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THE LOUIS CLARK VANUXEM FOUNDATION LECTURES FOR 1921
THE LOUIS CLARK VANUXEM FOUNDATION OF PRINCETON UNIVERSITY
was established in 1912 with a bequest of $25,000 under the will of Louis Clark Vanuxem, of the Class of 1879. By direction of the executors of Mr. Vanuxem's estate, the income of the Foundation is to be used for a series of public lectures delivered in Princeton annually, at least one half of which shall be on subjects of current scientific interest. The lectures are to be published and distributed among schools and libraries generally.
The following lectures have been published:
The Theory of Permutable Functions, by Vito Volterra.
Lectures delivered in connection with the dedication of the Graduate College of Princeton University, by Emile Boutroux, Alois Riehl, A. D. Godley, and Arthur Shipley.
Romance, by Sir Walter Raleigh.
A Critique of the Theory of Evolution, by Thomas Hunt Mor- gan.
Platonism, by Paul Elmer More.
Human Efficiency and Levels of Intelligence, by Henry Her- bert Goddard.
Civilization and Philosophy in The Middle Ages, by Maurice De Wulf.
c
Louis Clark Vanuxem Foundation
THE DEFECTIVE DELINQUENT AND INSANE
THE RELATION OF FOCAL INFECTIONS TO THEIR CAUSATION, TREATMENT AND PREVENTION
BY
HENRY A. COTTON, M.D.,
MEDICAL DIRECTOR, NEW JERSEY STATE HOSPITAL AT TRENTON.
LECTURER IN PSYCHO-PATHOLOGY, PRINCETON UNIVERSITY.
DIRECTOR, PSYCHIATRIC CLINIC FOR CORRECTIONAL INSTITUTIONS
OF NEW JERSEY.
WITH A FOREWORD
ADOLF MEYER, M.D.
DIRECTOR OF THE HENRY PHIPPS PSYCHIATRIC CLINIC. JOHNS HOPKINS HOSPITAL AND PROFESSOR OF PSYCHIATRY, JOHNS HOPKINS UNIVERSITY
\
LECTURES DELIVERED AT PRINCETON UNIVERSITY, JANUARY 11, 13, 14, 15, 1921
PRINCETON UNIVERSITY PRESS
PRINCETON
LONDON : HUMPHREY MILFORD
OXFORD UNIVERSITY PRESS
1921
Copyright, 1921, by Princeton University Press
Published, 1921 Printed in the United States of America
FOREWORD
Will the author pardon a frank appreciation of the present lectures by an old friend who has followed the energetic and aggressive work with interest and admiration?
The evaluation of focal infections is an outstanding contribu- tion of twentieth century medicine. To focus the attention up- on a potential enemy of health, and fortunately in a field ac- cessible to work without elimination of vital functions, such as we experienced in the days of wholesale ovariotomies and the like. Dr. Cotton has been among the foremost in pushing to its logical end the freeing of the organism of the insidious infec- tions. He appears to have brought out palpable results not attained by any previous or contemporary attack on the grave problem of mental disorder. The advocacy of the aggressive policy unfortunately caught the eager eye of the press and the public before the trial had run the gauntlet of professional criticism and, — what would be more important — retrial at the hands of others. To see the reports and promises spread in a popular or semi-popular course of lectures may add to the tendency to off-hand criticism, yet this is not an age in which paternalism is expected to protect the public with Latin pas- sages when only the initiated should be admitted. Hence why should we judge a frank utterance given at the author's and reader's own risks unless we can offer an equally good and convincing array of facts in favor of a more generally satisfying picture of "things as they are"?
To the physician I should recommend a patient reading, and the determination to judge only by the results of efforts which have been completely carried out. To pull a few teeth without doing a thorough and reasonably complete job, is not doing justice to the demands of the real cleansing. To say that everybody has these difficulties is also a very poor argument. The question is: Does the thorough cleansing show advanta- geous results or not? Is it possible to rouse the conscience for health sufficiently to see to it that the numerous focal infections are attended to before they infest or affect the whole organism?
vi Foreword
Can better methods and safe experience reduce the problem to a good preventive and curative technique?
To the lay reader I should give the warning not to sit in judgment over the physician who is conservative and not to run at once to the man who promises marvels. But I should advise those who can do it to ask that funds be put at the disposal of dependable organizations that can put such a promising issue to a thoroughly controlled test. It seems almost impossible to get the support for the necessary organization of controlled work, probably because of the wide-spread illusion that there already exist well-endowed centers of work.
If these lectures stimulate physicians and laymen to furnish means for extensive well-controlled trials, I shall feel that the somewhat extreme claims which go beyond what I personally believe to be my experience, may find their excuse in good re- sults. Let the best agencies come together and give the best talent, the best opportunities for work from all sides. Let crit- icism be constructive and not only restrictive. Let us see that under proper conditions we may even have a certain surplus of opportunity instead of the deplorable and disgraceful half- way measures with which the study of mental diseases has had to skimp along with just enough for administrative necessities, with hardly a cent of steady support for what the active work- ers have most longed for and worked for.
The work for mental health must be carried on where active and determined work is the order of the day. The New Jersey State Hospital at Trenton has proved to be such a place. An important experiment is being carried out there. These lec- tures give a forcible picture of what is being done on focal in- fections. If means could be made available to carry out and follow out Dr. Cotton's substantial and not merely speculative work, psychiatry would make another large contribution of im- portance far beyond its own special sphere of mental hygiene, and it would find for its own further development a group of patients relieved of one of the insidious sapping influences taxing humanity, thus offering a free field to work with the many other features which are bound to play a role.
Adolf Meyer.
Baltimore,
April 15, 1921.
TABLE OF CONTENTS
PAGE
Foreword iii
Introduction 1
Chapter I. The Problem of the Insane 4
( 1 ) Historical 4
(2) Sociologic Problems 6
(3) Problem of the Defective and Delinquent 10
( 4 ) Biological Consideration^f the Nature of
Insanity T 11
(5) Indirect Action of Physical Disorders on
the Brain 16
Chapter II. Causes of Mental Disorders 19
(1) Heredity 19
(2) Malevolence of the Doctrine of Heredity 21
(3) Psychogenic Factors 22
(4) Disturbances of Endocrin System 25
(5) Combined Factors in Producing a Psy-
choses 27
(6) Diagnostic Survey of the Patient 31
(7) Summary 31
Chapter III. The Systemic Effects of Chronic Infec- tions 33
( 1 ) The Nature of Chronic Infections 33
(2) Immunity 35
(3) Origin of Chronic Infections 35
(4) Dissemination of Bacteria Concerned in
Focal Infection 36
(5) Character of the Micro-organisms Causing
Focal Infection 37
(6) Mixed Infections 40
(7) Primary Foci of Infection — Teeth 41
(8) Types of Infected Teeth 42
vii
Vlll
Table of Contents
PAGE
(9) Unerupted and Impacted Teeth 43
(10) Teeth with Infected Roots, Apical Ab-
scesses 51
(11) Decayed or Carious Teeth 54
(12) Apparently Healthy Teeth with Peridon-
titis 55
(13) Poorly Filled Teeth with Evidence of In-
fection 56
(14) Pyorrhoea 58
(15) Exostosis and Sclerosis of Teeth 59*
(16) Children's Teeth 59
(17) Tonsils -62
( 18) Secondary Foci in Stomach and Duodenum 64
(19) Infection of Lower Intestinal Tract 66
(20) Genito-Urinary Tract 67
(21) Systemic Involvement through Focal In-
fection 70
(22) The Selective Activity of Pathogenic Bac-
teria 73
(23) Summary and Conclusions 74
Chapter IV. Types of Mental Disorders and their
Treatment 77
( 1 ) Toxic Psychoses 77
(2) Psychological Phenomena 80
(3) Paresis 81
(4) Psychoses Due to Alcohol 84
(5) The "Nervous" and "Neurotic" Individual 86
(6) The Treatment of Toxic Psychoses 91
(7) Detoxication of the Psychotic Patient ... . 91
(8) Methods Used in Making a Diagnostic
Survey 93
(9) Tonsils 95
(10) Gastro-Intestinal Tract 96
(11) Infections of Lower Intestinal Tract. ... 97
(12) Genital Organs 102
(13) Infection of the Sinuses 102
(14) Discussion of Treatment ,,.,.. 103
Table of Contents ix
PAGE
(15) Vaccine Therapy 103
(16) Serum Therapy 106
(17) Routine Treatment 107
(18) Necessity for Detoxication 107
(19) Other Methods of Treatment 108
(20) Hydrotherapy 109
(21) Psychotherapy 109
(22) Recreation and Occupation 110
(23) Results of the Work at the State Hospital
at Trenton HI
(24) Permanence of Recoveries 116
(25) Delay in Treatment 120
Chapter V. Report of Cases 123
Case 1 — Agitated depression with confusion in a man act 35, of 7 mos. duration. Re- covery 2 days after extraction of in- fected molars 124
Case 2 — Depression in a woman aet 55. Marked heredity (fa. died of melancholia, aet 64). Remained 2 yrs. in hospital be- fore infected teeth were extracted. Rapid recovery following extraction . . 124
Case 3 — Dementia Praecox Reaction in a Syrian girl, aet 17, of 4 mos. duration, with sudden recovery following extraction of 4 impacted third molars or wisdom teeth 125
Case 4 — Mute stuporous reaction in a young married woman, aet 22. Result of dis- regarding advice a year previous to on- set of psychosis. Recovery following extraction of infected teeth and re- moval of tonsils 127
Case 5 — Confused maniacal state in widow aet 26. Prolonged worry over death of husband and overwork. Three mos. duration and recovery after removal of tonsils and extraction of infected teeth . 127
Table of Contents
PAGE
Case 6 — Neurasthenic condition of 20 yrs. dura- tion, terminating in attack of depres- sion, caused by infected teeth and ton- sils. Gain of 40 lbs. in weight. Com- plete recovery 129
Case 7 — Depression of 2 yrs. duration in a man aet 53. Removal of infected tonsils and extraction of infected teeth with no im- provement. Recovery following treat- ment by autogenous vaccine 130
Case 8 — Confused depressed state in a man aet 35, with pronounced "hereditary taint" (father and grandfather depressed). Duration of psychosis 2 yrs. Recovery following extraction of infected teeth and treatment by autogenous vaccine. 130
Case 9 — Dementia Praecox reaction in a Ger- man girl aet 22. Pronounced psycho- genic factors, worry, illegitimate preg- nancy and loss of lover. Duration 2 1/2 yrs. Recovery following enuclea- tion of infected cervix and administra- tion of vaccines and removal of tonsils 131
Case 10 — Periodic attacks of depression, first at- tack aet 19, spontaneous recovery. Normal interval of 6 yrs. then a second attack lasting 3 yrs. with pronounced loss of weight. Impacted molars ex- tracted, infected tonsils removed, but no gain in either mental or physical condition until enucleation of infected cervix. Recovery and gain of 80 lbs. in weight 132
Case 11 — Maniacal condition in a married woman aet 31. Three attacks in four yrs. Spontaneous recovery from first two at- tacks. Recovery following extraction
Table of Contents xi
PAGE
of infected teeth, removal of infected tonsils. Recurrence of symptoms one year later which disappeared after enucleation of infected cervix 133
Qase 12 — Periodic depression in a married woman aet 27. First attack followed child- birth, aet 19. Second attack, aet 25. Spontaneous recovery first two attacks. Headaches, vertigo, bilious attacks and constipation. Infected teeth extracted, infected tonsils removed. Enucleation of infected cervix followed by prompt recovery. Three years in one hospital 135
Case 13 — Periodic maniacal and depressed at- tacks. First attack of depression aet 24. Second attack maniacal. Spon- taneous recovery of first two attacks. Third attack maniacal in type, aet 32. Prompt recovery following removal of infected tonsils, extraction of infected teeth and treatment by autogenous vac- cine. Psychogenic factors only cause considered in 1913 136
Case 14 — Depression in a single woman aet 48. Pronounced "heredity," father, mother, brother and sister had depressed at- tacks. Infected teeth extracted, tonsils removed. No improvement until in- fected uterus, tubes and ovaries re- moved and treatment by anti-strepto- coccus serum. Psychogenic factors — grief over death of brother and over- work 138
Case 15 — Chronic type of psychosis of 19 yrs. duration (10 yrs. spent in another hos- pital) in a woman aet 44. Recovery
xii Table of Contents
PAGE
following extraction of 11 infected teeth and removal of ovarian tumor 139
Case 16 — Dementia Praecox reaction in a man aet 32. Duration 7 yrs. with remissions. Removal of infected tonsils and extrac- tion of infected teeth without result. After 2 yrs. in hospital recovery fol- lowed enucleation of infected seminal vesicles 141
Case 17 — Paranoid condition in a married man aet 42. Duration 6 mos. prior to treat- ment. Recovery following extraction of infected teeth. Recurrence in a year with recovery following removal of in- fected tonsils and another infected tooth and administration of autogenous vac- cine 143
Case 18 — Maniacal state alternating with nega- tivism with vivid auditory hallucinations in a Russian Jewess, aet 17. Infected teeth extracted and infected tonsils re- moved with no improvement. Recovery following ileostomy, removal of in- fected appendix, and administration of antistreptococcus serum 145
Case 19 — Maniacal state in a married woman aet 28. No result from extraction of in- fected teeth, removal of infected ton- sils or administration of anti-strepto- cocus and anti-colon bacillus serum. Large portion of infected colon re- moved with prompt recovery in 2 days 147
Case 20 — Similar to Case 19. Maniacal state in a single girl, aet 28. No result from extraction of infected teeth, removal of infected tonsils, or administration of serum. Recovery followed removal of infected colon 150
Table of Contents xiii
PAGE
Case 21 — Maniacal state following childbirth in a married woman, aet 22. No result following extraction of infected teeth, removal of tonsils, or enucleation of in- fected cervix. Infected colon resected, but no improvement until administra- tion of anti-streptococcus serum. Re- covery 152
Case 22 — Dementia Praecox reaction in a single man aet 28. Exceptionally good family history. College graduate and lawyer. Psychosis of two yrs. duration. Ex- traction of infected teeth, removal of in- fected tonsils, autogenous vaccine fol- lowed by great improvement. Removal of infected colon, followed by recovery 152
Case 23 — Periodic maniacal attack following childbirth on two occasions in a colored woman, aet 31. Recovery followed re- moval of infected tonsils and enuclea- tion of infected cervix 155
Case 24 — Dementia Praecox reaction in a single girl, aet 25. Exceptionally good family history, environment and training. Duration nearly 5 yrs. Infected mo- lars, infected tonsils, infected cervix and serious infection of colon. Treat- ment unsuccessful. Death due to colon bacillus infection 156
Case 25 — Sudden maniacal excitement in a single woman, aet 43. Peculiarities for years. Sister found dead and patient in a maniacal delirium. Infected teeth, ton- sils and intestinal tract. Death 9 das. after onset of maniacal attack, due to general streptococcic infection 161
XIV Table of Contents
PAGE
Chapter VI. The Defective Types 166
(1) Mentally Retarded and Feebleminded. . . 166
(2) The Juvenile Delinquent 172
(3) Methods of Dealing with the Defective
Delinquent 175
Chapter VII. Mental Hygiene 177
(1) Prevention of Mental Disorders 177
(2) Mental and Physical Hygiene of the Child 177
(3) Children's Teeth 178
(4) Tonsils and Adenoids 179
(5) Gastro-Intestinal Tract 180
(6) The "Nervous Child" 181
(7) Sexual Irregularities 183
(8) Transmission of Infection from Parents
to Children 183
(9) Organization of a Model Psychopathic
Hospital 184
(10) Community Surveys 190
Conclusion 191
Bibliography 193
Index 197
LIST OF ILLUSTRATIONS
PAGE
Fig. 1 Chart showing fourfold increase of the insane as compared to the increase of the general popu- lation 7
Fig. 2 Chart showing the rate of insane per 100,000
population in institutions in the various states 9 Fig. 3 Chart showing rate of defectives per 100,000
population in institutions in various states. . 12 Fig. 4 Radiographs of the teeth in two patients suffer- ing from attacks of manic depressive insanity,
showing pivots or Richmond crowns 43
Figs. 5-6 Infected unerupted and impacted teeth 44-45
Fig. 7 Apical Abscesses and granuloma 50
Fig. 8 Apical abscesses and granuloma 52
Fig. 9 Poorly filled root canals with apical infection. Decayed teeth with apical infection and ap- parently healthy teeth with infection 57
Fig. 10 Peridonotitis 58
Fig. 11 Sclerotic roots of teeth in a case of paresis 62
Fig. 12 View of mouth showing enlarged and infected
tonsils 63
Figs. 13-14 Charts showing gastric acidity before and
after treatment by autogenous vaccines 65
Fig. 15 Photograph of the mucous lining of the colon . . 68 Fig. 16 Drawing of section of sigmoid and descending colon showing various types of chronic ulcer-
tion 69
Fig. 17 Chart showing proportion of the different types of insanity admitted in the New York State Hospitals in 1918, total admissions 6,797. . . 78 Fig. 18 Chart showing census of patients in the New York State Hospitals according to the types of insanity out of a total of 37,352 79
XV
xvi List of Illustrations
Fig. 19 Proportion of alcoholic insanity to total male
admissions, 1908 to 1920 85
Fig. 20 Radiographic studies of the fmiction of the gas- tro-intestinal tract by means of the barium test meal 98
Fig. 21 Megasigmoid 100
Fig. 22 Dilated cecum with constrictions causing ob- struction 100
Fig. 23 Table showing monthly average proportion of discharge to admissions, New Jersey State Hospital at Trenton, 1908-1918 112
Fig. 24 Table showing net annual increases and de- creases in population, New Jersey State Hos- pital at Trenton, 1908-1918 114
Fig. 25 Proportion of discharges to admission of pa- tients classified in the "functional group" 1908-1918 115
Fig. 26 Residual cases at the end of each year, in the
"functional group" 1908-1918 117
Fig. 27 Drawing of a section of the left side of colon
showing result of infection 121
Fig. 28a Enlarged glands in the mesentery of the je- junum or beginning of the small intestine. . 149
Fig. 28b Bands of adhesions forming typical "Elbow
Deformity" of the cecum 149
Fig. 29 Charts showing four different stomach tests in case 22, before and after the administration of autogenous vaccine 154
Fig. 30 Radiograph of an impacted molar in a boy age
13, suffering from an acute manic attack. . . 179
Fig. 31 Enlarged cecum and terminal ileum in a child 4
years old 182
Fig. 32 Functional organization Chart for a model psy- chopathic Hospital 187
INTRODUCTION
Science has thrown hght on almost every field of human en- deavor, to the lasting benefit of mankind. Only within the last two decades, however, has the beneficent power of scientific investigation infiltrated the realm of psychiatry.
Prior to the pioneer work of Adolf Meyer, there had been no evidence in America, except in an extremely fragmentary way, of any effort to apply scientific principles to the study of mental disorders. Those physicians are still young who were brought up in the age-old traditions which, like folk-lore, and equally unsuited to the task at hand, had been handed down from generation to generation, without question as to their ac- curacy and finality. Some of these traditions were part and parcel of the medical lore elaborated in prehistoric times when the function of priest and physician were one.
More than a century ago, general medicine began to break down these superstitions and to rebuild upon a scientific basis. Is it not to be expected that supernatural methods and ex- planations should have lingered longest about that branch of medicine which dealt with the invisible — the intangible factors of human life and human frailty?
Medicine is, very properly, conservative, for many new ideas are constantly being brought forward — often the result of im- mature speculation and without any scientific basis — and the physician must necessarily remain agnostic. But there is a distinct difference between fancy and fact, and if a new concep- tion of the etiology or nature of a given disease is advanced, no matter how much that conception may deviate from the tra- ditional teachings, if based upon scientific evidence and proof, it is not to be condemned simply because it upsets all previous con- ceptions and traditions.
Scientific achievement is usually the result of the summation of a large number of apparently unrelated discoveries, due to independent investigations. This is quite evident in such de-
1
2 The Defective Delinquent and Insane
velopments, for instance, as the aeroplane. Without our knowledge of electricity, and the internal combustion motor, the aeroplane would still be an impossibility. So with medicine and the epoch-making work of Pasteur. He was not a physi- cian but a chemist, who while attempting to alleviate the troubles of the silk industiy laid the foundations of the germ theory of disease and revolutionized the practice of medicine.
Malaria, known to all, and showing in its very name, the er- roneous notion of its origin, has been proven by scientific meth- ods of study to be due to the parasite of a certain mosquito, instead of to bad air, as was formerly believed.
A host of examples might be cited to show how our ideas have been upset over night, as it were, requiring a readjust- ment of our thoughts to the new truths which had developed and which today constitute modem medicine. All of these great truths have had to fight their way to recognition through a maze of opposition and apathy, due to the conservative dis- inclination of mankind to be uprooted from fixed, and crystal- lized hereditary ideas.
One notable fact in the progress of medical science has been the dissociation of mystery and medicine. Formerly, the pub- lic was kept in ignorance of the nature and cause of disease. Such confidence was placed in the physician that, irrespective of treatment, when he appeared the patient immediately im- proved. The mysteries of medicine were sacred to the physi- cian. He was impressive in garments and gold-headed cane. To further shroud his hypnotic power he wrote in Latin. Great care was exercised lest the patient become too familiar with medical lore.
As medicine developed, however, it became necessary that the public be informed on certain matters, especially those re- lating to the avoidance of disease, and with regard to legislation to prevent carelessness on the part of the unthinking members of the community. Thus, individuals with contagious diseases came to be isolated and for the time restrained of their liberty. Compulsory vaccination had to be enforced to prevent epi- demics of smallpox ; pollution of streams used for water for the community had to be prevented because of epidemics of typhoid
Introduction 8
fever; stagnant water had to be eliminated to prevent the breed- ing of the mosquito responsible for malaria. Many other ex- amples could be cited of public enlightenment having been necessary to prevent disease, an illustration of the natural growth of a collective, cooperative and protective power among the citizens of a democracy. This marked a decided change in the attitude of the profession and to none was it more welcome than to the progressive physician.
The writer considers himself extremely fortunate in having spent his early professional life under the inspiring guidance of Adolf Meyer and Stewart Paton. From them, in great de- gree, has sprung the initiative necessary during the past twenty years for the continued investigation of the problems herein discussed. To Kraeplin and Alzheimer he is indebted for the opportunity to study the subject from the anatomical as well as clinical standpoint, which has furnished the necessary groundwork for later investigations.
More recently, he has obtained help and scientific data from the pioneer work of Billings, Barker, Hastings, Rosenow, King, Draper, Rehfuss, Satterlee, Holman, Winslow, Dochez, Upson and others in the medical profession and from Thoma, Grieves and others among the dental profession.
To Adolf Meyer, John F. Anderson, John W. Draper, and Edwin G. Conklin, he is indebted for scientific advice, for en- couragement in the prosecution of these studies and for valu- able assistance in the preparation of these lectures.
To the member of the medical, the dental and the laboratory staffs, the Roentgenologist, the supervisors, nurses and attend- ants, and to the consulting and attending staff of the hospital, grateful acknowledgment is made for their individual interest and ability, and particularly for their persistency of effort and cohesion in the face of many difficulties and discouragements.
This, coupled with a remarkable solidarity of purpose has made it possible to further these researches and to achieve the results herein chronicled.
The drawings of the pathological conditions have been done by the well known medical illustrator, Henry E. Lehmann.
CHAPTER I
THE PROBLEM OF THE INSANE
Historical
A blot upon our civilization has been the lack of proper care of the insane. Prior to the epoch-making philanthropic work of Dorothea Dix — 1840 to 1880 — the insane were confined in jails, almshouses, dingy cellars, outhouses, often in manacles and chains. Deprived of medical attention; always in an un- favorable environment; always a subject of gross physical abuse by their keepers and often improperly fed and clothed, their lot in life was a deplorable one. This condition was the result of the traditional fear of the insane who, long before Biblical times, were considered as possessed of devils, incurable ; objects, sometimes, of derision and scorn rather than of pity and always of loathing and abuse. So great was the stigma, now happily set at naught, that many families actually hid or utterly repudiated afflicted members.
While there had been feeble attempts in other states, notably South Carolina, Virginia and Massachusetts, to furnish ade- quate accommodations, it was not until Dorothea Dix, at infi- nite pains and after long study, memoralized the Legislature of New Jersey, that the modern state hospital system was in- stituted. The State Hospital at Trenton was the first result of her efforts. Later on, this remarkable woman, hardly known to the present generation, succeeded in obtaining ap- propriations which established hospitals for the insane in twenty-one states.
The period prior to her emancipating work may well be designated as the "Age of Iron." The treatment by inflexible shackles reflected the inhuman attitude of the public and the profession toward this unfortunate grovip of patients. Al- though the physical surroundings of the patients were ma-
4
The Problem of the Insane 5
terially improved by the establishment of the state hospital sys- tem there still remained the traditional fear of the insane pa- tient and while the methods of treatment were modified and im- proved, mechanical restraint was considered proper and neces- sary.
Medical treatment did not follow the placing of these pa- tients in so-called "hospitals." They were, in fact, as well as in name, "Asylums." There was but little choice between re- straint by iron cages and leather straight- jackets. This was largely because of the persistence of the traditional fear of the patients on the part of physicians and nurses and it was not unusual for patients to be horribly abused. Innumerable deaths resulted from such treatment. This period may well be described as the "Age of Leather." It has been faithfully por- trayed by Clifford Beers in his remarkable book "The Mind That Found Itself."
That mechanical restraint is not justifiable was shown over a century ago by Pinel, in France, Tuke, Hill and ConoUy in England, and later by C. W. Page in this country. In spite of these demonstrations, which proved both the iniquity and the utter uselessness of mechanical restraint, the officials of institutions persisted in its use and unavoidable abuse.
Even today, at least 80 per cent of all hospitals for the in- sane throughout the country continue, to their own shame and to the detriment of their patients, to employ mechanical re- straint. There is no necessity for it, as the writer can testify from personal experience. When he took charge of the State Hospital at Trenton, in 1907, he found over ninety women in straight jackets and all other forms of restraint were in daily use. In less than two months over seven hundred pieces of restraint apparatus were removed from the wards and since that time no patient has been put in restraint for any cause. The present should be called the "Age of Non-Restraint." It is not surprising that with the state of affairs existing in almost all hospitals there was a total lack of constructive medi- cal work. While nominally called hospitals these institutions were, and many still are, merely custodial asylums.
The first ray of scientific light began to show itself with the
6 The Defective Delinquent and Insane
establishment of hospital laboratories and with it dawned the "Age of Research." The names and personalities of Adolf Meyer, Stewart Paton and August Hoch, will remain indellibly stamped upon this very important period. From their initia- tive and far-sighted vision in the application of scientific re- search to psychiatry this long neglected and important depart- ment of medicine has at length been accorded the position and consideration which is so necessary to its continued develop- ment. A forecast of the future should reveal the dismantling of the old asylums and institutions and the development of psychiatric clinics, synthesized and correlated with the groups of sciences which together make modern medicine. Then, and then only, will the defective, the delinquent, the "neurotic," the "neurasthenic" and the "psychotic" receive the modern care to which they are entitled.
Finally, is there any reason why these patients should be de- nied the physical studies, interpretations and general hospital treatment so profitable to the public at large simply because the infection to which they are subject happens to have affected the brain rather than the heart or joints? The answer is self- evident. Fortunately for the psychiatrist his function of classi- fying and diagnosing mental disorders will soon become a relatively minor part of his activities. In the future he will extend his work into the fruitful field of relief, so limited under the old regime. This will be made possible only through col- laboration with the best minds in medicine and surgery. This entente cordiale already developed in other fields of medicine is imperative in the field of psychiatry, for it will terminate the "Age of Isolation" and usher in that much to be desired epoch, the "Age of Treatment and Prevention."
SociOLOGic Problems
Recent statistics, compiled by the National Committee for Mental Hygiene, reveal the alarming fact that at the end of the year of 1918 there were 232,680 patients confined in the hospitals for the insane in the country. The insane in alms- houses, penal and reformatory institutions are not included in these figures. And further, over 75,000 patients are yearly
The Problem of the Insane
PEW CENT OF INCREASE
500
450
400
350
300
250
200
150
100
50
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1880
1890
PE8 CENT OF INCREASE
458.3
110..
1904* 1910 1918 1920
*No special census of patients was tai<en in 1900
Fig. 1. Increase of patients with mental disease in institutions compared with increase of general population of the United States, 1880-1920. (From reprint No. 103, National Committee for Mental Hygiene, by Pollock and Furbush.)
8 The Defective Delinquent and Insane
admitted to the state hospitals. This report also reveals the fact that the increase in the ratio of admission per 10,000 popu- lation during the last eight years has varied from 15 per cent in New Jersey to 68 per cent in Montana. In Michigan the increase has been 27 per cent ; in New Hampshire 25 per cent ; in Massachusetts 26 per cent; in Florida 48 per cent.
Only nine states showed a decrease in the admission rate. This varies from .02 per cent in Wisconsin to 1.4 per cent in Nevada and the latter was the highest rate of decrease reported. The ratio of the insane to the general population varies in the different states, the highest occurring in New York and Massa- chusetts. These facts show that the reports of the enormous increase in the proportion of insane to the population in this country, are by no means exaggerated, viz,: fourfold. (See
Until quite recently the medical profession and the public in general have viewed this condition with complacency and no serious attempt has been made to solve the enormous medical and sociological problems involved. It has been taken for granted that insanity was inevitable to a certain proportion of the population and that because nothing had been accomplished in the field of prevention and relief in the past, therefore noth- ing could be done. This general spirit of pessimism in regard to the problem of the insane made the future of this unfortu- nate class of individuals very dark indeed. But, forbidding as the problem may seem, it is our intention to show not only that there is hope for the recovery of many of these patients, now considered incurable, but also that if the methods herein presented are adopted early by the profession at large, much insanity will be prevented.
While the methods of treatment and prevention outlined herein are not presented as final, it is hoped and believed that like many other incompletely developed preliminary studies in a new field they may furnish a valuable, practical basis for further research which will ultimately result, if not in total prevention, at least, in the material improvement of the status of this great group of misjudged unfortunates.
The Problem of the Insane
PATIENTS WITH MENTAL DISEASE IN INSTITUTIONS IN THE UNITED
STA*"^, WITH RATES PER 100,000 OF GENERAL POPUIATION,
JANUARY 1, 1920
RATE PER 100,000 fOO too 900
1 NEW YORK
2 MASSACHUSETTS
3 CONNECTICUT
4 OREGON 6 VERMONT
6 WISCONSIN
7 CALIFbRNIA
8 NEVADA
9 NEW HAMPSHIRE
10 MARYLAND
11 RHODE ISLAND
12 WASHINGTON
13 MINNESOTA
14 IOWA
15 NEW JERSEY
16 ILLINOIS
17 DELAWARE
18 PENNSYLVANIA
19 MAINE
20 OHIO
21 MICHIGAN
22 MISSOURI
23 NEBRASKA
24 MONTANA
25 NORTH DAKOTA
26 INDIANA
27 SOUTH DAKOTA
28 VIRGINIA
29 COLORADO
30 KANSAS
31 KENTUCKY
32 ARIZONA
33 LOUISIANA
34 GEORGIA
35 WYOMING
36 FLORIDA
37 IDAHO
38 NORTH CAROLINA
39 WEST VIRGINIA
40 TEXAS
41 UTAH
42 SOUTH CAROLINA
43 TENNESSEE
44 MISSISSIPPI
45 NEW MEXICO
46 OKLAHOMA
47 ALABAMA
48 ARKANSAS
UNITED STATES
400
374.6 373.8 317.8 311.1 310.7 300.6 297.2 284.2 276.0 274.1 252.8 252.3 249.8 248.1 234.4 229.5 220.2 215.2 214.4 212 a 210.8 204.1 202.4 200.8 192.5 191.1 185.7 184.0 178.8 172.6 171.9 140.5 130.7 129.6 127.6 126.9 126.2 124.3 123.5 119.8 118.8 112.5 111.4 101.0 98.8 98.1 95.3 83.1 220.1
Fig. 2. From reprint No. 103, National Committee for Mental Hygiene, by Pol- lock and Furbush.
10 The Defective Delinquent and Insane
Problem of the Defective and the Delinquent
The study and care and treatment of the dehnquent class has not kept pace with the study of the same problems in the field of mental disease. It has been only recently that any at- tempt to depart from the old ideas of punitive criminology has arisen. That the delinquent has sinned and consequently must be punished was the fundamental idea activating all those con- cerned in the care of these individuals. The pubhc at large had, in great measure, the same idea regarding the punishment of those who came into conflict with the law. Whether or not the individuals were wholly responsible for their acts did not occur to those interested as even a possibility. A crime had been committed and the individual must be confined in an in- stitution not only for punishment but for the protection of so- ciety against future crime. With the expiration of a sentence, these individuals were again turned out into the community, many of them in the same condition or often worse than when admitted to the institution. No classification was made. No one attempted to differentiate between the mentally abnormal and the mentally normal delinquents but all were treated alike.
Recent figures, compiled by the Census Bureau, show that there are admitted to correctional institutions of this country over five hundred thousand persons annually. By the introduc- tion of the indeterminate sentence whereby parole boards have a larger latitude in the discharge of prisoners, the population of the various correctional institutions has been materially re- duced. But, there is still an ever increasing number of indi- viduals who come into conflict with the law with resulting loss of liberty.
That the public conscience is awakening to the necessity for a better psychological, psychiatric, and physical examiation of this class, is evident from the fact that recently a psychiatric clinic, connected with the prison at Sing Sing, under Dr. Bernard Gleuck, has been established, and at the Bed- ford Reformatory a similar clinic was opened for the study of these problems. The establishment of a psychiatric clinic for correctional institutions of New Jersey is another step for- ward in the proper classification and treatment of the delin-
The Problem of the Insane 11
quent group. In a few states the courts recognize the impor- tance of such a classification of the dehnquent — especially the juvenile types — and insist upon a thorough psychiatric and psychological examination before passing sentence in these cases. The physical examinations are only beginning to receive adequate attention.
While the work in these fields has not progressed to the point where definite information can be obtained, it is conservative to say that from sixty to seventy per cent of those confined in correctional institutions may be classed as normal, the other thirty or forty per cent as distinctly abnormal. One way this abnormality manifests itself is in the individual's reaction to discipline.
Instead of realizing the fact that they have done wrong and that by obeying the rules of the institution they will obtain their release, they develop an attitude of antagonism to the officers and the rules of the institution and have to be disciplined daily for habitual infractions of the regulations. They lose their chance for early parole and discharge from the institution and soon become the trouble makers, easily led into mischief and a source of disturbance in the institution. Continued dis- cipline only makes them worse and yet in a disciplinary insti- tution no other way has been found to treat them.
Such types as described above, from our experience and the experience of others who have taken a progressive and broad- minded view of the problem, do not belong in disciplinary in- stitutions but should be confined in hospitals where their ab- normality is recognized, the symptoms properly interpreted and the causative conditions treated. It is evident that the problem of this group becomes one for the psychiatrist, physi- cian and surgeon, rather than as heretofore considered, ex- clusively for the penologist.
Biological Considerations of the Nature of Insanity
For years we have been content to consider mental disorders in two large groups, designated as "organic" and "functional." This division was based upon the fact that in the first group pathological changes in the brain tissue, which could account for
12
The Defective Delinquent and Insane
MENTAL DEFECTIVES IN INSTITOTIONS IN THE UNITED STATES,
WITH RATES PER 100,000 OP GENERAL POPULATION,
JANUARY 1, 1920
RATE PER 100,000 *» » 1%
t I L_
1 MASSACHUSETTS
2 IOWA
3 NEW HAMPSHIRE
4 MARYLAND
5 MINI^SOTA
6 WISCONSIN
7 OREGON
8 MAINE
9 NEW JERSEY
10 NEW YORK
11 SOUTH DAKOTA
12 NEBRASKA
13 RHODE ISLAND
14 MICHIGAN
15 PENNSYLVANIA
16 ILLINOIS
17 WASHINGTON
18 INDIANA
19 OHIO
20 KANSAS
21 VERMONT
22 WYOMING
23 CONNECTICUT
24 NORTH DAKOTA
25 MISSOURI
26 COLORADO
27 CALIFORNIA
28 KENTUCKY
29 IDAHO
30 OKLAHOMA
31 WEST VIRGINIA
32 LOUISIANA 35 MONTANA
34 VIRGINIA
35 FLORIDA
36 UTAH
37 ARIZONA
38 SOUTH CAROLINA
39 ARKANSAS
40 MISSISSIPPI
41 TENNESSEE
42 NORTH CAROLINA
43 TEXAS
44 NEVADA
45 ALABAMA
46 GEORGIA
47 DELAWARE
48 NEW MEXICO
UNITED STATES
82.9
70.9
70.9
66.1
62.9
61.7
60^6
56.2
55.8
55.5
54.4
52.6'
51.6
50:4
49.1
48.5
44.7
4^.1
42.3
41.3
36.0
36.0
33.9
33.1
30.8
28.2
28.2
26.5
26.4
26.3
26.1
23.8
23.7
17.7
15.7
15.4
9.6
9.2
8.6
7.6
7.2
6.7
4.8
2,6
1.2
0.2
0.0
0.0
38.3
Fig. 3. From Reprint No. 103, National Committee for Mental Hygiene, by Pol- lock and Furbush.
The Problem of the Insane 13
the "mental disease," were demonstrable, while in the so-called functional group, for a long time, investigations, owing to in- adequate methods, failed to reveal changes in the brain which could account for the mental symptoms.
This led to the erroneous viewpoint that certain mental dis- orders could occur independent of any changes in the brain. From this view we unhesitatingly dissent. A too literal inter- pretation of Virchow'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 Enghsh 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 fur- ther supported 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 as the sole cause operating in this group. It 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 dis- ease in the last fifty years, during which time the mental picture has been subjected to the closest analysis, and every possible forni of psychic treatment has been tried and proved useless. This is evident also from the fact that the percentages of re- coveries of this class of patients has decreased rather than in- creased 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 ad- missions is only 6.9 per cent and if improved cases are included the ratio is only 24 per cent. It is conservative to state that not over 25 per cent of the patients admitted to state hospitals throughout the country are sufficiently improved to leave the institutions permanently. This rate is due entirely to spontan- eous recovery, not to any definite therapy, either psychoanaly- tic or otherwise.
One has only to turn to works on modem medicine for con- demnation of this misinterpretation of the relation of function
14 The Defective Delinquent and Insane
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 re- peatedly 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 func- tion is to structure." Also, "Any cell may be functionally modi- fied 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 ex- planation of this relief is that the epithelial cells of the appen- dix have undergone invisible but extensive bio-chemical alter- ations, 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 functional mental disturb- ances, the biologists have produced evidence regarding func- tion 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 corresponding abnormal struc- ture. 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 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. It cannot be considered apart from the body. Every known scientific fact substanti-
The Problem of the Insane 15
ates this viewpoint. When the brain tissue is affected or de- stroyed 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 prop- erly, 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 that 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. In senile dementia, the insanity of old age, it has been found that the disease is a result of definite destructive changes in the brain tissue. In arterio- sclerotic brain disease a similar condition is found, due to the diseases of the arteries and dis- turbances 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 the 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 en- tirely 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 con- ditions in the brain tissue; and while this may be difficult to demonstrate conclusively, sufficient data is at hand to prove that such a relation does exist and that, when the abnormal brain conditions are corrected, the abnormal mental symptoms disappear.
16 The Defective Delinquent and Insane
This viewpoint is in harmony with Meyer's well known con- ception of psychobiology, which he defines as forming "clearly and simply the missing chapter of ordinary physiology and pathology, the chapter dealing with functions of the total per- son and not merely of detachable parts." His conception of integration is far more logical than the discarded theory of Fechner's psycho-physical parallelism and gives us a better idea of the relations of body to mind. "By making of mind," he says, "something like the religious-philosophic concept of the soul, something opposed to the body instead of a function of the individual as a whole, traditional philosophy and psychology have rendered us a poor service."
His conception of psychobiology is opposed to "the ever lurking interest in the occult and semi-occult" seeking to "re- place it by solid confidence in reliable methods and by deter- mined interest in matters obviously calling for serious objective study/'
In the present state of our knowledge we cannot hope to construct a thorough and finished scheme which will explain everything, but many facts are now known which will help to a better understanding of the relations of body and mind.
Indirect Action of Physical Disorders ON THE Brain
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 ex- change 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
The Problem of the Insane 17
toxins. Or, the brain 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-nerv- ous replacement elements, 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 per- manent. Thus, in delirium tremens, the result of alcohol pois- oning, we have a profound mental disturbance. This, how- ever, may disappear within twenty-four hours after the alco- hol is withdrawn and the patient has had a good night's sleep. No lesion may be found in the brain. In other forms of alco- holic 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 the mental symptoms and in such cases brain cell changes may be found.
In other words, the changes in the brain, the result of poison- ing, may have reached such a stage that repair is no longer possible, even after the toxin is eliminated. They are perma- nent and often visible. It is logical to assume that these con- ditions 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 spon- taneously, even when the symptoms exhibited are very pro- found 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 re- covery.
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 neces- sarily true as we have already seen, on bio-chemical evidence, as well as clinically, in delirium tremens. In 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
18 The Defective Delinquent and Insane
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 interpreta- tion of the so-called functional mental disorders is following the course already taken in functional diseases of other organs, i.e., that we have to recognize the physical nature of the dis- turbance.
CHAPTER II
CAUSES OF MENTAL DISORDERS
Heredity
From time immemorial the influence of heredity has been considered of paramount importance in the causation of mental disease. This doctrine is not only fixed in the mind of the medical profession but also in that of the laity. Among the people at large, whether educated or otherwise, every family is stigmatized by the occurrence of insanity in a member. This viewpoint is so old, so deep rooted an inheritance from past ages that it is almost as fixed as are the immutable dogmas of religion.
We maintain that the doctrine of "hereditary transmission of mental diseases" is very unstable from a scientific standpoint. The term has been used rather loosely and often without justi- fication. The fact that there has been "insanity in the family" often without recording the relation between the member of the family and the patient, is used as a basis for hereditaiy taint and seldom, if ever, has the character of the mental disease, or the time of life in which it occurred in the parent, been brought into relation with the individual patient. Thus, an individual in a normal mental condition may have contracted syphilis long after children were born and still later have developed paresis and been sent to an institution. Then, from extrinsic causes, a child may have developed mental trouble later on and while there would be no scientific basis for considering heredity as a cause of insanity in this specific case, yet the fact that the father was insane would be considered in most hospital records as distinct evidence that heredity was the cause of the patient's trouble.
'No person is able to change his inheritance for that is de- termined as early as the fertilization of the egg. As to the
19
20 The Defective Delinquent and Insane
immutability of heredity and our strange and fatalistic de- pendence for what we really are on what has been called the "shuffle of the chromosomes," we have only to quote from E. G. Conklin: "Each living thing in the world has come into ex- istence by a process of development. The entire human per- sonality, mind as well as body, has thus arisen. The factors of development may be classified as intrinsic in the organization of the germ cells and extrinsic as represented in the environ- mental forces and conditions. The intrinsic factors are those that are commonly called heredity, and they direct and guide development in the main. The extrinsic or environmental fac- tors furnish the conditions in which development takes place, and they modify, more or less, its course."
As is well known, the intrinsic factors are determined wholly by the permutations and combinations of the chromosomes and these are beyond human control. Further Conklin says: "In man there are probably 48 chromosomes. The possible number of different types of fertilized eggs which could be pro- duced by a single pair of parents would be approximately three hundred thousand billions. The production of unique individu- als seems to be the chief purpose and result of sexual repro- duction."
These quotations are given to show the immense degree of complexity surrounding the entire problem of heredity and also to illustrate the positive, particular and definite facts which have been finally established regarding the mechanism of in- heritance. Chief among these, from a standpoint, both of pre- ventive psychiatry and of practical therapeusis, is the immuta- bility of the individual's inherited characteristics and the proof that the trend of these cannot be altered one iota by environ- ment. Under certain conditions they can no doubt be retarded, and under others accelerated, as Stockard has shown ; but under no condition can these inherent congenital characteristics be altered. Development may be modified but not heredity. The sooner this biologic law and its important relationship, not only to preventive medicine but to psychiatry as well, is more generally recognized, the better.
While we are thus hopeless, except for the far-off interven-
Causes of Mental Disorders 21
tion of eugenics, regarding a given individual whose character- istics and traits are irrevocably fixed by his antecedants, we are in no such dilemma as regards the effect on such individuals of pathogenic bacteria and their toxins.
Again, an extensive and important literature is developing as to defects, particularly in the alimentary canal, which de- fects are coming, or have come, to be regarded as due to heredi- tary transmission. These defects will be discussed later on.
Malevolence of the Doctrine of Heredity The doctrine of heredity as applied in the field of mental disorders has been detrimental and destructive. Not only have the individuals directly concerned suffered great hardships but others as well. For example, children having a parent men- tally affected have hesitated to marry because of a possible *'taint," and in addition have been terrified at the prospect of some day developing the same condition. Furthermore, it has exerted a pernicious influence on both the study and treatment of mental disorders. For if we believe firmly in these doctrines of heredity and the "inherited constitution" which means in a broader sense that in certain cases mental disease is inevitable and that nothing can be done to prevent or to cure it, then evi- dently it would be futile to try to arrest the disease or search for methods of relief except along eugenic lines. It cannot be denied that such has been the attitude of psychiatrists in general and when everything is blamed on heredity, this fatalism as- sumes the role of a cloak to hide our ignorance and stifle initia- tive in the investigation of causation looking to prevention and relief.
Fortunately, we are today in a position to show that the doc- trine of heredity as applied to mental disorders is not in har- mony with modern biological knowledge and is, therefore, obso- lescent. The "inherited constitution" in the newer sense would refer specifically to the individual's constitutional resistance to various toxins, rather than to merely mental instability. Thus, we have observed in one family the following phenomena : One brother, at the age of 35, developed an acute maniacal condi- tion and died one week after entering the hospital. Ten years
22 The Defective Delinquent and Insane
later a sister, who had previously been in perfect health con- tracted a "grippe" cold and one week later developed an attack of maniacal excitement. On admission to the hospital she was found to have badly infected teeth and tonsils. She died ten days later from generalized infection. At autopsy, cultures from various organs showed a virulent strain of streptococcus, confirming the clinical diagnosis. Another brother, who had been in perfect health died suddenly from streptococcus septi- cemia. The probable explanation of the deaths of these three individuals was the constitutional susceptibility and lowered resistance to the streptococcus.
The fact is that heredity, even under conditions of clinical examination most favorable to the finding of any possible her- editary taint, exists in only a little more than one half of the patients classed as in the functional group.
In conclusion then, it may be stated that, whatever may be the final decision regarding the relations between heredity and mental disorder, in practice it should be brought down from its present exalted position and more attention should be paid to the factors which lie within our control, unless we deal with the problems of eugenics and control of progeny.
Psychogenic Factors
The traditional attitude of psychiatrists that mental dis- orders 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 here entirely to eliminate the importance of the mental factors in producing a psychosis for they have their proper place. They are, however, of secondary importance to the toxic factors about to be described.
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
Causes of Mental Disorders 23
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 can- not 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 disappoint- ing.
Mental factors are contributory in the mechanism of the psychoses. Such factors undoubtedly lower the patient's vital- ity— lower the immunity to infection and produce profound physical disturbances. The loss of appetite, disturbance of nu- trition, 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 pro- found effect upon the ductless glands, lower the resistance suffi- ciently to allow the latent infection to become active. It must be admitted that the exact mechanism is not known. Further investigations will help to decide the relation of emotional dis- turbances 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 im- proper training, because they can be directly controlled.
Many cases occur in which such causes as love affairs, disap- pointment in love, domestic difficulties, conjugal disharmony, financial reverses, — to mention only a very few, — are consid- ered to be the only cause of the psychosis. In 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 disturb- ance is very apt to adjust itself. Often these patients have to return to the same environment and their domestic difficulties
24 The Defective Delinquent and Insane
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.
This patient had suffered from a prolonged depression with intervals of slight improvement, during which efforts had been made to keep her at home, but having on two occasions made attempts at 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-centred 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 re- covered, following the removal of her infected tonsils, her in- fected teeth having been extracted on admission. The change was most pronounced. When admitted, she was thin, emaci- ated, 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 cor- rect 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 re- turned home and after a year or more of extremely bitter ex-
Causes of Mental Disorders 25
perience, 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. It 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. It is also important to note that the psychosis was of ten years' duration and recovery followed removal of the tonsils.
Disturbances of the Endocrin System
There can be no doubt that the endocrin system plays an im- portant role in the mechanism of mental disorders. The duct- less 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 disturb- ances in the others. Their function may be inhibitory or stimu- lating, 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 infini- tesimal portion of a grain of the internal secretion of the adre- nal gland will cause an amazing reaction in the bodily metabol- ism.
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 thyroid gland is fed to these patients, early enough, the mental disease may be ar- rested. 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
26 The Defective Delinquent and Insane
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 re- moved.
It is not altogether clear what factors are concerned in pro- ducing these disturbances of the ductless glands. It has been demonstrated that anger, fear and other emotional disturb- ances, acting through the sympathetic system, will materially, but transiently, affect the secretions of these glands. Psycho- genic factors, then, existing over prolonged periods, may well cause extensive disturbance in the ductless glands, producing at first an abnormal hypersecretion, often followed by a dis- tinct, permanent, structural change. It 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 the chronic infections have a direct secondary influence upon the ductless glands. These ob- servers are of the opinion that it is possible to restore the func- tion of the ductless glands by removing chronic foci of infec- tion. 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 fre- quently the case, then the abnormal condition can be remedied only by excision of the gland. Very few of our patients were benefited by efforts to correct conditions in the ductless glands, without first eliminating the infection and toxemia. Conse- quently, 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.
Causes of Mental Disorders 27
Further investigation in this field is necessary before final and definite conclusion regarding the role of the ductless glands in the mechanism of mental 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 de- termined 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 persistence of these disturbances. Much work yet remains to be done in this most important field.
Combined Factors in Producing a Psychosis
From the discussion of the factors involved in the production of a psychosis it can be seen that the causes vary in different individuals. In 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 develop- ment it is not essential to its production. Furthermore, while psychogenic factors, when present, also exert an important in- fluence, these may be absent and yet a psychosis may develop. The most important and constant factor is the toxemia re- sulting from chronic infections.
In the majority of mental cases there is undoubtedly a com- bination 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. In the treatment of mental disorders it must be realized that hereditary influences are immutably fixed and that frequently the environmental influences cannot be changed. The attack then should be directed upon the factors which can be elimi- nated from the patient's system, which, in the present state of our knowledge, is limited to the chronic infection referred to above.
28 The Defective Delinquent and Insane
Other factors may appear to be the sole cause of the mental condition when, as a matter of fact, they are simply the pre- cipitating factors. These causes may be physical or mental and either may have the same effect. In women, especially, there are several physiological epochs in which the individual is more susceptible to a psychosis. These epochs are puberty, childbirth and the menopause. It is doubtful whether it is justifiable to consider them as having any direct bearing upon the development of the psychosis.
Puberty in the female is attended with more psychological disturbance than in the male. If the girl is unprepared for the appearance of the menstrual function there may be a dis- tinct psychic shock, but without the presence of chronic infec- tion it is doubtful whether this alone would be enough to pre- cipitate a psychosis. It is infinitely more doubtful that this shock could be the cause of a psychosis developing many years later.
Childbirth is the incident which ushers in many psychoses. While the relative percentage of psychoses to births is small, it is far from negligible. The older psychiatrists erroneously designated this as an entity which they called "puerperal in- sanity." This psychosis does not differ from those produced by many other causes and there seems no justification in con- sidering this to be a special form of mental disease.
It is evident that this physiological incident in a woman's life, because of the severe mental and physical stress and strain, reduces her vitality to a serious degree. In some of the acute mental conditions following childbirth, fulminating infection of the uterus may be the cause of the psychosis. In others, the infection may be a distinctly focal one, occurring in the lacer- ated cervix. Finally, there may be no definite infection relat- ing to the childbirth and the infection must be looked for else- where.
In reviewing a large number of these puerperal cases we have found that the patient harbors infection in the teeth and tonsils, which infection is latent and may become virulent only through the devitalizing effect upon the system of the labor. When these, apparently irrelevant, sources of infection are re-
Causes of Mental Disorders 29
moved the patient recovers. For example, following child- birth, a young woman developed a psychosis which lasted six months before admission to the hospital. She was admitted in the spring of 1918 in a wildly maniacal condition. Examina- tion showed a torn and infected cervix. This was enucleated and the infected portion removed without apparent benefit. She continued in her maniacal state and it was not until after extraction of four gold capped infected molars that she re- covered, which recovery occurred four days later.
Psychoses resulting from the too frequent bearing of chil- dren may be explained on the same basis. Hence, it is im- perative that the mother, during childbearing age, should be kept particularly free from chronic foci of infection. Any tears or lacerations should be promptly and properly remedied so as not to leave an area of low resistance where, sooner or later, micro-organisms will lodge and produce serious infec- tion. Incidentally, this also relieves her of the grave danger of cancer.
It has been more difficult to explain the occurrence of a psychosis at the menopause. This period has become so asso- ciated with serious nervous and mental trouble that it is ap- proached by many women with fear and apprehension. So fixed has this conception become in the minds of physicians in its relation to nervous and mental conditions that such disturb- ances have been classified as "involutional melancholias" and "menopausal insanities." It is illogical to ascribe abnormal mental conditions to normal physiological phenomena, especial- ly when the same type of mental disease is frequently found oc- curring at other periods.
From the examination of our cases, it appears highly prob- able that the menopause, representing a period of decline in the vitality of the individual, permits latent infection to be- come active. Any emotional or physical disturbances occur- ring at this time are apt to have a more pronounced effect than at earlier periods. It is not unusual to note the following among women patients. After an attack of mental trouble, during adolescence, there may be normal mental conditions until the menopause, at which time a second attack may occur.
30 The Defective Delinquent and Insane
From this, recovery is apt to be slower and they frequently fail to recover, even though the patient be properly treated. There is not the resiliency and recuperative ability which was characteristic of earlier years.
All of our cases, occurring at this period, have shown evi- dences of chronic infection and when these were eliminated early enough in the disease the patients have recovered. (Case 14.)
Finally, this is the most difficult period in which to treat mental disorders as even with the removal of infection the physical condition of the patient is such that it takes a much longer time for her to recover. A latent infection, which may have existed for ten or fifteen years, may, through lowering of immunity at the menopausal period, become active and virulent.
Menstrual irregularities have frequently been blamed for mental and nervous troubles. These irregularities are, in re- ality, symptomatic of infection and toxemia in the patient, and like many other symptoms are undoubtedly protective. It is not unusual to note the cessation of menstruation during a psychosis. When the patient recovers the menstrual function is re-established. In some cases cessation may indicate serious infection of the cervix, tubes and ovaries. In others, disturb- ances of internal secretions may have a direct bearing on the abnormal function. Whatever the origin, it is highly improb- able that menstrual irregularities ever stand in direct causal relation to the psychoses. In like manner, sexual excesses and masturbation are properly to be looked upon as symptoms of a disordered metabolism rather than causative factors in in- sanity.
Certain general infectious diseases, however, bear a very im- portant role in the causation of the psychoses. In the last few years, the epidemic of influenza has been responsible for the later production of many psychoses. In delirious conditions, occurring during influenza, the direct relation between the in- fluenza and the psychosis will be noted. When the psychosis develops months after the disappearance of the influenza, a different interpretation of the relation of the psychosis to the influenza must be sought. The tremendous devitalization by
Causes of Mental Disorders 31
influenza of the individual would act as any other physical cause in lowering the patient's vitality, allowing a latent in- fection to become virulent. All of our post-influenza cases were found to have serious multiple foci of infection, recover- ing only when the foci were removed.
Diagnostic Survey of the Patient
It is self-evident that in order to reach these conclusions the psychiatrist has to enlist the aid of his medical and surgical colleagues, and to utilize their methods and findings, adapting them to his own problems. Recent medical developments are fviUy as revolutionary in general medicine and surgery as are the ideas expressed in these chapters. In fact, the psychi- atrist, no matter what progress has been made in psycho- pathology, cannot afford any longer to disregard the all-im- portant developments in the field of chronic infection. Now that these great truths have been proven and accepted by the leading investigators he should have no hesitancy in adopting them. It is important to state that all the methods utilized in our preparation of a proper diagnostic survey of the psychotic individual are nothing more or less than those in general use in the best equipped modern medical centers.
Summary
Such are the pros and cons relating to some of the aspects of the causation of the "functional psychoses." In brief recapitu- lation, the most important points are the following: aggres- sive work in the solution of the problem of the insane is im- perative; insanity is increasing out of proportion to the gen- eral increase in the population; in spite of, or, perhaps in con- nection with, our highly developed civilization, the problem of the defective and the delinquent has become an equally pressing one; a small beginning has been made in the establishment of psychiatric clinics for the proper medical study of these con- ditions and for the proper classification and segregation of the mentally normal and abnormal.
Biological knowledge, based upon evolutionary development,
32 The Defective Delinquent and Insane
has been instrumental in clarifying our ideas, broadening our views, and placing the classification herewith presented upon a scientific basis. To biology, also, we are indebted for all of our important knowledge concerning structure and function. It is a biological axiom that there must be a physical basis for all so-called functional disorders and as our knowledge in- creases, the truth of this, in the entire field of medicine, becomes apparent.
The recognition of this law is of as fundamental importance in understanding the nature of the psychoses as in comprehend- ing disease in other parts of the body. Instead of dealing with disorders of the mind as if they were independent of bodily con- ditions— a hypothetical conception, based neither upon scien- tific laws nor upon biological facts and necessarily utterly bar- ren of result as to treatment — we have endeavored to show that we are in reality dealing with disorders of the brain. Such dis- orders, induced by physical factors, produce the phenomena known as "functional psychoses."
Heredity, environment, personality and psychogenic factors are given their proper place in the constellation of causation. They may all be absent and yet a psychosis may develop. Their place need by no means be a dominant one, a viewpoint quite at variance with that now generally held.
Psychoses arise from a combination of many factors, some of which may be absent, but the most constant one is an in- tracerebral, bio-chemical, cellular disturbance arising from cir- culating toxins, originating in chronic focal infections situated anywhere throughout the body and probably to some extent in disturbances of the endocrin system.
In the following chapters the methods of determining the presence of these foci and the results of their elimination will be considered.
CHAPTER III
THE SYSTEMIC EFFECTS OF CHRONIC INFECTIONS
The Nature of Chronic Infections
Since the epoch-making work of Pasteur, who laid the foun- dation for the germ theory of disease, remarkable progress has been made in determining the relation of micro-organisms and bacteria to a multitude of diseases. As a result of the work that has been done we have come to believe that nearly every disease process is caused by a specific micro-organism and this has led us confidently to expect that in time specific organisms will be found for all.
The specific causes of typhoid fever, diphtheria, malaria, pneumonia, syphilis, tuberculosis — to mention only some of the better known ills — are now almost as well known as ordinary garden plants, but there are still many conditions in which the causative factors remain ' unknown and the origin, therefore, obscure. Such disorders as arthritis, neuritis, endocarditis, per- nicious anemia, and various disturbances of the gastro-intesti- nal tract, which until recently had baffled all investigation, are gradually coming to be understood.
Finally to Roger, another gifted Frenchman, we are in- debted for much of our present knowledge concerning the ef- fect upon the human body of practically all forms of intoxica- tion to which it is liable.
Chronic infections are to be differentiated from acute in- fections by the fact that the latter are characterized by the presence of pus, pain, and frequently of swelling and by ele- vation of temperature. These symptoms leave no doubt in the mind of the patient or of the physician that infection is present in a given area. In the last few years, however, it has been found that there is another type of infection which has been
33
34 The Defective Delinquent and Insane
designated as "focal infection," or chronic infection, which fre- quently gives no evidence to the patient because of an absence of the symptoms, pain, pus, swelling and fever.
These two types differ in many ways. Often a chronic in- fection persists for years and may in the end actually cause the death of the individual without its presence having been recog- nized by the methods used in the ordinary physical examina- tions. That such dangerous infections could exist without giv- ing more evidence has been doubted by many, but recent re- searches have proven conclusively that such conditions can and do exist and are constantly being overlooked. All too fre- quently the patient is still merely treated for the sj^mptoms; superficial manifestations for which the physician has been consulted.
The modern methods of clinical diagnosis — such as the X- ray, bacteriological and serological examinations — in conjunc- tion with a careful history and a thorough physical examina- tion, will, in the majority of cases, bring to light these hidden infections of which the patient is usually blissfully ignorant. No individual, suffering from whatever cause, should permit himself to be treated until a proper diagnosis has been made by these methods. It will at once be asked why that priceless, protective symptom, pain, should fail the patient in so critical a moment. The reply must be that pain, like all the protective processes of nature, cannot be one hundred per cent effective and that for some unknown reason it is not often elicited by this most dangerous type of infection.
By means of such examination, which has been termed a "diagnostic survey" of the individual, it has been found that the symptoms of which the patient complains may be caused by an unrecognized infection of an organ or organs situated in an- other part of the body, which superficially present no causal relation to the symptoms, and of which the patient is ignorant.
These chronic infections are of a very low grade of virulence and show very slow rate of progress. It usually takes years be- fore the symptoms develop as the result of these infections and during this time the virulence of such infection is very slight, or^ indeed, may be negative. However^ after having gained
The Systemic Effects of Chronic Infections 35
sufficient headway, any change in the individual — whether caused by mental or physical factors — may cause a latent in- fection to become virulent and bring about the death of the patient in a very short time. This quality of mutation or change in the virulency of a micro-organism is one of the most interesting of the many intricate problems arising out of the relationship of parasite to host.
Immunity
All infections call forth defensive reactions on the part of the individual, and these may lead to immunity in which case spe- cific anti-bodies are found in the blood. Were it not for this immunity, in which the body produces a specific substance an- tagonistic to the various bacteria, we should not recover from any of the many infectious diseases to which we are subject and all vertebrate life would become extinct. In overwhelming infections of extreme virulence the micro-organisms destroy the individual before this immunity can be established. The sud- den extinction of the passenger pigeon has been attributed to this fact.
It is necessary to speak only of the wonderful results ob- tained in artificially producing immunity in such diseases as smallpox by vaccination, and as seen in the late war, in typhoid fever by means of vaccine, to understand the remarkable pow- ers resident in the blood to combat disease caused by micro- organisms. In such conditions as diphtheria, the natural im- munity is strengthened by anti-toxin, a serum made by inocu- lating horses with the diptheria toxin.
The Origin of Chronic Infections
Investigations in the field of chronic infections have con- clusively demonstrated that many of the chronic infections originate in the oral cavity, or mouth, and specifically around the teeth or in the tonsils. It was formerly considered that the mouth contained many types of micro-organisms which were non-pathogenic in character, or which were not causing any serious trouble. We doubt the truth of the statement in so far as it refers to the type of organism which affects the teeth and
36 The Defective Delinquent and Insane
tonsils, although nearly thirty harmless forms have been found free in the mouth. It is probable that the type of streptococci found in infected teeth and tonsils and which were formerly considered of no importance, may be the agents responsible for the chronic infections originating in the mouth. The im- portance of oral infection today cannot be doubted and is recognized by the most progressive men in the medical pro- fession.
It is difficult to determine the importance, relatively, of the teeth and tonsils as a source of infection, or, which is primary and which secondary. The age of the individual has some bear- ing on the subject. In children, it would seem that the tonsils are the primary source of infection and that the infection of the teeth is secondary. In adults, with previously healthy teeth and tonsils, it would appear that the origin of the infection is from the teeth, due to many causes, the tonsils becoming in- fected secondarily. At any rate, both of them are of extreme importance and it has been shown that infection, originating in the mouth, in the course of time spreads to other parts of the body.
Dissemination of Bacteria Concerned in Focal Infection
Even if the infection remained strictly localized in the teeth and tonsils, it is definitely known that serious systemic effects can be produced. Only in very few cases is such infection limited to the mouth. However the tendency of the organisms to migrate from the primary source of infection and set up multiple secondary foci of infection is of the greatest danger to the individual. The route by which these organisms migrate has not been definitely determined in all cases. In some in- stances secondary foci may be cavised in the gastro-intestinal tract by means of swallowing, but the tendency, more and more, is to look to the blood and lymph streams as the chief dissemi- nators. Once these secondary foci are established in areas which have no connection with the gastro-intestinal tract the only other method of further transmission is, certainly, through either the blood stream or the lymphatic circulation. While it is impossible, conclusively, to determine whether one or both
The Systemic Effects of Chronic Infections 37
of these routes are concerned in the transmission, it is probable that the evidence points more to the lymphatic system than to the blood stream. At any rate, it is a fact that bacteria do migrate from the original source of infection and can be found in the joints, muscles, nerve sheaths, the generative organs, gall bladder, lining membrane of the heart, etc.
Another means by which the micro-organisms of focal in- fection cause serious harm to the individual is through systemic intoxication. By this is meant that highly toxic poison may be carried by the blood stream to various parts of the body, pro- ducing harmful effects. This is especially true of the nervous system, in which the trouble is caused, not so much by the in- vasion of the bacteria in the brain and spinal cord, as by the poison generated by the bacteria. An idea of the small amount of this necessary to produce serious symptoms can be formed from the fact that some of these toxins have been estimated to be upwards of a million times as poisonous as rattlesnake venom. Just how these toxins are formed is not definitely known, but it has been suggested that upon the death of the micro-organisms certain bio-chemical reactions take place, caus- ing these toxic substances to be liberated. Whatever their exact origin, it is sufficient to know that they are capable of causing death within a few days after the onset of symptoms.
Character of the Micro-organisms Causing Focal Infection
There are many forms of micro-organisms concerned in the production of chronic infections. The principal ones, however, belong to the streptococcus group which are organisms ar- ranged in either long or short chains. According to their action on the blood, they are divided into hemolytic and non-hemoly- tic types. The former type is usually more virulent than the latter, although, at times, both may become virulent and cause the patient's death, either directly or indirectly. The two types of the staphylococcus, aureus and albus, are less frequently concerned in focal infections, and probably the latter is never pathogenic. It has been found that the streptococcus group is made up of many different strains, which strains can be dif-
38 The Defective Delinquent and Insane
ferentiated by growth on various culture media. This dif- ferentiation is important from the standpoint of treatment for it has been found that these various strains do not im- munize against each other and that vaccines, to be effective, must contain the strain that is to be attacked.
Below is given a table showing the strains classified accord- ing to Holman.
HEMOLYTIC STREPTOCOCCI
Type Mannite Lactose Salicin
Infreq -f- -f~ +
Hemolyt. i -|- -|- —
Pyogenes — + +
Anginosus — -|" —
Hemolyt. ii + — +
Hemolyt. iii -j- — —
Equi — — +
Subacidus — — —
NONHEMOLYTIC STREPTOCOCCI
Type Marmite Lactose Salicin
Fecalis + + +
Nonhemolyt. i + + —
Mitis — + +
Salivarus — + —
Nonhemolyt. ii + — +
Nonhemolyt. iii + — —
Equinus — — -|-
Ignavus — — —
These sixteen types represent the grouping of 1,122 strains of Holman and taken with strains from the literature the total number is 2,463, a sufficient number to come to some conclusion as to their biological types. While some types can be identi- fied under the microscope, only by their cultural reactions can they be accurately differentiated.
We have so far been able to isolate five strains of the hemo- lytic group ; i.e., the infrequenz, pyogenes, anginosus, equi and subacidus, and five strains from the nonhemolytic group; i.e., fecalis, mitis, salivarus, equinus and ignavus. We have found representatives of both these groups in various sources of cul- ture. Occasionally the hemolytic strains are found in the teeth,
The Systemic Effects of Chronic Infections M
but more frequently this type is found in the tonsils and gas- tro-intestinal tract. Nine tenths of the tonsils harbor the hemo- lytic strains and often the nonhemolytic strains as well, and it is not unusual to find two or three strains in the cultures from the stomach and duodenum, both hemolytic and nonhemolytic types. Later investigators have shown that the "Viridans" is a form of the nonhemolytic streptococcus, but not all of the latter can be classed as "Viridans." So it is better to substitute the exact type for this term.
This differentiation can be made by growing the organisms upon the various carbo-hydrates media — as shown in the above table. This will avoid the confusion and error now so common of designating all non-hemolytic types of streptococci — "Viridans."
It is useless to argue which types may or may not be patho- genic, or which types may be more virulent than others. We have not found that the hemolytic types were more virulent than the other group or that they produced more marked symptoms. In fact, any of these organisms may become so virulent at any time that they cause the death of the patient, although for a long time they may be latent and no marked evidence of their presence shown other than by the fixation tests.
We are still of the opinion that the complement-fixation tests of the blood for determining the presence of chronic infections are of value as are also the agglutination tests for the same purpose. Further standardization is necessary, however, be- fore they can be used as routine laboratory tests.
A third form of micro-organism, known as the colon bacil- lus, which is normally found in the large intestine, may cause secondary foci of infection when, probably because of damage to the mucous lining of the intestinal tract, this organism mi- grates to other organs. It has recently been found that there are many types of colon bacilli, differentiated by means of their cultural reaction on various types of media, probably all of them capable of producing disease, and all extremely toxic.
Whether these various types are pathological variations of a non-pathogenic colon bacillus, or whether they arise from sources outside of the body and are taken into the body with
40 The Defective Delinquent and Insane
impure food, milk, water, etc., has not yet been determined. Bacteriological studies in our cases have shown conclusively that they do migrate, having been found in the walls of the in- testine and appendix, in mesenteric lymph glands, the gall bladder, the genito-urinary tract, especially the seminal vesi- cles in the male and within the cervix uteri in the female. In one case the pleuritic effusion and pericarditis was the result of the invasion by this organism.
The tubercle bacillus is usually found in the lung, but it also causes secondary infection in the lymph nodes, the intestinal tract, and other organs of the body. The spirochete pallida, the organism causing syphilis — a venereal disease — is a striking ex- ample of chronic infection. It may migrate from the original lesion and remain latent in other organs of the body for years before its presence becomes known, often, too late for remedial measures to save the individual. It frequently involves the nervous system and produces no symptoms for fifteen and even thirty years after the initial lesion, when symptoms of loco- motor ataxia or paresis insiduously develop, at which time a comparatively small number only of patients can be benefited by treatment.
Mixed Infections
Many of the organisms we have above enumerated appar- ently become more virulent when associated together in the tissues. Thus, the tubercle bacillus and the streptococcus are a bad combination, for the former apparently becomes more active in the presence of the latter. This is probably an ex- ample of symbiosis, a condition often observed in nature. In most cases, colon bacilli are found associated with streptococci to the evident detriment of the patient. It is also possible that the organism of syphilis may become more active in the pres- ence of the streptococcus. These postulates receive some sup- port from the dangerous conditions mixed infection is known to produce in tuberculosis.
In view of the intimate relation existing between these or- ganisms which work together — and usually the streptococcus is the one which prepares the way for others — it is easily seen how
I
The Systemic Effects of Chronic Infections 41
necessary it becomes to keep the body, as far as possible, free from streptococcic infection. By recognizing its presence and adopting proper measures to eliminate it from the system the individual will be saved much serious trouble later on.
Primary Foci of Infection Teeth
The credit for the recognition of the importance of infected teeth belongs to both the medical and the dental professions. As early as 1908, Henry S. Upson, of Cleveland, called at- tention to the relation of infected teeth to mental disorders. He cites the fact that Savage, the English alienist, in 1876 re- ported several cases of acute mania recovering suddenly after the extraction of bad teeth. Upson reported his conclusions, based on thorough clinical observations, that many cases of acute psychoses were caused by infected teeth and that after extracting them the patient recovered. He also emphasized the relation of infected teeth and impacted molars to dementia praecox. Unfortunately, his work was not taken seriously and from our experience in the last three years we can but marvel at the scope of his investigations and his vision of the future development of our knowledge of mental disorders.
His work is more remarkable from the fact that the whole question of infected teeth, from the standpoint of general medi- cine, was not investigated until some years later. It was only in 1912 that Billings called attention to the relation of infected teeth to arthritic conditions and later Hastings and Rosenow also published conclusive studies in the same field.
The most scientific contribution from the dental profession is the work of Kurt Thoma, of the Harvard Dental School. His work is based upon very thorough and accurate investigations and is well worth the perusal of those interested in the subject. He shows pictures of pre-dynastic Egyptian skulls with un- doubted alveolar abscesses. This disposes of the question that infections of the teeth are of recent origin and, therefore, could have no bearing on the mental disorders which existed centuries ago. But, it is undoubtedly a fact that the population, as a
42 The Defective Delinquent and Insane
whole, suffers more from infected teeth than did that of several generations ago. It has been estimated that eighty percent of the population have infected teeth and this is, indeed, a con- servative figure.
That modern dentistry is responsible for a large proportion of the dental infection of today is admitted by the leaders in the dental profession. The high degree of mechanical skill of American dentists has produced wonderful cosmetic effects, but, unfortunately, the teeth have been treated without regard to the individual as a whole, and without realizing that in their worthy efforts to save teeth, incalculable damage has been done. In spite of the evidence produced by the radiograph and the warnings uttered by the leaders of the profession, the majority of dentists persist in doing work which has been condemned because it may produce serious systemic disease. One has but to examine X-ray plates of teeth which have been treated by the usual modern methods of repair and conservation to see that, in the case of Richmond crowns or pivot teeth, at least, the patient carries a quaint and interesting symbol. In fig. 4 will be seen an excellent example of how the dentist has be- stowed upon the patient a "cross as well as a crown," a burden so grievous as to force the individuals, because of the resulting mental symptoms, to seek relief in the State Hospital.
If the dentists persist in this practice, in spite of the dangers which have been shown to result from such work, it is only by educating the public to these dangers that we can hope for an improvement in the health of the nation, both mental and physical. It seems incredible, but it is nevertheless a fact, that the dental schools of today are teaching the installation of gold crowns, fixed bridge work, pivot teeth or Richmond crowns, all of which have been definitely proven to be a serious menace to the individual's health. To paraphrase an old proverb, "Unhealthy is the tooth that wears a crown."
Types of Infected Teeth
No attempt will be made to classify all infected teeth or to differentiate the various lesions, but some of the types which are necessary for the education of the public will be described.
The Systemic Effects of Chronic Infections 43
Most of the conditions can be determined by a thorough X- ray examination and frequently an inspection of the mouth will reveal the fact that dental infection is present. In no
Fig. 4. Radiograph of Richmond crowns or pivot teeth, improper bridge work, and gold shell crowns, from two cases of manic-depressive insanity, in both instances necessitating extraction to eliminate this defective dental work. Note the symbolic crosses.
case should the diagnosis be made on the X-ray picture alone and vice versa no diagnosis of the mouth should be accepted by the patient from the dentist unless radiograms have been made and a proper interpretation given by one experienced in making them. We would emphasize the importance of radiographing all teeth and not only the suspicious ones.
Unerupted and Impacted Teeth
This form of dental pathology, from our standpoint, is one of the most important factors in producing systemic disease in young people. Unerupted and impacted third Jmolars are
44
The Defective Delinquent and Insane
often overlooked by the dentist because the rest of the patient's teeth may be in perfect condition. The third molars, or wis- dom teeth, are most commonly found impacted, but impactions of other teeth may occur. For a long time it was considered that these impacted molars, by pressing on a nerve, caused mental conditions. We have repeatedly shown that all im-
D
Fig. 5. Examples of impacted and unerupted teeth, from psychotic individuals.
A. Impacted upper canine.
B. Impacted lower third molar, with decayed roots of second molar.
C. Impacted lower third molar, second molar with decayed roots and an apical abscess, first molar capped, with necrotic and fractured roots.
D. Unerupted third molar.
The Systemic Effects of Chronic Infections 45
Fig. 6. Radiographs of impacted and unerupted molars.
A and B impacted third lower molar. C Unerupted upper third molar in a case of dementia praecox, whose teeth had been pronounced normal by a dentist with- out radiographing.
D. Impacted lower third molar in a man of forty with nocturnal convulsions for four years, with cessation of the convulsions after extraction.
E. Partially impacted lower third molar in a case of dementia praecox.
F. Impacted bicuspid.
46 The Defective Delinquent and Insane
pacted molars are infected — indeed, it is probable that they are impacted because they are infected. The theory of pressure fails to explain the relation of impacted molars to arthritis which has been found in so many cases.
The only satisfactory explanation for the occurrence of impacted and unerupted molars and their influence on systemic disease is the one advanced by us that these teeth are infected early in their development and that by reason of this infection they fail to mature properly and continue to contaminate the system with micro-organisms. While it is true that in young people the wisdom teeth should not come through until a cer- tain age and that an unerupted wisdom tooth at this age may be normal, at the same time we have found impacted wisdom teeth in children as young as thirteen. (See Fig. 30) It is also true that when unerupted molars occur in adults, even though they are not impacted, one is justified in considering them pathological.
A careful bacteriological examination of impacted molars in young adolescents proves conclusively that they are all in- fected. We have been able to obtain a pure culture of vari- ous strains of both the hemolytic and the non-hemolytic strep- tococci in these cases. The absence of other non-pathogenic organisms in these cultures would eliminate the criticism of contamination at the time the cultures were made.
The question may well be asked, "How do these unerupted and impacted molars become infected?" Often, they are below the gum and embedded in the bone and have no connection with the oral cavity. From the fact that a number of these cases have badly infected tonsils it is reasonable to assume that the infection is transmitted from the tonsils by means of the lymph channels or blood stream to these teeth.
These impacted molars are harmful not only in distributing micro-organisms to other parts of the body, but they will also, in time, infect the adjacent teeth and in cases of long duration it is not unusual to find the entire quadrant also infected. We occasionally find other teeth impacted, especially the canines and bicuspids. They also have been found to be infected.
To the question, ''Should these teeth be extracted when they have been accidentally found and the patient presents no sys-
The Systemic Effects of Chronic Infections 47
temic evidence of infection?" we would answer unreservedly in the affirmative. It is possible, of course, for young adults to have impacted molars, which at the time are producing no systemic symptoms, but from our knowledge of the harm these teeth can do we would consider them a menace to the patient's health and requiring extraction. There could be no criticism in extracting these teeth for if impacted they could never be of any use to the individual, and are often extremely danger- ous. We would also condemn the practice so often resorted to by the dentist of extracting the adjacent molar in order to allow the impacted tooth to grow into position. While this may occasionally cure the impaction it certainly does not elimi- nate the infection.
What has been said about impacted and unerupted molars would apply with equal force to partially erupted molars. In many cases we find that a portion of the wisdom tooth is pro- truding just above the gum line and in such cases radiograms will fail to disclose any evidence of infection in spite of the fact that there are definite symptoms and in the absence of other infected teeth such partially impacted molars should be ex- tracted. In an otherwise healthy individual persistent head- aches, irritability, insomnia and other nervous symptoms have often been observed. Frequently the pulse is rapid and there may be stomach disorders. These symptoms are often ante- cedents of serious nervous and mental trouble, and disaster may be averted if they are recognized and offending teeth ex- tracted.
In many young patients, with well developed psychoses, we find that the infection has spread from the impacted molars to the gastro-intestinal tract so that extraction of these molars, alone, will not produce results. The infection must be elimi- nated in the secondary foci before results can be obtained. The tonsils in these patients must be removed as they are always infected.
A realization of the fact that infected teeth, especially the impacted molars, may occur in very young people and continue throughout the life of the individual, offers a probable expla- nation for the peculiar personalities and abnormal dispositions
48 The Defective Delinquent and Insane
noticed in cases of dementia praecox years before the psy- chosis, as such, develops. Several cases might be cited to em- phasize the importance of impacted molars and infected tonsils in producing serious systemic conditions.
One was that of a previously perfectly healthy and robust girl of nineteen years who had been "ailing" for some time. She was cross, irritable, fault-finding, had frequent crying spells and wanted to spend her time in bed. Fortunately for her, one day at dinner, the gum over the right third molar which was considerably swollen suddenly ruptured while eat- ing. A radiogram revealed an impacted wisdom tooth. This was extracted, but her symptoms continued. Her tonsils had been enucleated over a year previous. All of her teeth were then radiographed and three more unerupted wisdom teeth were found. On extraction, her symptoms rapidly disappeared and for the last two years she has been perfectly well. There can be no doubt that had not these impacted and infected mol- ars been found, sooner or later, she would have developed a serious mental disturbance of more or less permanent character.
The following two cases are cited to show the absence of any definite relation between the mental symptoms and the loca- tion of the foci of infection. The first was that of a young, single man, eighteen years of age, with negative family history, who developed a psychosis. His early development was nor- mal. He completed one year of high school at the age of six- teen and worked as a carpenter for a year and a half, but was never successful. For two years he had frequent spells of mel- ancholia and irritability, lasting a few days. He worked at in- tervals only, was asocial, over-religious and had no interest in the opposite sex. An acute outbreak occurred one week be- fore admission to the State Hospital at Trenton, June 20, 1919, following an attempt to commit suicide by jumping in a lake. He had vague self-accusations, refused to answer questions, and kept repeating, "It is my fault, the devil has got me." Casual examination revealed nothing particular in his physical condition. Shortly after admission he had some sort of an attack in which he lost consciousness, upper extremi- ties rigid, the lower extremities moving up and down, slight
The Systemic E feats of Chronic Infections 49
frothing at the mouth, stertorous breathing. His teeth and gums were practically in a healthy condition, but radiograms showed four impacted third molars. The tonsils were enlarged, inflamed and infected. He was depressed and mute, insist- ing on getting out of bed, and wandering aimlessly about the ward. He broke a window pane, stuck his head through the glass, causing a skin wound. The impacted molars were ex- tracted in August and infected tonsils were enucleated in Sep- tember. He improved rapidly following the extraction of the impacted teeth and on September 29th, one month later, he was discharged as recovered. For the past year he is reported as normal and earning his living.
The second case was that of a Princeton University student of nineteen years who was somewhat exhausted from his work in the students' army training corps and suddenly, in Novem- ber, 1918, developed a profound depression with suicidal ten- dency. Examination showed nothing abnormal except foin- impacted third molars, revealed by radiogram, also badly in- fected tonsils. He also showed a serious gastro-intestinal in- fection which was demonstrated by X-ray studies. He was taken liome for Christmas as he had improved somewhat. A few months later he became maniacal and since then has al- most continuously been confined in various institutions, but no attention has been paid to the gastro-intestinal tract and there is little hope for recovery until this infection is eradicated.
The mental symptoms in these two cases are very similar, although the first case was more deeply depressed than the sec- ond, but he recovered rapidly after the impacted molars and infected tonsils were removed and from his subsequent history it can be assumed that his infection did not seriously involve the gastro-intestinal tract, as undoubtedly was the condition in the second patient.
We would emphasize the fact that in the young patients with psychoses and the juvenile moral delinquents and some pseudo feebleminded and subnormal children, impacted molars have been present in a large majority of cases. Of course, this con- dition of the teeth is not the only pathological condition found and it is surprising to note the involvement of the gastro-
50
The Defective Delinquent and Insane
D
Fig. 7. Apical abscesses or granuloma.
A. Granuloma at the apex of one root of a gold-capped tooth. (Manic-dep. Ins.)
B. Extensive granuloma involving the four lower incisors. These teeth pre- sented no evidence of this lesion from external appearances, as they were not de- cayed or even filled (dementia praecox).
C. Granuloma involving one lower incisor, nothing to indicate this lesion ex- ternally, as the tooth was apparently vital (paranoid condition).
D. Inter-radial granuloma of lower first molar and apical granuloma of lower second molar in case of manic-depressive insanity.
E. Apical granuloma of first molar and bicuspid (lower).
The Systemic Effects of Chronic Infections 51
intestinal tract, in extremely young individuals. In one pa- tient, for example, three and a half years, and in another, six years old, severe lesions of the lower intestinal tract existed. These were proven to be present on operation.
Teeth with Infected Roots, "Apical Abscesses"
This type of infection should be familiar to all dentists and is known as periapical granuloma. It is very well shown by the radiogram in the shape of dark areas indicating necrosis and rarefaction of the bone surrounding the tooth. It is usu- ally found in devitalized teeth — in which the nerve has been killed — or teeth with gold shell crowns, pivots, or Richmond crowns, and usually in all fixed bridge work where the bridges are anchored to devitalized teeth. Not infrequently these ab- scesses are found at the roots of teeth which, from external ap- pearances, present no diseased condition. ( See Fig. 7 and Fig. 8.) There is absence of decay and the only indication may be the presence of receding gums. Any dentist having experience in the interpretation of radiograms should have no difficulty in identifying these abscesses.
The most important question concerning such conditions is the method of treatment. In spite of the fact that Thoma, Grieves, and other prominent dentists, have repeatedly dem- onstrated that these apical abscesses cannot be cured there are a great many dentists who not only disagree with this but at- tempt to cure them by various medical and electrical agencies. In the recently mentioned work by Grieves is this statement, with which we entirely agree, "One of the gravest mistakes of dentists is the stubborn belief that correct canal filling will cure apical abscesses."
In our own experience, in the early part of our work, we
Fig. 8. A. Drawing of a gold-capped or crowned tooth with distinct apical granuloma. Four views of the same tooth,
B. Radiograph of first upper molar with gold cap, and very slight indication of root infection. Also unerupted third molar,
C. Drawing of the same tooth as in B, showing extensive granuloma.
D. Radiograph of a gold-crowned tooth with distinct apical involvement.
E. Drawing of same tooth (D) showing very large apical granuloma (from a case of long standing neurasthenia).
52 The Defective Delinquent and Insane
D E
(For dcscri])tion, see page 51.)
The Systemic Effects of Chronic Infections 53
have had many cases in which gold shell crown molars with apical abscesses have been treated by having the caps removed, root canals thoroughly cleaned out, followed by perfect filling of the root canal. For a while the symptoms disappeared and it looked as if the desired result had been obtained. In the course of a year or two the symptoms recurred and radiograms showed that the apical abscesses had not only persisted but were ver}^ much worse than previously. We have had the op- portunity to examine the work of men who make a specialty of filling the root canal, but we have found, in spite of the as- surance given to the patient that the abscesses were cured and would cause no further trouble, that these teeth, when ex- tracted, were badly infected and cultures showed streptococci in abundance. You should not allow your dentist to fill root canals — if the tooth is dead it should be extracted.
In spite of the various opinions regarding the question of treatment of apical abscesses, there is ample justification in emphasizing the opinion that all teeth with apical abscesses should be extracted. While this opinion may seem radical, it is the only rational viewpoint and we would advise all persons to insist upon this method of procedure if they would preserve their future health and prevent serious mental and physical complications. Indeed, it is more than probable that all de- vitalized teeth, i.e., those with root canal fillings especially, gold shell crowns, pivot or Richmond crowns, should be ex- tracted whether or not the radiogram shows extensive involve- ment of the bone ; the most progressive dentists today support this viewpoint.^
We have many examples where, for instance, a devitalized, capped tooth appeared perfectly normal in the radiogram, while upon extraction a ver}^ large granuloma was proven to exist. When the radiogram shows extensive necrosis of the
1 As a result of an agitation against the error of modern dental conservation, cer- tain progressive and conscientious dentists of the country have formed an association known as the American Academy of Applied Dental Science and one of the prin- cipal tenets of this organization is that "all dead or devitalized teeth should be ex- tracted." They are opposed to all caps, crowns and pivot teeth, and fixed bridge work, and are particular that their extraction work should be of the highest char- acter and not of a type which will later produce the S£ime condition which caused the patient's trouble originally.
54 The Defective Delinquent and Insane
alveolar process or jaw bone it must be remembered that it often has taken many years for this necrosis to occur. Unfortunately, the radiogram does not show the soft granuloma, and where this condition has not had time to pro- duce extensive bone necrosis we can be misled in the belief that the tooth is not infected. Cultures of these teeth have demon- strated that serious infection is present and the clinical evi- dence, i.e., the patient recovering following the extraction of such teeth, substantiates our view that such teeth should be extracted. From this it must not be inferred that even among the seriously ill patients at the State Hospital at Trenton an unnecessary or, indeed, unusual number of teeth per patient are extracted. The average is now not over f^Ye per capita.
Decayed or Carious Teeth
Many patients show evidence of serious neglect of their teeth and of course a dentist is not to be blamed for this con- dition. Teeth with superficial decay can be filled and are not a menace to the patient's health, but when the decay is exten- sive and when it involves the pulp chamber the tooth is prac- tically dead and extraction is the only course left. In such cases, radiograms will usually reveal apical abscesses and ex- tensive involvement of the bone. (See Fig. 9.)
The cause of carious teeth is still a disputed question. Many dentists claim that diet has a great deal to do with this con- dition and it is possible that the eating of too much sweet food, such as candy, sugar, etc., may have some remote bearing on the subject. On the other hand, it is certain that infection plays a very important role in causing decay. Perhaps the excess of carbohydrates supplies favorable culture media for the growth of bacteria. Very often "bacterial placques" form on the tooth as the result of the neglect to properly clean them, and decay under these placques is the usual result.
It has also been shown that anatomical defects in the teeth, frequently found in children, such as roughness and irregulari- ties, favor the production of these placques and the resulting decay. By proper attention to children's teeth and the removal of these anatomical irregularities by planing, the tooth is made perfectly smooth and decay prevented.
The Systemic Effects of Chronic Infections 55
Apparently Healthy Teeth with Periodontitis
In examples of this type of infection there frequently is no distinct apical abscess as shown by the radiogram. The absence of external decay and the lack of shell crowns, pivots, etc., often leads to the incorrect conclusion that these teeth are normal. A close inspection of the X-ray, however, will show that there is a distinct area surrounding the tooth, indicating that the peridental membrane has been destroyed and that the tooth is extensively infected. This infection evi- dently comes from the outside of the tooth and works its way down the sides, destroying the membrane surrounding the tooth. (See Fig. 10.)
According to Grieves, a tooth may be invaded by infection without evident decay. When these teeth are extracted we frequently find the presence of a gingival granuloma which is infected tissue, attached to the tooth at about the upper third, and directly under the gum. Often the only indication, aside from the black line adjacent to the tooth shown in the radiogram, is a faint red line in the gum tissue adjacent to the tooth. In most cases. pressure on the gum will disclose an exudation which when cultured shows the presence of stepto- cocci.
Frequently the gums are much swollen, purple instead of pink and hard. This condition has been classed as pyorrheal pockets, but no one has called attention to the importance of these gingival granuloma which furnish a large area of ab- sorption into the system through the soft gum tissue. We have many cases on record where the patient's life has been saved in some instances, and his mental condition restored in others, due to radical treatment of these conditions by extraction.
We would cite the following case: In the spring of 1917, a boy, twenty years of age, a patient of Dr. William A. Clarkj was admitted to Mercer Hospital, suffering from polyarthritis of a severe type and complicated with a valvular heart lesion. He was anemic, emaciated, and in an extremely nervous con- dition. An examination of the teeth by the X-ray method showed several apical abscesses. These teeth were extracted. He did not improve and soon left the hospital, and his treat-
56 The Defective Delinquent mid hisane
merit was considered by the patient as well as ourselves a failure.
Soon after leaving the hospital he became worse. When I saw him, I was convinced that something must be done if his life was to be saved. An examination of the molars showed a condition that I had not seen before. The teeth were milky white, apparently vital and had no fillings or evidence of decay. The gum was swollen and almost covered the crowns of the molars.
The boy protested when extraction of these teeth was pro- posed because the extraction of the other teeth had not bene- fited him. I could not give him positive assurance that ex- tracting the eight molars would benefit him, but I told him that nothing else could save him. Finally, his family prevailed upon him to have them out. Four at a time were extracted and the result was remarkable. He began slowly to improve and his pulse subsided from 120 to normal in a few days. His con- valescence was rapid and in a few months he was able to re- sume his former occupation.
In March, 1920, this patient spoke to the writer who did not recognize him until he introduced himself. He had been steadily employed at war work for the past two years and was in a perfectly healthy condition. An examination of the ex- tracted molars confirmed our opinion that they were the cause of the boy's trouble. Each of the eight molars had a large gingival granuloma just below the gums, and cultures gave lux- uriant growths of streptococci. The patient's rapid recovery verified the diagnosis of toxemia due to infected molars.
Poorly Filled Teeth, with Evidence of Infection In examining patients' mouths, we frequently see no bridge work, capped or crowned teeth, but very heavy fillings, many of the teeth having been devitalized. We have found a large proportion of these teeth, especially where the root canals have been filled, either poorly or well, to be infected, and it brings up the question as to how bad a tooth can be before it reaches the point where it should be extracted, or stated better, how much of the tooth can be filled and the tooth still remain healthy. (See Fig. 9.)
TJie Systemic Effects of Chronic Infections 57
If the radiogram is not absolutely clear, if the roots are somewhat hazy and the surrounding bony tissue abnormal looking, we unhesitatingly extract these teeth. In our cases,
Fig. 9. Poorly filled root canals. Decayed teeth with apical infection and ap- parently healthy teeth with infection.
at least, we have found them badly infected. It may be that the tooth was not properly filled. I have seen teeth where the fillings were taken out carefully and cultures made from the tissue below and we have found abundant, virulent strepto- cocci. It is a question whether these teeth could have been aseptically filled, if they were already infected. At any rate, if the tooth is at all suspicious, we are of the opinion that it should be extracted and not left as a menace after all foci of infection have been removed.
Pyorrhoea
We class together pyorrhoea and infected teeth and it is especially gratifying to find that Grieves supports our view. Under his heading of sound tooth pulps, diseased by pyorrhoea, he goes into the subject in an exhaustive manner, showing that the pulp disease is induced from the gingiva, and also states that "pyorrhoeal teeth, damaged to the middle third, and swathed in purulency, must be removed." We have followed
58
The Defective Delinquent and Insane
the practice where there was any severe disease of the gum, whether it could be classed as pyorrhoea or not, of extracting the teeth.
I have argued with specialists in the treatment of pyorrhoea who claim they can cure the condition and the teeth remain healthy. I do not deny that this may be possible but I would rather take the opinion of Grieves that in these cases the teeth should be extracted. In most of our cases we do not see the typical pyorrhoeal conditions, that is, there is not the extensive pus to be squeezed out of the gums, and I am inclined to think that the pyorrhea, due to amebae, is rather rare in our cases.
Fig. 10 A Fig. 10 B
Fig. 10, Periodontitis.
A. Drawing of molar with gingnial granuloma.
B. Radiograph of same tooth (A) showing separation of peridental membrane.
What we do find is chronically infected gums, due to strepto- coccus infection, but, whether this is pyorrhoea or not, we have found that only by extracting the teeth could we obtain re- sults. The emetin treatment of pyorrhoea, which promised so much, has not proven successful and has been abandoned by the best dentists. This is in exact accord with the results ob- tained from the use of emetin in treating amoebic dysentery, in which it has unfortunately been proved to be a failure.
The Systemic Effects of Chronic Infections 59
Exostosis and Sclerosis of Teeth
In many cases we find a condition which is not easily de- scribed and which is frequently overlooked. We refer especial- ly to the exostosis and sclerosis of the roots of the molars. Frequently these roots are fused and no clear picture can be obtained by the X-ray. Frequently the roots become very large, and often the radiogram is somewhat hazy (Fig. 10). Careful culture of these teeth has shown them to be infected and exostosis and sclerosis is probably due to the irritation of the infection, causing the bony tissue to proliferate. In one case there was a ball-like exostosis of the roots of all the teeth and they were extracted with difficulty. (See Fig. 11.)
Children's Teeth
No one who has made an investigation of the subject would dispute the fact that the teeth of the children of this generation are proverbially bad. This has been found by investigation of the teeth of the children in the schools and it certainly is a fact that the abnormal children present even worse conditions. Improper cleaning of the teeth, or lack of cleaning, improper diet, such as excessive sweets, have been blamed for this con- dition. We admit that dietetic errors and lack of cleanliness may play a part but we do not think that this is the whole cause of the trouble. It is possible, also, that a diet which is confined to soft foods, with not enough hard food, such as crusts and hard bread, might account, to some extent, for this defect.
That the importance of proper care of children's teeth is be- coming better known can be seen from the following extracts from the bulletin of the Department of Health, New York, issued January 1, 1921:
"Effect of Dental Decay."
"It is still very little realized by most people that the teeth play a very important part in determining general health. Careful scientific investigations of recent years, however, have shown that uncorrected dental defects in children may seri- ously injure the growth and development of the body and
60 Tlie Defective Delinquent and Insane
greatly lower the child's resistance to communicable disease. From the standpoint of school progress carefully kept records have indicated toothache as one of the most frequent causes of absence from school and that neglected mouth conditions are responsible for a very high percentage of retardation in school work. In addition to these immediate results of dental ne- glect the X-ray has pointed to diseased teeth as the starting point of many of the so-called degenerative diseases of later life the onset of which might have been delayed or prevented by proper dental attention during childhood."
"In Bridgeport, Conn., where during the last five years spe- cial attention has been paid to the operation of dental clinics, reports by the city board of health indicate that there has been a very considerable reduction in the incidence of communicable diseases in that city during the period following the establish- ment of school dental clinics in the year 1914. During this period diphtheria showed a decrease from 26.6 per cent to 18.7 per cent, measles 20 per cent to 4.4 per cent, and scarlet fever from 14.1 to 0.5 per cent."
"The neglect of the teeth in earl)^ life usually means an in- fected mouth with abscesses at the roots of the teeth which, unless cared for, persist in later life. It may readily be seen that such abscesses may act as reservoirs of infectious material which may enter the blood stream and be carried to the re- mote parts of the body, frequently causing rheumatism, heart disease, kidney trouble, and other ailments which may ma- terialty shorten life. It has been said that one-fourth of all of the people who die annually in the United States have their life shortened frorn five to ten years by these so-called degener- ative diseases/'
In many instances the first, or milk teeth, of the children, are badly decayed and infected and in such cases the infection is undoubtedly passed on to the second teeth. We have been closely observing the teeth of the parents of many of our pa- tients with infected teeth and in hardly a single instance do we find them free from evidences of infected teeth, such as bridge work, shell crowns, Richmond crowns, etc. In many instances, after clearing up the patients' mouths, we have had
The Systemic Effects of Chronic Infections 61
to take the parents in hand and clear up their mouths as well. Frequently, the parents show no systemic effects of their in- fection at the time, but in many instances, later on, serious physical conditions have arisen as a result of these infections and they have sought advice in regard to their teeth.
We should like to call attention to the possibility of the transmission of infection from the parents to the children and point out the dangers to which parents with such teeth expose their children. There are many ways in which this infection can be transmitted, especially through close contact of parents and children. Indiscriminate kissing of children, by people with infected teeth, whether parents or not, should be dis- couraged. The practice of feeding children with the same forks and spoons used at the same time by the parents should not be allowed. This would also apply to nurse maids and nurses caring for children.
It has been determined that tuberculosis is transmitted to the children, not through the medium of heredity, but through contact of the child with tubercular parents, and by the child's habit of pvitting everything in its mouth, and bj^ other means which are very numerous. There are so many methods bj^ which infection can be transmitted from the adults to children that we are justified in warning those with infected teeth, even though no systemic effects be evident in them at the time, against this danger. In other words, if you desire your chil- dren to be free from this infection, the best plan is to see that your own teeth and tonsils are not infected or your mouth swarming with virulent bacteria.
When the first teeth of children are infected and badly de- QSiyedj it has been our practice to extract them as I know of no other way by which the infection can be removed. Some authorities hold that the extraction of the fh'st teeth will inter- fere with the proper alignment of the second teeth, but the ad- vantages of eliminating the infection should far outweigh the dangers which might arise as a result of extraction.
There can be no doubt that infected teei;h may develop at an early age and after some years produce sufficient toxic poisoning, as in the case of impacted teeth, to account for the
62 The Defective Delinquent and Insane
peculiar and abnormal personalities of these individuals long before a psychosis has developed.
We would conclude, then, that it is necessary not alone that the child should be taught the importance of cleanliness and
Fig. 11. Radiographs of teeth in a case of paresis, showing exostoses or en- largement of the roots, due to infection.
proper diet, but that the parents should be taught the danger of allowing their own teeth to be neglected, for although they have no particular symptoms at the time, they may have badly infected teeth, and be guilty of transmitting infection to the child.
Tonsils These important and much discussed structures are thought to exert a developmental as well as a protective function in the early life of the child. Like the thymus gland, at puberty these functions cease and they tend to atrophy. In many ways they resemble an ordinary lymphatic gland but the important point is that they contain crypts (Fig. 12). These are blind cavities which extend through the organ and which normally contain cells and food remnants. Thus they furnish an ideal soil and breeding place for the development of bacterial growth. They are apt to be contaminated by the child putting soiled toys, etc., into the mouth and infection may also occur directly from the parents as has been noted in case of the teeth. Disease produc- ing bacteria are able to penetrate the mucous membrane of the
The Systeinic Efects of Chronic Infections
G3
Fig. 12. Drawing of the mouth showing enlarged and infected tonsils (from a case of periodic depression).
tonsils. In whatever way the infection occurs, infected tonsils are to be considered of equal importance with the teeth in pro- ducing systemic diseases and mental disorders and are to be removed irrespective of the age of the patient.
64 The Defective Delinquent and Insane
Secondary Foci in Stomach and Duodenum
It has been shown that these harmful micro-organisms, which frequently originate in the teeth and tonsils, do migrate to other parts of the body and set up secondary foci. In some cases, these secondary foci may disappear with the removal of the primary focus. In the large majority of cases, however, the secondary foci have become entrenched so that means have to be used to get rid of them, independent of the elimination of the primary focus.
The stomach and duodenum are ver}^ frequently the seat of secondary foci. The infection is conveyed to the stomach, either by means of constant swallowing of infected material from the mouth — teeth and tonsils — or through the lymph or blood circulation, more probably the former. The bacteria in- vade the stomach wall and appear to interfere with the secre- tion of hydrochloric acid, so necessary to digestion. Cultures of the stomach contents will reveal the presence of various types of streptococci and frequently of various types of colon bacilli. The chemical examination of stomach contents will show either a very low secretion of hydrochloric acid, or in many cases, its entire absence during the test meal. Fre- quenth^ the duodenum is also infected and occasionally the stomach may be normal, the infection being localized in the duodenum. (See Figs. 13 and 14.)
It is believed by many investigators that acute and chronic ulcers of the stomach and duodenum are often the result of this infection. The latter are four times as common as the former. Autogenous vaccines, made from the cultures of the stomach and duodenum, have been frequently used successfully in elimi- nating the infection with subsequent restoration of the hydro- chloric acid and gastric juice to normal.
The small and large bowel may frequently become the seat of secondary infection. In the majorit}^ of cases, the infection is limited to some part of the colon or large bowel. There may exist certain abnormalities of this portion of the intestinal tract which predispose to the invasion of the intestinal wall, by strep- tococci and colon bacilli and other micro-organisms.
Frequently these anatomical variants are congenital and in
The Systemic E feats of Chronic Infections
65
FIRST test: APRIL 9,1918.
SECOND test: may 20. I9IQ.
HO
loo- se
60
ro-
60
50 40. 30 20 lO o <
MINUTES 15 30 45 60 75 90 I05 I20 137 I50
15 30 A5 60 75 90 I05 I20 135 I30
Fig. 13. Two charts showing range of gastric acidity by the Rehfuss fractional method. April 9, there was a total absence or lack of free HCl, and cultures made from the stomach contents gave streptococcus, B. Coli and staphylococcus aureus. After the administration of an autogenous vaccine made from these bacteria, the sec- ond test on May 30, 1918, the HCl curve has become normal and cultures were sterile. (This patient recovered after the administration of the autogenous vac- cine, from an unclassified psychosis of nine years' duration.)
= total acidity
. — . — .—= free HCl
FIRST TEST. APRIL 15.1918.
SECOND test: OCT 7, 1918.
|
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|
|
2 |
no |
|
Z |
lOO- |
|
O |
|
|
o |
90 |
|
Q |
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|
y |
80- |
|
8 |
70- |
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MINUTES 15 30 45 60 75 90 I05 I20 135 I30 15 30 45 60 75 90 105 I20 135 150
Fig. 14. Similar charts as in Fig. 13, with return of the HCl to normal after ad- ministration of the autogenous vaccine of streptococcus and staphylococcus aureus. The cultures from the duodenal contents gave the same type of bacteria. From a case of depression lasting some years, with recovery after vaccine treatment.
:r= total acidity
. — . — .—= free HCl
66 The Defective Delinquent and Insane
some cases the same abnormalities have been found to exist in parent and child. The localized "areas of delay" are, natm-- ally, predisposed to infection, because of the stagnation of the bowel contents at these points, a gravitational disorder. In some cases the colon may have no evident anatomical defects, but the infection may gradually destroy the normal lining and even the muscular coats of the intestinal wall and produce a serious pathological condition. This often causes great ir- regularity of the bowels and the absorption not only of bac- terial toxins, but also of harmful putrefactive material from the bowel contents arising chiefly from the protein foods. On the other hand, in rare instances, all the bowel functions may remain subjectively normal. These considerations call to mind recent investigations regarding the relative importance to us of the stomach and colon. All of us have been brought up to believe that our food is digested largeh% at least, in the stom- ach and that it is a most important organ. As a matter of fact, it has been found, chiefly through indisputable proof, after its removal by surgery, that it is one of the least important organs in the body, for patients often gain much weight with only a fragment of it left. The principal function of the stomach is storage and motilit}^ each easily dispensed with. Digestion is completed in the first part of the small bowel. The stomach is for all the world like a cement mixer often used in the erection of large buildings and just about as necessary. The large bowel is, similarly, for storage and we can dispense with it just as freely as with the stomach.
Infection of Lower Intestinal Tract
A further consideration of the cause of these intestinal difli- culties centers upon gravity and the upright position. We have never become adapted to this position, still paying the penalty, as Shaler remarks, for "getting up on our hind legs." This position forces the bowel contents to run uphill in certain parts of the colon and causes it to work constantly against gravity. This imposes a load for which the organ was not originally devised and for which it has not yet become wholly adapted and which in turn often seriously interferes with the
The Systemic Effects of Chronic Infections 67
circulation of the blood. An exhausted organ is of course prone to infection.
These conditions are responsible for large numbers of chronic gastro-intestinal invalids. Their protective symptoms which include pain, vomiting, diarrhoea, etc., and which persist for years are often disabling and the infection finally leads to serious trouble. The lesions found in the colon vary from iso- lated chronic punched-out ulcerations, to diffuse folliculitis, with serious damage to the entire mucous lining (Figs. 15 and 16). When this infection has persisted for years, the colon may lose its normal appearance and function. We have found, in some cases, only a thin membrane left, in which the muscular and epithelial coats had been entirely destroyed. In these thinned out sacs the putrefying bowel content has been proved by the X-ray to have remained for as much as ten days, pour- ing toxins, bacteria and all forms of poison into the patient's system. The extensive distensions often foimd, may be ac- quired or congenital, or due to both causes. The small bowel is less frequently infected than the large bowel.
In many of our cases, however, we have found extensive in- fection extending the whole length of the small intestine. Surgical measures have proven successful in eliminating the infection in the colon but it is evident that when the whole in- testinal tract is invaded, surgical procedures are unavailable and the infection must be combated by means of vaccines or sera. These are the most powerful adjuncts to surgery and may in the end almost wholly replace it.
The appendix and gall bladder are frequently involved, whether primarily or secondarily is not yet known, and when infected should be removed. The rectum is not an unusual site for infection and in some of our cases chronic ulceration has been found associated, frequently, with infected venous thrombosis, cryptitis, fistula and fissure.
Genito-Urinary Tract
The cervix or neck of the uterus has been found to harbor extensive infection which, aside from an unpleasant discharge, produces no marked subjective discomfort to the patient. The
68
The Defective Delinquent and Insane
Fig. 15. Photograph of the mucous lining of the colon after resection,
A. Punched out ulceration.
B. Destruction of the rugae or folds of the intestine due to chronic infection.
tubes and ovaries may also be involved and the organism in- fecting both areas may be either streptococci, or colon bacilli, or both. Emphasis must be laid on the fact that these infec- tions bear no relation whatsoever to venereal disease. As in
The Systemic Effects of Chronic Infections 69
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70 The Defective Delinquent and Insane
the case of localized infections occurring elsewhere in the body, so also in these conditions surgical procedures are necessary to treat the infection. The cervix should, in all cases, be enuc- leated, according to modern methods. The infected tubes and ovaries are secondary foci from the primary infection in the cervix. Unless too extensive, they will often subside and re- turn to normal after the removal of the primary focus. This takes time, but, as conservation of these organs is of the most vital importance to the patient, both because of the reproduc- tive function and of the very important internal secretion of the ovaries as well, except in extreme conditions these should never be removed, unless it be found unavoidable after a lapse of several months.
In this way, gynecological surgery becomes, as it should be, essentially and primarily protective; safeguarding the ovaries from destructive infection which would ultimately necessitate removal. The uterus is involved in very few cases as this organ seems to present special resistance to chronic infection, al- though occasionally marked changes occur, probably due to infection, in which cases it is necessary to remove the organ.
In the male, when primary foci of infection have existed for years, we often find infection of the seminal vesicles and less frequently of the prostate gland. It is possible that a previous gonorrheal infection may have lessened the resistance of these areas, allowing invasion by streptococci and colon bacilli, but venereal disease is not as important a factor in the chronic in- fection of these organs as was generally supposed. Surgical procedures are also necessary here to remove the infection.
Systemic Involvement Through Focae Infection
The foci of infection in the organs considered above may persist for years and yet produce no very evident effects upon the individual. In many cases they may be considered latent infections capable at any time of becoming actively virulent and migrating to other parts of the body, causing verj^ serious disturbances. If the invading micro-organisms become virulent and are in sufficient number, the tissue reaction is correspond- ingly severe and the systemic disturbance is apt to be acute. If
The Systemic Effects of Chronic Infections 71
the tissues involved are limited in area no anatomical damage may result from the attack and the systemic reaction may be less severe.
Permanent diseased conditions may result from such an in- vasion and the function of such organs be disturbed. Chronic foci of infection, whether primary or secondary, may serve as a source of constant or intermittent supply of pathogenic micro-organisms of low virulence and of toxins to other areas. These same organisms of low virulence, by repeated invasion of the tissues, may finally cause serious anatomical lesions and disturbances of function.
Thus, acute rheumatic fever is without question due to the invasion of the joints of various types of micro-organisms, originating from the source already described. It is usually due to a form of streptococcus but may be caused by other or- ganisms. One or more joints may be involved and the condi- tion may remain acute or become chronic. There may be also repeated attacks from which the patient recovers, then finally a more severe attack occurs, from w^hich the patient may not recover. As the heart linipg is similar to that of the joints it h often attacked by these organisms. This explains the popu- lar expression that "the rheumatism had gone to the heart."
In arthritis deformans, a chronic involvement of the joints, the disease is usually progressive and remedial measures must be used in the early stages. For, while the acute joint condi- tions may clear up spontaneously, this chronic form goes on to the production of serious anatomical changes in the joints, so that while the removal of the source of infection may stop the pain it will have very little effect in reducing the joint deformity.
Various forms of heart disease, described as endocarditis, or disease of the lining membrane of the heart and valves ; myo- carditis, or disease of the muscular tissue of the heart; peri- carditis, or disease of the sac surrounding the heart, are all the result of the invasion of the heart, usually by streptococcus. It comes from the chronic foci of infection referred to, often the tonsils. In one case we have found the colon bacillus respon- sible for pericarditis which caused the death of the patient.
72 The Defective Delinquent and Insane
The liability of such a serious condition as heart disease de- veloping suddenly, from chronic foci of infection, emphasizes the importance of eliminating all chronic foci of infection from the system.
Nephritis, or as it is commonly called, "Bright's Disease," diseases of the liver, pancreas, bones, muscular rheumatism, chronic neuritis, diseases of the eyes, various skin lesions and other conditions, have been found to be due to chronic infec- tions. Following the removal of such infections many of these conditions disappear, showing that they are in reality the visible symptoms, only, of the invisible and unrecognized focal infec- tions elsewhere in the body.
Disturbances of the endocrin system, or the ductless glands responsible for the internal secretions, are frequently caused, either by direct invasion of bacteria or by toxins, produced by the chronic infection. This is especially true of the thyroid gland and Billings calls attention to many cases where an en- larged thyroid gland, producing serious systemic disturbances, has become normal after the removal of the chronic foci of in- fection and the systemic disturbances have ceased. If the thy- roid gland has become permanently damaged, removal of the infection will not restore the gland to normal, in which event it will be necessary to treat it by surgical measures.
In all of the conditions described above, the disturbance is undoubtedly caused by the invasion of the tissue by micro- organisms or their toxic products. In mental conditions, the result of chronic infection, only in rare cases do the micro- organisms themselves invade the tissues of the brain. The dis- turbance is produced by the toxin, generated by the bacteria and transmitted to the brain through the blood stream. The mechanism of the development of mental disease is more com- plicated and the relation of physical causes to the psychoses is more difficult to understand than in the various physical ail- ments just described, but it will be shown that it also is subject to the great biological laws relating to function and structure.
The Systemic Effects of Chronic Infections 73
The Selective Activity of Pathogenic Bacteria
It has been very difficult to understand why the streptococci, in one individual, will attack the heart and joints; in another individual, the kidneys; in another, the stomach; in still an- other, the gall bladder, etc. As has been stated, it has been hard to comprehend how a group of organisms, apparently all alike, could cause so many diseased conditions in very diverse organs. Taught to expect specificity in all disorders — a spe- cial organism being responsible for the bulk of all known in- fectious diseases — physicians were, naturally, at a loss to un- derstand such great diversity, both in the character of the les- ions and in their distribution, as was noted in the disorders long known to have streptococci associated with their occur- rence. For a long time, this prevented the acceptance of these organisms as causative factors.
This erroneous conclusion is now known to have been due to a faulty premise, viz., that because the organisms in question were alike in morphology they were consequently alike in func- tion. There is no better example than this of the decline of the influence of morphological standards in medicine and their re- placement by functional or biological criteria. As a matter of fact, the streptococci differ widely and it is not surprising that they may cause a diversity of lesions.
Rosenow, in a long series of experiments, proved that vari- ous strains of the streptococcus possessed a selective activity or special affinity for certain tissues. He has demonstrated by animal experimentation that strains of streptococci, taken from the teeth in an individual having a heart lesion, would produce in the majority of instances, a heart lesion in an experimental animal and this holds good for many other conditions. This selective nature of the streptococcus is very important in solv- ing many problems relating to the causation of diseases of obscure origin.
Thus, in mental diseases, the toxins generated by the bac- teria, undoubtedly impair the nervous tissue of the brain, in obedience to this law of selective activity, and it is, therefore, important to note that seldom do mental cases have any rheu- matic trouble. One case, only, has come under the writer's
74 The Defective Delinquent and Insane
observation, in which a psychosis directly followed acute rheu- matism and there is but one case in the State Hospital where the mental disease is associated with arthritis deformans. Very few mental cases are associated with primary lesions of the heart and kidneys, although these organs usually become in- volved in the terminal stages of the disease.
Summary and Conclusions
It has been shown that chronic infections may occur, and cause serious damage, without the individual being aware of their presence and the danger lies in this strange fact. In this they differ from the well known acute infections in which the patient, by reason of pus, pain, temperature, and other symp- toms, is only too well aware of the presence of infection.
Particular attention should be paid to the teeth and tonsils if chronic infection is to be eliminated at its onset. The indi- vidual should insist upon a thorough examination by means of the X-ray, as well as a thorough examination of the mouth and the decision should always be based upon these two factors and never upon one alone. All badly decayed teeth and all dead teeth should be extracted without delay and under no circumstances should these teeth be saved by any methods used in modern dentistry for cosmetic or other effects. Fixed bridge work of every description, gold shell crowns and Richmond crowns, should be eschewed by the individual in every instance, and teeth in need of such work should be extracted, even if the individual has no special systemic symptoms at the time. The aversion for artificial dentures or plates by the people at large, especially in the younger individuals is not justified. Instead of creating the impression of advancing age and as ushering in a period of decline, artificial dentures are in reality the greatest possible safeguards against premature old age. Moreover, with the increasing public demand for properly fitting dental devices, there has come immediate response from the resourceful and ingenious dentists in America. Examples of these are the modern removable bridge and the newer forms of plate adjusted to the soft parts of the mouth, rather than to the bony parts as was the case with the older devices. Ton-
The Systemic Effects of Chronic Infections 75
sils once infected, are always a source of danger and should be removed.
It should be distinctly understood that infectious bacteria originally in the teeth, may become disseminated throughout the system and form secondary foci of infection, which will persist after the source in the teeth, tonsils and other regions has been eliminated.
The selective action of the streptococcus and other organ- isms accounts for the many and diverse symptoms which may result from hidden infection in tonsils, teeth and elsewhere and the development of general systemic diseases in organs like the heart and kidneys. Such systemic involvement may be the re- sult of a direct invasion by the bacteria from other organs re- mote from the original source or by the transmission of the toxins generated by these bacteria, through the blood stream, as is the case in certain systemic and mental diseases. Do not let your dentist delude you with the statement so often heard that "bad health causes bad teeth" as we know that such a theorj^ is absolutely false, the cart leading the horse. The bad health is the result of had teeth and not a cause as many would have us believe.
It is no new theory that infection and toxemia can cause mental disturbances for psychiatrists have, for many years, classified such disturbances under the specific terms "Toxic- infectious psychoses." This diagnosis was, however, limited to a small group of cases in which, from the acute nature of the infection, its presence was readily recognized by the routine examination. We have merely extended this group to include types of mental disorder of a hitherto unknown origin, in which the existing infection, because of its nature, eluded the scrutiny of the physician, was unknown to the patient, and was brought to light only by the newer methods of physical diagnosis.
This should answer any destructive criticism of this work, i.e., that while infection may be present in the psychotic patients it has not yet been proven to cause the psychosis. Fortunately, as we have stated above, infection is a well proven factor and one generally recognized by psychiatrists. Neither does the criticism apply that such infection is very prevalent in the
76 The Defective Delinquent and Insane
population at large and the proportion of mental diseases is relatively small. As has been explained, the individual's im- munity will protect him, not only from mental symptoms re- sulting from infection, but from other physical troubles as well just as long as equilibrium is maintained between his sus- ceptibility and the virulence of the bacterial parasite.
The same situation exists in the relation of alcohol to in- sanity. Many people formerly consumed more or less alco- holic beverages but only a small proportion of the population developed alcoholic psychoses. But no one would deny that alcohol was the cause of the psychosis. And the same may be said of the relation of syphilis to paresis, which develops in only about 4 per cent of the individuals infected with syphilis.
All infected tonsils should be removed. Children's teeth should be properly protected from infection and repeated ex- aminations made to check beginning signs of infection. Im- pacted and unerupted molars in the adolescent should be ex- tracted to prevent further trouble, either mental or physical. Scrupulous care should be exercised by the parents to prevent infection of their children's teeth by contamination. The same rules should be enforced as are required in fighting tubercu- losis. Better still, parents should have all infections in their own mouths eliminated if they wish their children to be healthy.
CHAPTER IV
TYPES OF MENTAL DISORDERS AND THEIR TREATMENT
Toxic Psychoses
As has been stated, mental diseases are, for convenience, usually divided into the "organic" and "functional" groups, principally because no definite lesions have been found in the brain to account for the symptoms of the so-called functional group. It has been explained why such a classification, based upon this view-point, is untenable today. If we believe that there cannot be function without structure we must also be- lieve that disturbance of function depends upon the disturb- ance of structure. Perversions of mental adjustment are then to be considered the result of brain lesions rather than the cause of the mental disorder. Therefore, we prefer to regard the "functional" group as toxic.
These comprise the acute conditions, known generally as the manias and melancholias, or as is said today, manic-depressive insanity, and the chronic conditions characterized by brain deterioration and grouped under dementia praecox, including paranoiac conditions, or chronic delusional states. Many of the psychoneuroses, such as hysteria, neurasthenia, and psy- chasthenia, generally regarded as functional in origin, are now known to respond to the form of treatment herein outlined and frequently to no other. They are, therefore, properly to be placed in the toxic group.
Formerly, the dementia praecox group was always asso- ciated with incurability and after such a diagnosis was given very little attempt was made to do anything for the patient. The family was told that the patient should be made as com- fortable as possible with the result that he was usually com- mitted to an institution, and, except in rare instances, was con- fined for the rest of his life.
77
78
The Defective Delinquent and Insane
This large, so-called functional group, comprises at least 50 per cent of the admissions to the state hospitals and at least one-half of this number consists of the dementia praecox group, the individuals of which formerly remained permanently in institutions and constituted one-half of the permanent residents of state hospitals. These residual cases, in a large measure, account for the net annual increase in the insane population. This net annual increase varies according to the number of cases admitted, but has become so large as to constitute a press- ing problem in the care of the insane. Any methods which would tend to decrease this yearly increment, aside from any humanitarian aspect of restoration, would lessen materially the economic load which is becoming more and more burdensome to the community.
It is unnecessary to go into any discussion here of the justi- fication of closely differentiating this great "functional" group
6797 Fii:st Admissions • NewTork State Hospitals <- 1918.
All olher
Psychoses
30% ■
Senile Dementia
Manic
Depressive
insanity
\4t
Alcotiolie Insanity
5%
f Dementia Praecox 28%
Fig. 17. Ctiart showing the relative number of types of insanity admitted to the New York State Hospitals in 1918, compiled by Dr. George H. Kirby, Director of the Psychiatric Institute, from a total of 6797 first admissions, and used by his kind permission.
Types of Mental Disorders and Their Treatment 79
Psychoses 3Z352 Cases- in NewMSfateHospitals<- June 1918.
^ TYm^"^''^ Dementia
All olher^,---'^ inmTSS.
Psychoses^x^ / 1 1 1 1 1 1 1 1 1 /V.Pai-esis
20^
Manic
Depressive
Insanity
3%
Dementia Ptaecox 59% Fig. 18. Chart showing the types of insanity in the New York State Hospitals in a population of 37,352 patients on the first of June, 1918, prepared by Dr. George H. Kirby, and used by his kind permission. It will be seen that more than half of the insane population in these hospitals is composed of the dementia praecox group, or the chronic types.
into distinct entities. It is true that certain cases of dementia praecox can be diagnosed in the incipient stages and a bad prognosis given, and certain types of the acute psychoses can also be easily diagnosed. It is sufficient for the purpose of this work to recognize acute and chronic mental conditions and not to burden the reader with complicated differentiations. When such factors as alcohol, syphilis, arteriosclerosis and se- nility can be eliminated, which formerly comprised the organic group, we still have this large balance, constituting 50 per cent of our admissions, classed as "functional." (See Figs. 17-18.) While the course and termination of the various types in this class may differ materially, it has been found that the causative factors are the same. In one type, hereditary influences may be more prominent, in another the psychogenic factors, but in the entire class we have found that the presence of chronic in-
80 The Defective Delinquent and Insane
fection and resulting toxemia is the constant and most impor- tant factor. In this "functional" group, now classed as toxic, the spontaneous recovery rate was only 37 per cent for the decade prior to 1918. Since then and as a result of instituting the detoxication treatment, the rate has reached 77 per cent.
An explanation of the chronicity, or the tendency toward incurability, may be found in the varying susceptibility of the individual to infection as well as in the character, the severity, and extent of such an infection. The constitutional reaction, inherent in the individual, towards these various factors, is dis- tinctive and specific varying with the patient's physical condi- tion. These elements are evident in all chronic infectious dis- eases and are not limited to abnormal mental conditions.
It can be shown, no matter what the hereditary influence has been, or what the environmental difficulties to which the patient has been subjected, that there are factors in the physical condi- tion of the patient which should be eliminated, if the toxic pro- cess is to be arrested and the patient restored to normal. This change in mental and physical conditions, resulting from the process of surgical and medical detoxication of the individual, is to be described as an arrest rather than a cure^ just as is customary in describing the conditions of patients recovered from tuberculosis or any other chronic infectious disease.
Psychological Phenomena
In spite of the tremendous amount of work which has been accomplished in the field of psychological research it must be evident from statistical studies that very little benefit to the patient has accrued by reason of such work. The recovery rate has decreased rather than increased during the last twenty- five years, due possibly to the over-crowding of the hospitals and to lack of ordinary sanitary and hygienic surroundings, so necessary to the health of the patient. Psychological investi- gations, while offering elaborate and helpful explanations and leading us to a better understanding of the nature of the psy- chosis, have failed to offer any explanation as to their cause and development.
The attempt to find a logical sequence in the psychological
Types of Mental Disorders and Their Treatment 81
phenomena and to limit the study of the pathological mental condition entirely to the psychological field has been unsuccess- ful and has led to the error of disregarding or discarding all anatomical and physiological factors, either somatic or cere- bral, as the case may be. The later conception of the Freudian school, regarding the subconscious and disturbing elements, which may persist in our minds and finally come to the surface, while very interesting as a hypothesis, has led nowhere in the successful treatment of patients having pronounced mental disorders.
A systematic and thorough study of the mental phenomena by any psychological method which will lead to a clear under- standing is always to be encouraged, but, to limit the search for the causative factors exclusively to the psychological field is out of accord with the spirit of modern medicine and hence im- sound. It is only by examining the patient as a whole and subjecting him to a most careful examination, both physical and mental, that one can hope to succeed in finding the causes of the mental disturbance. These are often of a physical na- ture and the psychological phenomena may be merely the re- sult of the somatic pathology.
It is naturally in this large field of the so-called functional class that the need for a better understanding of the causative factors has become imperative. Here, as in every other de- partment of modern medicine, possibly even more so, the cry- ing need is for prevention far more than the relief of the indi- vidual patient and prevention cannot be thought of until causation is known.
Paresis
Paresis, commonly known as "softening of the brain," is a disease in which the cause is definitely known and in which suc- cessful treatment and prevention has been made possible by reason of this knowledge. For years it was considered a "mental disease," the result of over-work and mental strain, but the fact of the existence of definite physical signs led to a further investigation of its nature. After years of investi- gation it was definitely determined that the principal cause of
82 The Defective Delinquent and Insane
paresis is syphilis, that the germs of syphihs actually invaded the nervous system and that the resulting disease was deter- mined by the destruction of the nerve cells and fibres, whether in the spinal cord or brain tissue. Although for years there was much skepticism regarding this theory, the perfection of laboratory methods has enabled us to demonstrate the presence of active syphilis in every case and today no one will deny that the cause of paresis is known. Other forms of infection may be co-existent but the main cause is syphilis.
Fortunately, only a small percentage of individuals, who contract syphilis, develop paresis, namely about 4 per cent. Formerly, syphilis was considered cured after years of treat- ment and the disappearance of all signs of the disease, but here, as in all other chronic infectious diseases what was thought to be a "cure" proved only to be an arrest and that, in spite of the apparent "cure," in the course of time, sometimes as long as twenty years, paresis would develop. Hence, it was diffi- cult to trace the relation of syphilis to paresis until it was dem- onstrated that the germs were actually in the brain tissue itself and were the direct cause of the disease.
The mental symptoms were, in certain cases, characteristic of the disease, and in the majority of cases a diagnosis could be made easily, especially in the later stages. In the early stages, however, the mental symptoms were not so pronounced and often errors in diagnosis occurred. The introduction of the method of lumbar puncture by means of which the spinal fluid could be withdrawn for examination, microscopic and chemical, offered a diagnostic method which was accurate and reliable, often long before the development of characteristic and distinguishing nervous sj^mptoms.
The changes in the spinal fluid which were found to occur in paresis were diagnostic for the disease and did not occur in other conditions, so a positive diagnosis, in doubtful and early cases, and corrective treatment, at a time when it would be effective, both became possible. Moreover, examination of the spinal fluid furnished conclusive evidence in determining the presence or absence of involvement of the nervous system in the acute stages of syphilis, thus indicating the necessity for
Types of Mental Disorders and Their Treatment 83
further treatment in such cases as had been erroneously con- sidered cured.
Paresis, therefore, is nothing more than a late symptom of syphihs and is theoretically a preventable disorder, for if syphi- lis could be prevented there would be no paresis. We know that syphihs can be prevented, largely through education of the youth as to the danger of sexual immorality and promiscu- ous sexual intercourse. When the disease is acquired, then prompt and efficient treatment should be sought and carried out by speciaHzed, reputable physicians. This means that in every case the spinal fluid must be examined to eliminate pos- sible involvement of the nervous system. If it, too, has been invaded then the proper treatment must be instituted to eradi- cate the germs from this field.
There is a possibility of a cure in the very early stages of paresis, but the greater the interval between the onset of symp- toms and treatment the lesser is the outlook for permanent arrest and the patient should continue treatment until assured by the physician that every test for the disorder has been nega- tive for a long time.
Paresis was formerly considered incurable and the patient usually died within three years of the onset of the symptoms. In the last few years, however, a method of treatment has been developed and has been used successfully in a few hospitals in the early stages of the disease and before very extensive and permanent damage has been done to the brain tissue. This treatment consists of introducing into the spinal canal, or bet- ter, the ventricles of the brain, the patient's blood serum pre- pared after he has been treated by salvarsan, more properly called Arsphenamine, an arsenic preparation, capable of de- stroying the minute organism which causes syphilis much as quinine destroys the organism which causes malaria. This treatment, however, must be continued fpr a long period of time before the germs are eradicated from the brain and sur- rounding tissues and to be effective it must be begun in the early stages of the disease. Another very important step in the treatment of paresis consists in eliminating all other types of chronic focal infection wherever found. The patient with
84 The Defective Delinquent and Insane
paresis should be subjected to the same routine examination and treatment recommended for chronic infections before the best results can be obtained.
Psychoses Due to Alcohol
Alcoholic insanity formerly accounted for over 20 per cent of the male admissions to many state hospitals in this country. With the advent of prohibition this ratio has been materially reduced, even with the present lax enforcement of the laws. In the State Hospital at Trenton the reduction has been from 21 per cent to 7 per cent in the last year. While there is con- siderable drinking it is evidently not done by those who for- merly filled our hospitals. (See Fig. 19.)
If prohibition really becomes effectual there can be no doubt that alcoholic insanity will be a thing of the past and there is every reason to believe that with it the pernicious social factors, the ethical disorders and physical diseases which actuallj^ seemed to hatch and grow fat in the bad beverages of the old saloons will have forever passed away. This at once presents the abstract problem as to the justice of curtailing the personal freedom of action of the individuals of the highest type who are not jeopardized by having free access to alcohol, for the protection of the less fortunate congenitally defective class to whom free alcohol has been a menace. One answer may be drawn from the biological evidence, already noted, that human social evolution has outrun all other forms of progress. This limitation of personal freedom is merely one expression of the great force which tends to protect the masses at the expense of the individual and which in sweeping away the saloon has lifted the heaviest yoke from the neck of this vast mass of hu- man defectives. These, it will be remembered, constituted Bis- mark's famous "Kanonenfutter" and even in prehistoric times they constituted the great bulk of primitive societ}^ The ratio of officers to privates was fixed years ago when the really fit seized command by virtue of superior intelligence. That ratio remains about 5 to 95, as is shown by the fact that in the pres- ent army five men still control one hundred. This helps one to realize that human effectives constitute today only about
Types of Mental Disorders and Their Treatment 85
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86 The Defective Delinquent and Insane
5 per cent of society, the remainder being utterly dependent upon this small group both for protection and for progress. It emphasizes also the ancient maxim "noblesse oblige," and indicates the responsibilities of this small group.
The other answer as to the ethics of prohibition is based on practical considerations, in proportion as the alcoholic wards are empty the homes are filled and happy. The use and even the abuse of alcoholic beverages did by no means always pro- duce psychoses, but the effect on the individual in impairing his moral and ethical sense led to a subversion of his normal character so that his actions in many instances were far worse than those of an insane man. Thus, prohibition has solved for us the problem of alcoholic insanity and has lifted a heavy burden from the community as well as from the families of those who were alcoholics.
The "Nervous" and "Neurotic" Individual
Closely related to the psychotic, these unfortunates are per- haps more misunderstood than any other class of patients. Improperly diagnosed upon subjective symptoms alone, they go from physician to physician always regarded as "pests" and their complaints as unworthy of consideration. Most of them have been told over and over again that their troubles were "imaginary" or "in their heads," that they had "nervous dys- pepsia" or, more recently, that they had a "dropped stomach" or "nervous heart" or that they had "uric acid poisoning." Dosed with drugs and dieted to a point of emaciation, the symptoms persisting, they have been ordered to the country or to travel afar. This unfortunate method of treatment has arisen through no fault of the profession, there being in most cases no definite evidence of organic trouble on casual investi- gation. The modern methods of examination, now aptly de- scribed as a "diagnostic survey," and practised in such great medical centers as Johns Hopkins, under Lewellys Barker, and at the Mayo Clinic, have rapidly raised the ratio of find- ings of physical causes. At the latter place, over eight years ago, J. W. Draper summarized the analysis of seven hundred and fifty cases all diagnosed as "neurasthenics" or "neurotics,"
Types of Mental Disorders and Their Treatment 87
with the result that, at that time even, 48 per cent were found to have had a physical basis for their symptoms which was recognized and removed in the clinic with consequent arrest of the symptoms. Of the remaining 52 per cent, resulting from the then inadequate methods of diagnosis. Mayo said with pro- phetic insight, "They are all due to a physical cause, only we do not yet know enough to recognize it. Ten years from now 60 per cent will be diagnosed ; twenty-five years from now 70 per cent, and a century or less from now, we shall be able to find and remove the cause in over 90 per cent." This was the cor- rect vision of a practical idealist and its result is seen in the remarkable development of the Mayo Foundation.
There has come a great change in the attitude of the profes- sion toward the patient, due largely to the recognition that, if searched for, a cause can be found for his seemingly foolish complaints. Physicians have found out that they were the fools rather than the patients, to the great benefit of all con- cerned. When we think of the continued suffering due to failure to recognize the underlying causes of these "neuroses" we can but rejoice in the modern development of diagnostic methods which goes far to make such mistakes a thing of the past. This is in no sense a criticism of the earlier work which failed only because of inadequate knowledge. Criticism will be justified, however, if the modern methods of diagnosis and treatment are withheld, not alone in this group but in the psychotic group as well. It is more than a coincidence, prob- ably, that many of these truths were recognized first by such men as William Mayo, Robert T. Morris, J. W. Draper and others, who were able to confirm their abstract researches and theories by practical demonstration in the operating room. They found in these so-called psychasthenic, neurotic, or psy- chotic patients, visceral and other lesions which are now known to stand in direct causal relation to the subjective and often vague symptoms.
During the past twenty years many diseases, formerly con- sidered purely medical and of unknown origin, have been proven by surgery or otherwise to be of known and often pre- ventable origin. Through the closer association and cooper-
88 The Defective Delinquent and Insane
ation of highly developed special workers in progressive medi- cine we are on the threshold of developments of the very great- est importance in the extension of this new knowledge in the field of psychiatry and neurology.
On every hand there is now abundant proof that so many neurotic cases are due to physical causes that all should be sub- jected to a thorough diagnostic survey by modern methods of examination. The following case is reported to show the rela- tion of the toxic factors to the neurosis. A successful busi- ness man, married, age 28, and previously healthy, but un- der considerable financial strain, went abroad to visit his old home in 1912. While on the boat he developed obsessions of a peculiar character, whenever he saw any paint, especially green paint, usually in the toilet, he imagined that he had wrapped this paint up and sent it back to his home in order to poison the children of certain friends. He knew he had done nothing of the kind, but the obsession persisted. After spending a few weeks abroad he returned and then consulted the writer. At that time the obsessions were very vague and weak and soon dis- appeared without any special treatment, except the reassur- ance that there was nothing for him to be alarmed about.
He had no further trouble until the Fall of 1915, when he again went abroad to see his father who was dying of cancer. After he had been a few days on the boat, the same obsessions again developed, but this time much stronger and could not be overcome. He made himself a nuisance by asking the other passengers if they had seen him wrap up the paint and send it back. On being assured that he had done no such thing, he would be satisfied for a short time, but would soon ask the same questions, so that he soon began to be shunned by the other passengers. He remained abroad but a short time and upon his return he again consulted the writer. This time the obses- sions instead of fading away gradually became worse. He could not attend to business, and he sought the writer two or three times for assurance that he had done nothing. He had perfect insight into his obsession; knew when talking to the physician that it was foolish, but as soon as he left the office they would appear stronger than ever. He was afraid also
Types of Mental Disorders and Their Treatment 89
that because of his sending this paint to the children and caus- ing their death he would later be charged with murder and convicted. He was sent to the Mercer General Hospital on Oct. 8, 1915, in order to try out the rest treatment and isola- tion, but here he developed other obsessions, — for example, that he had put paris green in the butter that was left on his plate, and that this was given by his direction to children and caused their death. He became worse at the hospital, could not sleep and remained only three days. Following this it was necessary for the writer to see him twice and often three times a day. Usually a final visit had to be made at night at his home, before he could be made to go to sleep. He always had his wife present during the doctor's visit so that she could re- assure him later that the doctor had said he had not done these things. All forms of psychotherapy were tried, psycho- analysis, hypnotism, etc., without effect. It seemed that the more the writer assured him that he had done nothing the stronger the obsessions would become. It would be necessary to repeat to him over and over that he had not done these things and that nothing was going to happen to him. Finally one night the writer's patience, after months of such visits, became exhausted and he refused to tell him again that he had done nothing, and left him. He did not return for some weeks, but when he did the obsessions were much worse. Besides this he was beginning to have auditory hallucinations. He imagined that his children were accusing him of these acts. With all these symptoms he still had good insight as long as his physi- cian told him nothing was wrong. There was nothing espe- cially abnormal in his physical condition, although he was poorly nourished. For over a year he was unable to care for his business and was constantly under the influence of these obsessions.
His blood was examined by various methods. The Abder- halden tests for disturbances of the ductless glands were nega- tive, but the fixation test for streptococci was positive. The writer then had his infected tonsils removed and his infected teeth extracted. In a very short time all his symptoms disap- peared and since the fall of 1916, after a year's misery, he re-
90 The Defective Delinquent and Insane
covered and has had no return of these symptoms since. He has conducted his business successfully, since then. If he had not received relief it would have been necessary to send him to the State Hospital.
A married woman, age 44, accomplished, previously [healthy, suddenly, in February 1918, developed severe at- tacks of dizziness and vertigo, so that it was impossible for her to raise her head from the bed. She had suffered from habitual constipation since girlhood, which had gradually be- come worse, and during this attack of vertigo, there was much distention of the abdomen and considerable pain. She was ad- mitted to Mercer Hospital, Trenton, in February, 1918, and after having her teeth X-rayed, all of the upper teeth and the molars and bicuspids of the lower jaw were extracted, but with no apparent benefit. Her dizziness was so severe that she was confined to bed and relief was obtained only when lying flat upon her back. She remained in the hospital about one month and then returned home, but in April, because of a severe en- dometritis the uterus was dilated and curetted, but the dizzi- ness persisted. There was partial suppression of urine for some weeks, but this gradually improved and culture of the urine showed streptococci and colon bacilli. The stomach was examined by the Rehfuss fractional method and colon bacilli with a very low hydrochloric acid content was found. Auto- genous vaccines were prepared and given but with no apparent results. In the fall of 1918 her tonsils were removed, and for two months following this operation there was an entire ces- sation of all dizziness and peculiar head sensations, but after that the dizziness returned. In the spring of 1920, radio- graphic studies of the gastro-intestinal tract revealed an enor- mously distended descending colon and an extensive resection or removal of the colon of the left side was done. She made a good surgical recovery and soon after this her headaches, dizzi- ness and vertigo disappeared and now for over a year there have been no symptoms and she is entirely normal in every way.
Types of Mental Disorders and Their Treatment 91
The Treatment of Toxic Psychoses Detoxication of the Psychotic Patient
If, as has been intimated, mental disorders are the result of chronic infection, often augmented by mental factors, then our treatment should consist of eliminating as many of these fac- tors as may be possible. The patient's environment should be changed as soon as convenient and, by all means, long before pronounced disorders of conduct render confinement necessary. The best place for such treatment is in the psychopathic wards of general hospitals or well-equipped psychopathic hospitals.
In either case, there should be facilities for investigating ab- normal conditions which may exist anywhere in the individual. The patient should be subjected to a diagnostic investigation which would reveal any pathological condition, either in the brain or in any other organs of the body. In the early stages of any psychosis there is usually a distinct realization, on the part of the patient, that something is wrong with him, — he may have persistent headaches, peculiar sensations in the body or head, difficulty in thinking and of concentration, and in- ability properly to perform his duties. During this period, the patient will go willingly to a hospital, especially when as- sured that the mental difficulties may be the result of some physical disorder.
The practice of ordering patients, at this stage of the disease, to give up work, change their environment, or go to live on a farm, or travel extensively, is beneficial only in a very few in- stances. Prolonged rest in bed as in tuberculosis must be in- sisted upon. It is a weak evasion of our duty not to hunt for the cause. The mental condition often becomes worse through the loss of valuable time and a lack of recognition of the funda- mental causes indicated in these lectures. It is true that a cer- tain number of patients will spontaneously recover, and, tem- porarily, at least, develop sufficient immunity to control their infection, but in the majority of cases when the patient resumes life's burden, the trouble is apt to recur, and usually, the prob- lem of relief becomes more difficult with each succeeding attack.
This is especially true in young adults where the first symp-
92 The Defective Delinquent and Insane
toms are misinterpreted both by the family and the physician, being ascribed to "pecuHarities" of the individual. A distinct change in the disposition, — a tendency of the person to become irritable, morose, and seclusive, — should be sufficient evidence for a thorough physical investigation of that individual, and as a result, in many cases, the cause can be found and removed and a serious mental breakdown later on averted. These types, with an insidious onset, extending over years and pro- gressing slowly, are the very ones that tend to become chronic and in which often, when treatment is at last started, the dam- age is so far advanced that all effort is unavailing.
In other types, especially those with maniacal excitement, the attacks come on very suddenly, often the case in psychoses following childbirth, and it is necessary to confine the patient in a hospital at once. This type furnishes a large number of spontaneous recoveries, but unfortunately, many of them re- cur later on. The fact that they recover spontaneously does not invalidate the theory that infection may be the cause of the trouble, as explained elsewhere.
It is possible, as has been stated, for the patient to develop immunity to the infection and so spontaneously to recover, but any unusual condition, whether mental or physical, may break down the immunity with resulting recurrence of the mental trouble. Even some of the cases with very acute onset do not recover spontaneously and if untreated physically the patients remain permanently in the hospital. In reviewing over six hundred of these cases, it was found that only 84% of the pa- tients presenting symptoms of acute mental disorders, usually considered recoverable (manic-depressive insanity), recover spontaneously from these attacks and that recurrence is fre- quent. If thoroughly detoxicated, however, in the early stages of the disorder, practically all of this entire group will be ar- rested, recurrences being extremely rare. When this occurs it has been found that the work of detoxication has been incom- plete, and further examination will reveal the fact that there are foci of infection remaining. If the treatment is not in- stituted early, the symptoms having lasted two years or over, in the average case we have found that no matter how thorough
Types of Mental Disorders and Their Treatment 93
the detoxication, whether in the acute psychoses (manic-de- pressive insanity) or the chronic types (dementia praecox) lit- tle result can be expected from such treatment. This is exactly analogous to the situation in other fields of medicine, i.e., ar- thritis, cardiac lesions, etc., where the tissue changes have gone beyond the point of repair.
The essential point, which we wish to emphasize, is that pa- tients should be placed under physical treatment as soon as any unusual symptoms appear — no matter how trivial they seem to the parents or relatives — and the only place where such treatment can be given successfully is in a well equipped hospital.
Methods Used in Making a Diagnostic Survey
As we are dealing, to a large extent, with hidden infections of which the patient does not complain, it is evident that the ordinary casual physical examination will fail to reveal these foci. Our failures in the past to recognize these hidden infec- tions have been responsible for the unsuccessful attempts to benefit the patient who did not recover spontaneously, and to prevent recurrences. From our knowledge gained in the last three years and the results obtained from applying this knowl- edge, we should be culpable if we failed to search for every hidden focus of infection and to adopt measures to eradicate it.
Every patient should have the teeth radiographed as soon as possible after admission and a thorough inspection should be made by a competent dentist in conjunction with X-ray findings. As soon as possible all infected teeth should be re- moved. Mere extraction alone, especially if there is extensive involvement of the alveolar process, will not, in itself, eradicate the infection. A thorough curettment of the socket should be done in every case and even then all necrotic bone cannot be removed. The safest method to use is what is known as the Novisky method of surgical removal.
By this method, the tooth and its cavity, are opened for in- spection and the infected area then becomes visible. In the old method of extraction it was necessary to work in the dark and many abscesses and other areas of infection were left. In
94 The Defective Delinquent and Insane
some of our patients, where the teeth had been extracted some time before and we had been confident that all infection had been removed, when radiographed again, we have been sur- prised to find evidences of necrotic areas. When these regions were opened up and the infection removed, the patient im- proved immediately.
The necessity for a thorough elimination of the dental in- fection is self-evident. If this is not done, physicians will have the unfortunate experience, — as we have had in some cases, — of a return of the mental symptoms because some infection was overlooked. One case in particular illustrates the necessity for a thorough and complete removal of all dental infection. A young married woman, age 34, suddenly developed a mani- acal attack eight months after influenza and was admitted to the State Hospital at Trenton, July 5, 1919. The infected teeth were extracted and infected tonsils removed, but with no relief of the mental symptoms. In October 1919 the infected colon was resected and the infected gall bladder removed. She rapidly recovered and was discharged December 7, 1919. She remained at home ten months when the mental symptoms recurred and she was readmitted to the hospital October 5, 1920. She had very vivid auditory hallucinations and was quite exhilarated. A thorough examination of the teeth re- vealed the fact that we had neglected to extract all those in- fected. When this was done her hallucinations disappeared in less than a week. Many patients have exhibited the same re- action.
In our experience we have found it necessary to remove all devitalized teeth whether the X-rays show infection or not. These dead teeth, if allowed to remain, are a menace to the patient's health and if not seriously infected at the time, the chances are that they will become so later on.
It is always necessary to radiograph the alveolar processes in patients who are toothless and are wearing full upper and lower plates. It is possible that a portion of the roots of some of these teeth may have been overlooked or that the necrotic area was so great that extracting the teeth did not remove all the infection. Both of these conditions would be revealed by
Types of Mental Disorders and Their Treatment 95
a radiogram. It is possible even for an elderly patient to have an impacted or unerupted molar, although all the other teeth have been extracted. This has occurred in three of our patients who were apparently toothless.
Tonsils
The tonsils are the next area in point of importance in the investigation. Inspection of the throat will frequently reveal enlarged and inflamed tonsils from which pus can be expressed on pressure. In many cases the infection is not evident from a casual examination but all throats showing purplish red pil- lars are suspicious. The tonsils may be small and buried and it is only by getting back of them with an instrument that in- fection can be demonstrated. If in doubt, the crypts of the tonsils may be cultured and the presence or absence of strepto- cocci determined in this way. Occasionally the colon bacillus is unexpectedly met with. The highest authorities agree that infected tonsils should be removed, no matter what the age of the patient unless the physical condition is so very grave that any operation would be too great a shock.
The old idea, held by many physicians, that it was danger- ous to remove the tonsils in an adult, has been found to be un- justified and a serious error. Barring extraordinary condi- tions infected tonsils should be removed. Such conditions oc- cur verj^ infrequently.
Some of our most successful cases occurred in adults who had failed to respond to other methods but who finally re- covered after the removal of the tonsils. In about 85 per cent of toxic psychoses we have found the tonsils infected and often they have been considered normal on the first examination. When, however, the patient failed to recover, the opinion had to be reversed, and after tonsillectomy the patient recovered.
It is extremely easy to overlook an infected tonsil, especially when small and buried. Such tonsils often appear normal on the outside, even after removal, but they have been found to contain a hidden abscess. Frequent attacks of tonsillitis or quinsy sore throat invariably leave behind a permanent infec- tion which cannot be removed except by operation. In many
96 The Defective Delinquent and Insane
cases, however, there is an absence of history of any previous tonsiUitis, although the tonsils may be infected and producing serious systemic conditions. In case of doubt, cultures, made from the crypts, may be necessary to reach a final decision. (See Fig. 12.)
Gastro-Intestinal Tract
The stomach contents should be examined in every case by means of the Rehfuss fractional method. This test is as fol- lows : Fifteen minutes after a test meal of two pieces of toast and a cup of unsweetened tea, the Rehfuss duodenal tube is swallowed and by means of a syringe attached to the tube some of the contents is withdrawn every fifteen minutes. Part of this is used for chemical analysis and another part put in cul- ture tubes of boullion to determine the bacterial content.
In the severely affected stomachs there will be found an absence of hydrochloric acid, which condition is alwaj^s associ- ated with the presence of bacteria of the streptococcus and colon bacillus groups, either alone or in combination. In many patients, accompanying these severe disturbances of the stom- ach, as revealed by the examination of its contents, there may be an absence of subjective symptoms; in others severe indi- gestion, extending over a long period of time.
These conditions have been successfully treated by Rehfuss and other gastro-enterologists, as well as by ourselves, by auto- genous vaccines made from the bacteria found. In practically all of the cases, after thorough treatment by the vaccines, a re- examination will show a normal hydrochloric acid content, and cultures of the stomach contents will be sterile. If all infec- tion in the mouth has not been thoroughly eradicated there may be a return of the gastric disorder and with it the mental symp- toms are apt to recur.
In a certain proportion of cases, the duodenum, the next link in the chain of gastro-intestinal infection, is also infected.
In some cases the stomach may be normal and the infection entirely in the duodenum but, as a rule, both are involved. Only occasionally do we find the presence of duodenal ulcers in our cases. The lesion seems to be limited to chronic diffuse
Types of Mental Disorders and Their Treatment 97
infection of the walls of the organ. We have found very lit- tle improvement from diet or medication in such cases as we have described. The autogenous vaccine seems to be the best method of restoring the stomach and duodenum to normal con- ditions. It is useless to try to improve the stomach unless the primary foci in teeth and tonsils have been eradicated.
In a considerable number of patients in whom, after the re- moval of all infection in teeth and tonsils, the symptoms still persist, improvement and recovery have followed only after ad- ministration of the autogenous vaccines obtained from cul- tures from the stomach. The question as to the relative ster- ility of normal stomachs is an academic one, but the presence of pathogenic colon bacilli and streptococci associated with ab- sence of hydrochloric acid certainly cannot be considered nor- mal. The fact that the acid returns to normal and the bacteria disappear after vaccine treatment is convincing evidence of the relation of the infection to the decrease of the acid.
It should not be implied that merely by clearing up the stomach conditions such good results are obtained in the pa- tients. In all probability the vaccine has a very potent effect on the whole system as well as upon the stomach and probably eliminates the infection wherever it may be. This is especially true in the cases where colon bacilli exist in combination with various types of streptococcus.
Infections of the Loiver Intestinal Tract
While a large percentage of our cases presented evidence of gastric infection, fortunately only a small proportion showed infection of the lower intestinal tract. In the latter condition, treatment is more difficult and complicated, and often surgical means are necessary to produce results. This is especially true of lesions in the colon. The diagnosis of this condition is made, first upon the history of habitual constipation, some- times alternating with diarrhoea and the passage of large quan- tities of mucous, usually extending over a long period of time and existing long before the development of mental symp- toms. Accompanying this constipation there are frequent
The Defective Delinquent and Insane
c D
Fig. 20. Radiographic studies of the gastro-intestinal tract in a case of demen- tia praecox of three years' duration.
A. Plate made 48 hours after barium meal. Retention of the bullc of meal in the ascending, and transverse colon. Appendix visualized.
B. Plate made 4 days after meal. Retention of meal in cecum, ascending and transverse and descending colon. Some of the meal is in the rectum.
C. Plate made immediately after barium enema, showing outline of colon, with pronounced ileo-cecal leakage. The enema has passed from the colon through the ileo-cecal valve into the small intestine; indicative of a pathological condition of the cecum.
D. Plate made 24 hours after barium enema, showing marked retention in cecum^ ascending and transverse colon.
Types of Mental Disorders and Their Treatment 99
"bilious attacks," with more or less abdominal pain often mis- construed as "indigestion." Any patient, with such a history, probably has had chronic appendicitis. Physical examination will, in most cases, reveal a tenderness on the right side and a certain amount of rigidity of the right abdominal muscles. Often the colon is filled and dilated, especially on the right side.
The third means of diagnosing this condition is by complete radiographic studies of the tract after a test meal of barium sulphate. Plates taken at twenty-four hour intervals will show pronounced delay in the movement of the test meal through the intestine and will usually indicate localized areas of delay. In most cases where there is marked localized delay, after 48 hours, evidence of intestinal lesion is shown at opera- tion. In some cases, such delay may persist for six and even nine days. Plates made after administration of barium enema also give valuable information. (See Fig. 20.)
From the diagnostic methods referred to above, it can be determined that there is abdominal disease, and that an ex- ploratory abdominal operation is justified. The detailed ex- tent and nature of the lesion cannot be determined except at operation. In some cases a chronic infection of the appendix is found to be the cause of the trouble, but in others the condi- tion is more extensive and the right side of the colon may be seriously involved. In these cases a partial resection of the colon is necessary, — a successful procedure, only, in the hands of a highly trained abdominal surgeon. (Figs. 21, 22.)
If the infection is limited to certain areas, segmental in char- acter, it may be possible to remove such infection by resection. Marked improvement in the mental symptoms has repeatedly been observed following such a procedure. If, however, the in- fection is very extensive, involving more of the bowel than is considered wise to remove, the disease must be attacked either by vaccine or serum. This is especially true when evidence of infection is found to extend throughout the whole length of the small intestine. In these cases the administration of specific anti-streptococcic and anti-colon bacillus serum, made from strains isolated in the laboratory of the State Hospital, has proven very successful.
100
The Defective Delinquent and Insane
Fig. 21. Megasigmoid ineusuring ;28 inches in length. and numerous enlarged mesenteric glands.
Note large stellate scar
Fig. 22. Dilated cecum, with constriction at hepatic flexure, indicated by finger. Dilated transverse colon, all in course of excision. Note great many enlarged glands in mesentery opposite to the constriction. Mesentery ready for ligation.
Types of Mental Disorders and Their Treatment 101
While the mortahty rate of operation for removal of a part of the colon is not high, — being slightly under 8 per cent — psychotic patients in whom the infection has been of long stand- ing and of great and specific virulence, are not good surgical risks and yield a higher mortality rate. This is, in part at least, due to the fact that the heart muscle has undergone seri- ous damage from the infection and that organ is unable to meet the slightly increased strain of post-operative conditions. Carefully administered gas-oxygen anaesthesia with a mini- mum of ether is a sine qua non in the successful conduct of these cases.^
A very common sequel of this work is the surgical relief of constipation. Many psychopathic patients in the State Hos- pital are thus proven, in reality, to have been chronic intestinal invalids in whom the psychic phenomena were purely secon- dary to an unrecognized, but nevertheless extensive, disease in a congenitally misshapen and deformed bowel. Indeed, it is not uncommon to observe restoration, by means of this new and daring surgical departure, of the daily bowel function, iri patients, who, from earliest childhood, had been obliged to resort to the use of strong purges every night of their lives.
It must be clearly understood, however, that the improve- ment in this type of chronic intestinal invalid comes not prin- cipally from the relief of the constipation, valuable as this is, but primarily from the removal of the immense focus of infec- tion in the bowel structure itself. This explains the futility of treating these patients by cathartics or by rectal irrigations, as the trouble is not principally in the lumen or cavity of the bowel, but in the wall. We are indebted to Dr. John W. Draper for his interest and valuable investigations of infec- tions of the intestinal tract in the patients at the New Jersey