagulated. If these words are more satisfactory to the medical profession, they should be adopted. In this phraseology, this case of dementia praecox catatonia is of the schizoid type of insanity. Case 18 was diagnosed as epilepsy. Before treatment he was uneasy, talkative, restless, threatening, subject occasionally to terrific excitement when he requires restraint t o prevent injury. After oral administration of sodium amytal, he fell into a deep sleep. On awakening he was irritable, restless, would not work, and refused to co-operate. After administration of sodium rhodanate, there was slow but steady improvement. He became wellbehaved and quiet, worked occasionally on ward which he does very well; sleeps the entire night which is in contrast with previous behavior. This man is definitely of the agglomerated or cycloid type. His improvement was not accompanied by any change in blood pressure. Case 3 4 was diagnosed as manic depressive, depressed. Before treatment she was restless, agitated, anxious, whining, and slept very poorly. Sodium amytal produced deep narcosis, followed by agitation, excitement and worry. After administration of sodium rhodanate, she was at first agitated and disturbed, but became quiet. She is clear mantally, not so noisy and no longer untidy. Her condition is improved and she was definitely the agglomerated or cycloid type. Case 14 is interesting and shows one of the complications that may occur in short tests. He was diagnosed as manic depressive, manic. Before treatment he showed marked excitement; was noisy, restless and agitated; refused food, was destructive to clothing; showed impulsiveness and assaultiveness. Was mute. On administration of sodium amytal he shon-ed intoxication, followed by narcosis. After that he was more excited and his condition was worse. I t is quite clear that sodium amytal made him worse. Consequently sodium rhodanate should make him better. The actual results were not quite what was expected. With sodium rhodanate he became depressed. There was a brief normal period and then he became stuporous and negativistic, refusing food. He slept well; he would not speak but would shake hands. When the sodium rhodanate was stopped, there was a slow recovery and he is still improving. He will speak a t times now.
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The explanation of this seems to be that the patient responds quickly to sodium rhodanate, that he was given too much, and that he was carried clean over from the cycloid insanity to the schizoid insanity. After stopping the sodium rhodanate he came back to a much more normal period than he was in before treatment. It is probable that small enough doses of sodium rhodanate will improve his condition dist'inctly. Case 35 is similar in principle but with the drugs reversed. The diagnosis was dementia praecox catatonic and the behavior before treatment was uneasy, quiet, restless, and wanders about disturbed. When sodium rhodanate was given she became very noisy, depressed, and stupid; was unable t'o help herself and very untidy. There is no doubt' but that she became worse under sodium rhodanate. Sodium amytal produced deep narcosis and then short periods of stimulation. She became more alert and was co-operative, which was all as it should be. Continued dosage with sodium amytal resulted in excitement and she was apparently carried over from schizoid insanity to a mild form of cycloid insanity. I n a number of cases tmhetests witli sodium amytal and sodium rhodanate have led to a change in the diagnosis. Case 2 was diagnosed once as alcoholic and once as apathy and depression. Before treatment the patient showed stupor and depression, was negativistic and generally untidy but not dirty. He had to be coaxed to eat. He was fearful but' could not give the cause of his fear. After oral administration of sodium amytal, he became alert and interested, cared for his person properly and slept well. R h e n the sodium amytal was stopped, the stupor returned promptly but was no worse than before. With sodium rhodanate the stupor was increased. The patient was untidy, and dirty, and did not feed himself properly. 7Vhen the sodium rhodanate was stopped, the patient returned to the original state. The case could not possibly be an alcoholic one because sodium rhodanate should have helped it and could not h a w made it worse. The diagnosis was changed because of these tests. When the patient was in the improved state due to sodium amytal, he described his depression as due to an unknown fear. He had the delusion war was to occur all over the world. The test indicated that a state of over-peptization existed and that the diagnosis should have been schizophrenia. Case 5 was diagnosed as dementia praecox, hebephrenic. Before treatment the behavior was excited, restless, untidy, noisy, with. an occasional clear time when he would speak English. At other times his productions were incoherent and in German, his childhood language. With sodium amytal he became excited, stimulated, and drowsy, after which there was a short narcosis. Following this he was over-active and destructive. He showed many mannerisms, grimaces, and fantastic poses; but while he was in these bizarre attitudes that appeared catatonic-like, he only adopted them when he knew that he was being observed. He enjoyed the effect of this behavior on others. This indicates the presence of a strong affect but mischievous in direction.
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WILDER D. BANCHOFT AND J. E. RCTTZLER, JR.
With sodium rhodanate there was slow and steady improvement. He requested his own clothes, talked in English coherently, and has maintained this improvement for two months. Drs. Lang and Paterson say that “this is an individual whose behavior reaction under amytal would be called dementia praecox catatonia. Actually in his usual state the diagnosis has alternated between dementia praecox hebephrenic and manic depressive mixed, according to the observer. This alternation indicates that we have here a case with marked schizoid tendencies; but that affect was not split off, was still strong, and was adapted to the situation a t an adult level. The behavior under sodium rhodanate would, according to our experimental findings, place him in the agglomerated or cycloid group, which correlates with the manic depressive classification.” Case 9 was diagnosed as mental deficiency, excitement. Before treatment he appeared very fearful and anxious; was noisy, excited, over-active, violent, destructive, and untidy; but not dirty in personal habits. Oral administration of sodium amytal caused excitement with increased restlessness and overactivity. With sodium rhodanate there were increased periods of quietness and he slept well. He appeared stupid at times; but there was slow improvement. He ate better and was neat and tidy in appearance. He is now at home on parole. Drs. Lang and Paterson say that in this case not only was the exhibition of sodium rhodanate of diagnostic value, indicating a manic depressive type; but it was also therapeutic in action. Case 2 1 was diagnosed as manic depressive, depressed. Before treatment he was depressed, worried, fearful, anxious, untidy in personal appearance, confused, and required constant supervision to keep him from getting into difficulty. He would not, eat well. K i t h sodium amytal there was deep sleep and ataxia. He became clear mentally, was happy, alert and able to discuss the situation. While in this state he was able to tell of his fears, anxieties and delusions of persecution, and ideas of bodily harm. With sodium rhodanate he became sulky, sarcastic, noisy, irritable, and violent. He slept fairly well at night. Drs. Lang and Paterson say: “Again we find our tests indicating that our classification was wrong, that it was based on the symptoms presented t o us by the patient and not on knowledge of his mental state. JVhen contact was made, we then found a delusional state with fears and ideas of persecution, indicating a schizophrenia. He presents an over-peptized state that is improved by agglomeration. Because of our more adequate information we do not now consider that he is a case of manic depressive.” Case 24 was diagnosed as involut,ion melancholia. Before treatment he was depressed, anxious, fearful, worried, and constantly complaining of somatic difficulties. He was restless at night and could not sleep. With sodium amytal he became more interested and alert; showed improvement and enjoyed deep sleep. With sodium rhodanate he appeared uneasy, stuporous and confused. He did not talk but slept well at night. The comment on this case is that we find here that more definite information was obtained when the patient was able to discuss the situation more
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freely under sodium amytal. The somatic ideas were predominant and delusional in character. Schizoid tendencies predominated; this has been recognized in involution melancholia so that in this classification we have two types-one benign or cycloid-predominant which would recover and the other schizoid-predominating with a poor prognosis. Case 37 was diagnosed as dementia praecox (?) or manic depressive, manic (?). Before treatment she was disturbed, restless, uneasy, and violent at times. She would stare continuously at the ceiling. With sodium amytal there was deep sleep and no intoxication. She has shown steady improvement and is clearing very quickly. With sodium rhodanate she became stuporous, untidy, destructive, and definitely worse. The physicians say: “This case was a t first diagnosed manic depressive and was then changed to dementia praecox. From the test she would be considered as of the over-dispersed group. The diagnosis might very properly be catatonic schizophrenia. The patient would not co-operate in examination and further could scarcely speak English.” Case 39 is just the reverse. She was diagnosed as dementia praecox, paranoid (?). Before treatment she was restless, uneasy, crying, and noisy. With sodium amytal there was deep narcosis, marked intoxication, severe dizziness, and excitement. With sodium rhodanate she became quiet and assisted with work. She had periods of excitement and short periods of restlessness; but has shown a steady improvement. Because of the positive reaction to sodium rhodanate, she belongs to the agglomerated group. No information as to mental content was obtained as she could not speak English and would not talk to the interpreter. She appeared under much fear, which is not unusual in these cases. Case 40 \
