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.