MENTAL DISEASES
BY
L. Van H. Gerdine and A. G. Hildreth.
INTRODUCTION
The subjects herewith presented, while including certain of the most important sections of mental disease, make no claim to completeness either in the subject matter presented or in the attempt to cover the entire field of the psychoses. They cover those portions, however, with which we have come in closest touch at the Still-Hildreth Sanatorium, and in which we have the most complete records. I have been aided in the compilation of the essential facts and statistics by the able staff of the institution and wish to acknowledge especially the valuable cooperation of Dr. C. M. VanDuzer in the Dementia Praecox group, Dr. H. P. Hoyle in the Manic Depressive group, Dr. B. L. Jemmette in the group entitled Delirium, Confusion and Stupor, Dr. J. C. Snyder in the Senile Dementia group and Dr. G. S. Elkins in the Involutional group. The opinions concerning each type held by Dr. A. G. Hildreth are appended under its appropriate heading. I wish to state emphatically that the sole treatment carried out in the Macon Institution is specific corrective work upon spinal lesions, and it is upon this treatment that the statistics are based which are to be found throughout the text. These records cover more than 700 cases, including complete histories of the patients with the physical and mental findings on examination; these represent, therefore, by far the largest body of statistics ever accumulated in the study of osteopathic results in mental disorders. While the results naturally vary in different types of mental disease the grand total shows that more than one-half of all patients admitted recovered. Details for each group will be mentioned under its appropriate heading. While adjuncts such as diet and hydrotherapy have been utilized; we certainly cannot attribute any curative value to their influence.
It should be further emphasized that in no case whatsoever has medicine been used as a curative agent. And the same may be said of surgery. It has indeed been conclusively proved even in the medical world that medicines and surgical procedures are absolutely ineffective; from the osteopathic viewpoint this of course is perfectly reasonable since the theory calls for definite lesions as causative factors and these lesions can hardly be reached other than by the osteopathic method of correction. The results obtained, therefore, could only be attributed to the genuine osteopathic principle enunciated by Dr. A. T. Still who kept in close touch with the work and gave it his approval up to the time of his death. He had always maintained that the osteopathic principle could accomplish remarkable results in this field and considering the previous inefficiency of any other method his confidence has been fully justified.
Dementia Praecox
This condition refers to mental disorders arising usually during the period of puberty or adolescence, therefore, between the ages of fourteen and twenty-five for the most part, although apparently similar cases may arise in later years. The term dementia refers to mental deterioration and enfeeblement, while “praecox” signifies adolescence, though some writers infer that the term praecox may be used to indicate the early or precocious development of the mental enfeeblement. Certain it is that in most cases deterioration, with its resulting symptoms of mental enfeeblement giving rise to the term dementia, usually occurs in time, though by no means always early. It is a chronic progressive disease which may terminate in a complete loss of mentality; in other cases it may become arrested in any stage and remain so permanently; in still others it may recover, though this is rare. By reason of the variability of the symptoms, three groups are generally recognized, first suggested by Kraepelin. Each is differentiated by more or less characteristic symptoms and referred to under the head of the Hebephrenic, Catatonic and Paranoid types, although all have certain symptoms in common and there are mixed types.
Etiology.—According to the authorities some form of hereditary factor can be found in some fifty per cent or more of all cases; this is supposed to create a predisposition, a natural weakness of the nervous system, which renders it unable to bear the ordinary storm and stress of life, so that the mechanism becomes according to the French expression, “wrecked upon the rock of puberty or adolescence;” in other words, a premature giving way of the nervous system, being inherently unable to stand the strain of life. Another suggestion is that it represents the outcome of abnormal types or reactions of the individual to the environment, with a failure of proper adjustment to surroundings and the formation consequently of mental problems which to the patient are incapable of solution. This may be called the psychological theory. The most commonly accepted idea, however, is the physical causation. According to this the disease results from auto-intoxication, the intoxicant arising from the disturbances of the glands with internal secretions, more particularly the sexual glands. This endocrine theory is supposed to be supported by the fact of the appearance of this disease most commonly at the time of puberty and shortly thereafter.
The osteopathic conception fits in very well with this latter view, inasmuch as the spinal lesions are quite capable of explaining not only a disturbance of innervation to the glands with the resultant interference in their normal secretion, but also could produce disorder of the circulation and nutrition to the brain.
Symptomatology.—Although each variety of Dementia Praecox has special symptoms characteristic of the type there are certain symptoms common to all forms, and these will be first considered. All the functions of the mind in the course of time tend to become disturbed and to be weakened, but in the earlier stages we find marked differences as regards the disturbance of different functions, thus memory and orientation in most cases seem good; on the contrary, attention and association of ideas somewhat poor. Emotional life is almost always markedly affected, even in the beginning. Very commonly at first there is depression to be followed later by expansive feelings and then by apathy in general. The will power is altered early and the conduct is apt to be peculiar. The judgment becomes impaired. All of these symptoms mentioned are deviations from the normal in the patient and therefore presuppose that the patient was formerly normal. This should sharply differentiate the praecox group from cases of defective development (imbecility or idiocy). In this latter group there is an arrest of development of the mind, whereas in praecox there is a loss in a developed intellect. We see a young patient, for example, who has lost interest in things about him, neglects his work at school or at home, remains alone for long periods of time and seems unwilling to mingle with other people. He gives the impression of one depressed and worried about something he is trying to solve, perhaps he mutters to himself or gives way to unprovoked laughter, he may refuse to eat, or to talk unless questioned and may even then not answer. When he does talk it will be discovered that he knows perfectly well where he is, and knows people around him and understands everything that is going on; his memory will be found good, he can usually recall past incidents and tell what he has been doing recently. As the condition progresses, however, while the patient may still for a long time retain fair orientation and memory for past events, his accumulation of recent ideas will be found poor, so that he will recall them with difficulty. We notice that it is difficult to get the patient’s attention and concentration seems to be impossible, he may answer a direct question, but immediately seems to be occupied with other thoughts and it takes some little effort to gain his attention again. If he continues to talk it is plain that the association of ideas is poor, giving rise to disconnected phrases which usually come forth sluggishly and without show of emotion. Dissociation of ideas occurs; that is, different ideas expressed may practically contradict themselves. For example, the patient may say he is a king and yet when asked to sweep the floor will do it perhaps without hesitation, not considering that is hardly the kind of work a king would do. The dissociation is also marked in the contradiction found between the content of the thought and its associated emotional idea, for example, the patient may speak of a near relative as dying recently, yet with no show of emotion, even with a meaningless laugh. This dissociation may ultimately result in complete incoherence, in which no sense can be found whatsoever in his speech. Emotional indifference is noticeable early and sluggishness of reactions to stimuli, even failure of such reactions; the patient will neglect himself, stay away from meals, express no desires and make no complaints. In the earlier stages, however, the patient who may have been for some little time apathetic, suddenly without apparent cause becomes angry, noisy, and possibly violent and destructive, again gradually relapsing into his quiet, apathetic state. The thought content is commonly associated with delusions, that is obviously false ideas, but which the patient is unable to perceive are false. Delusions of persecution are most common, the patient feeling in a dim way that everything is not right; and in attempting to explain to himself the reason, often attributes causes to people or forces outside of himself, and on account of the feeling of bodily discomfort, also by reason of the depression, he explains the external forces as unfriendly to himself. Hallucinations may be present and furnish the material around which the delusions form; on the other hand hallucinations may result from the delusions. By hallucination is meant a false sense perception, as the patient may state he sees someone before him who is not there, or that he hears voices from individuals who are not around him; he may also complain of receiving electrical shocks, or wireless messages, which he usually states come from his persecutors. Symptoms of this nature form a good example of the so-called split personality, or “schizophrenia,” wherein certain idea complexes are split off from the main personality and address themselves to the main portion, the patient attributing these noises (voices), sensations (visceral and tactile), tastes and smells to an objective rather than a subjective source and subsequently forming delusions. However, unless we are dealing with the paranoid form the delusions are fragmentary, transient and absurd.
Hebephrenia.—This is a progressing mental enfeeblement, terminating usually in deterioration, and without showing marked peculiarities in thought or action aside from the progressing deficiency. The patient appears in general inactive, lacking in energy and ambition, indifferent, depressed, incapable of much concentration and hence the efficiency becomes progressively impaired until he is unable to accomplish anything. From time to time there may be periods of confusion, depression, passivity, at other times periods of excitement.
Catatonia.—In this form the general symptoms are similar to those of the simple type above described with the addition of the special symptoms referred to as catatonic excitement and catatonic stupor. The excitement period is manifested by an unrest and monotonous activity, stereotyped actions and speech, the patient constantly repeating some act, such as moving the hand, foot or head over and over again in the same way, or repeating the same word or phrase indefinitely. This occurs apparently involuntarily, the actions being automatic in character. The patient who has been in a semistuporous state may pick up a glass or chair and without show of emotion break it against the wall. In catatonic stupor the patient may show in the lighter degrees a simple loss of interest and feeling with sluggish reaction to stimuli, or a profound inactivity and stupor in which state he cannot apparently be reached by any stimuli; nevertheless, he apparently retains consciousness. In this type we observe the interesting symptom of negativism in which the patient always does the opposite of what he is requested, or refuses outright to obey any command. There may be a refusal of food so that the patient has to be fed by a tube, mutism may be present, the patient may go for weeks or months without saying a word; stereotype of attitude results in cataleptic poses and rigidity, in which the patient may maintain any particular pose for a prolonged period of time, and if placed in some other attitude may similarly retain the new attitude for a long time. This constitutes the so-called wax like rigidity, the patient reminding one of a wax figure. Pathologic suggestibility occurs in which the patient imitates movements, or repeats words and phrases that are spoken or performed before him.
Paranoiac Form.—In this type delusions predominate and are characterized by variability, inconsistency, illogicality and transitoriness on the one hand, with many gradations to the opposite extreme where they become more or less fixed, and often dovetail into each other forming apparently a systematic whole. They tend to be usually of a persecutory and hypochondriacal character and in later stages when the mind is distinctly weakened are often of a grandiose type. Sometimes the patients have some kind of explanations for them and at other times none whatsoever, and they are often curiously dissociated from the emotional accompaniment. The patient may state there is poison in his food, in an indifferent tone of voice or even with a laugh; he may claim that his teeth are all set in wrong and offer no explanations to these obviously false ideas. The patient commonly thinks that somebody “has it in for him,” someone will do him mischief, will kill him, that people are talking about him and criticizing him, everything that he hears or reads he thinks has some bearing on himself, so-called “delusions of reference.” Hallucinations may be present, the patient hearing voices, or receiving impressions or ideas which he claims come from without. These external impressions he misinterprets as voices or forces which are accusing, threatening and slandering him. Later on, the patient tends to change from the depressed persecutory stage to an expansive one, when he claims he is some celebrated person, king or president, or pope. The impairment of the judgment is clearly demonstrated in these cases since the patient who may claim to be the king of England may beg the attendant to change his place at the table or for a postage stamp.
Pathologic Anatomy.—This is obscure. Since a certain proportion of cases recover, there can evidently be no degenerative changes at the outset, though some cases deteriorate fairly early, others only after several years. In some chronic cases there have been observed degenerative changes in the cortical cells.
Diagnosis.—First, the common age of onset during puberty and adolescence, fourteen to twenty-four in the vast majority of cases, this being the only common mental disease occurring during this age period. Second, the progressive character terminating in mental enfeeblement or deterioration, that is “dementia” proper. Third, the evidence of defect or deficiency symptoms indicating that the patient’s mind has altered in the sense of deterioration from its former normal condition, whereas, in imbeciles or idiots the mind has failed to develop in the first place. Fourth, in the earlier stages particularly the marked dissociation of the brain powers, some being well maintained as memory and orientation (that is knowledge of time and space), others being weakened, such as judgment, power of attention and the like. Fifth, the early appearance of the emotional defect, a remarkable indifference and apathy of the patient to people and surroundings, the patient being unsocial and taking no interest in anything. Sixth, all the peculiar motor reactions, which are mentioned above under the catatonic head, and which very rarely occur in any other mental disorder. Seventh, the delusional content nearly always refers to the patient’s exterior, forces outside of him, people or things which are exerting an unfavorable influence upon him, delusions of persecution and reference. The patient practically never accuses himself, as is the rule in cases of true melancholia, never blames himself, but always the other party or the other force outside of him. Eighth, the delusions of grandeur are usually indicative of a stage of deterioration.
Prognosis.—Some authorities are inclined to doubt if any case ever completely recovers, claiming that in apparent recovery it may have been a question of mistaken diagnosis, or that the recovery is more apparent than real, that the patient is not truly well, or will have a relapse, so that a permanent cure will be impossible. Other authorities admit the possibility of recovery though in a very small minority of cases. The statistics of the Still-Hildreth Sanatorium, covering more than two-hundred fifty cases show total recoveries of at least one-third. This includes all types and all stages of progress, many being advanced on entrance. Of the less advanced cases and those of not more than two or three years’ standing there have been some fifty per cent recovery. Many cases make improvement or become stationary in greatly improved condition, but are not included in the thirty per cent. Of the three types, the catatonic offers the best prognosis, the hebeprhenic the poorest, while the paranoiac occupies an intermediate position.
Treatment.—Of the etiologic factors above mentioned, that of auto-intoxication, resulting possibly from endocrine disturbances or other sources, is most generally accepted in the medical world and agrees excellently with the osteopathic point of view. Spinal lesions are regularly found more particularly in the dorsal region, which are quite capable of disturbing the innervation to the glands; therefore, their nutrition and activity. A correction of these before the disturbance has continued too long, and hence before deterioration has set in, should theoretically normalize the glandular condition and therefore prevent deterioration and enable the patient to recover. Such is the probable explanation of the results, and in many cases the recoveries were obtained in patients previously considered hopeless.
Remarks by Dr. Hildreth
In a great majority of the cases the cause lies in the interference between the fourth dorsal vertebra and the eighth, which analyzed means a disturbance of the great splanchnic nerves, through whose interference would be caused the toxic condition and even the sexual disturbance described in so many cases from standard authorities. The same lesion, if deep seated enough, could produce an interference with the vasomotors and reflexly interfere with the circulation to the brain. In many we also find a first, second or third cervical lesion. The effects of these lesions on the equilibrium of the circulation to the brain are easily traced through the superior cervical sympathetic ganglia. These lesions, namely, the mid-dorsal and upper cervical, especially when corrected in the earlier stages, have thus far proven to produce successful results. In a lesser number of cases we find the cause to be from the first to the fourth dorsal vertebræ; our reasoning here being that the interference or the physical disturbance must be so deep that it reaches and interferes with the deeper nerve currents, both downward and upward, thus disturbing the equilibrium of the circulation to the brain. We have found this class to be the hardest to respond to treatment; however, that may be due to the fact that the physical defects at that point are harder to correct. Osteopathic treatment applied to the lesions above described without question offers therapeutics of intrinsic value to this class of patients.
Delirium, Confusion and Stupor
This clinical group has become well established, not only in its recognition from the dominant symptoms as indicated above, but also from rather definite causes. The immediate cause seems to be an abnormal blood state, or so-called toxemia, which may result from infectious diseases, or states of exhaustion, or autointoxications, or foreign poisons; the poison acts as an irritant to the brain. In states of exhaustion so-called “fatigue bodies” are formed and are apparently toxic in character. The autointoxicants may have various sources, such as chronic kidney disease, or diabetes, and the like. The most important of the foreign poisons are alcohol and morphine. This morbid group is further characterized not only by a toxic cause and dominant symptom complex of delirium, or confusion, or stupor, but by a similar onset and course. The onset is usually acute and the course somewhat wave like, gradually reaching a climax and subsiding, or resulting in death or becoming chronic. To emphasize the clinical symptoms of confusion which is so important the term “acute confusional insanity” has often been used, or “amentia,” according to the common German terminology. Hallucinations also play a prominent part, particularly those of vision; hence, another common appellation, “acute hallucinatory confusion.” Heredity is mentioned at most as creating a predisposition, though often the personal and family histories show no such evidence whatsoever. Intellectually there is a definite lack of orientation, the patient is unable to identify himself or his surroundings in time and space. He cannot clearly understand what goes on around him, that is, consciousness is “clouded;” the clouding may be of such extreme degree the patient’s mind becomes blank, due to complete psychic inhibition. This is referred to as stupor. The emotional life plays a secondary role subordinate to the intellectual content. The patient may be greatly excited for example, resulting from a frightful hallucination. The hallucinations are mainly of the visual type and are almost always present. The patient lives in a perpetual state of sense deception as if he were constantly dreaming; the hallucinations for the most part are of distressing, disagreeable or even frightful character. These may give rise to delusions, which are manifold, often fantastic and usually transitory.
Physical changes are always found associated with the disturbed mental status. If it arises during the active stage of an infectious process there is of course the high temperature and all other physical signs of fever. In a certain number of cases with temperature no definite signs can be found indicative of any of the well known fevers, hence has been called by various names, such as “Bell’s Delirium,” “Acute Mania Gravis,” or “Acute Febrile Delirium.” This ordinarily runs an acute rapid course with very high temperature, very marked delirium, followed by stupor and usually death from exhaustion. Even though no temperature be present the physical condition reminds one very much of that found in fever diseases. There is the lost appetite, resulting emaciation and malnutrition, insomnia, exhaustion, etc.
Osteopathic Theory.—While it may be admitted that the various factors mentioned above may take part as exciting or predisposing causes, it is obvious that in numerous instances mental disorders do not arise whatsoever, even when the patient is subjected to these factors. There must necessarily be other elements essential to produce the psychosis. The osteopathic theory comes in at this point to fill in and complete the chain of causes and to initiate the onset by the introduction of the idea of nutritional and circulatory disturbances resulting from the spinal lesions.
The records of the Still-Hildreth Institution show 18 of the toxic type, in which the poison is derived from without, who were treated, with 17 recoveries. There were 25 cases connected with the infection and exhaustion group, with 20 recoveries.
Remarks by Dr. Hildreth
In this group we have to do with blood disorders, resulting from the infections, conditions producing exhaustion, and the various toxins, or poisons, whether originating within the body or derived from without. These disorders are largely functional in character, resulting from brain irritation due to the toxemia or disturbance to the centers of nutrition. The main object of the osteopathic treatment, therefore, is to aid elimination and regulate and build up the nutrition. In most of the patients the physical lesions are found in the mid-dorsal area, chiefly from the 4th to the 7th, and in the cervical region, the 1st to the 3d. In aiding the kidneys in elimination the 10th and 11th dorsal vertebræ must be looked after. These conditions commonly respond very rapidly to the treatment and represent one of our most successful groups so far as results are concerned.
Manic Depressive Psychoses
The psychoses which are brought together under this classification include mental disorders which at first glance would appear to be of very wide variation, namely, conditions of maniacal excitement and those of depression. Further consideration, however, reveals the very evident reasons why they should be united as sub groups under the one head. The fact that these two mental states of seemingly opposite characteristics often appear alternately in the same individual, that in certain cases of each type there is a wave like feature in the nature of the attack and the frequency with which they tend to recur, together with other points of similarity in respect to duration, prognosis, etc., tend to point to their very close relationship. Kraepelin was the first to draw attention to these facts and advocate the present convenient and widely accepted classification of these disorders.
The outstanding feature is the disturbed emotional state which dominates and overshadows all other symptoms and is fundamentally the same whether expressed through the excitement of mania or the depression of melancholia.
Etiology.—Heredity is considered an important factor. Various authorities claim to have demonstrated direct hereditary influences in as many as eighty per cent and more of cases. Individual predisposition resolves itself into a matter of constitution and temperament in which there seems to be a greater tendency among those who are subject to the emotional extremes.
Early adult life is by far its most frequent period of onset, though it may arise also somewhat later. In certain cases the beginning of the disorder dates from some psychic or emotional shock. Just what importance these factors have as causes is little known since other cases develop in which the constitutional element alone seems responsible and no immediate exciting cause can be demonstrated.
The osteopathic viewpoint emphasizes the all important influence of spinal lesions as exciting factors. In individuals who have a tendency to this reaction their presence disturbing the cerebral circulation and nutrition may act as the direct causative factor.
Manic Phase.—The manifestation of this condition is brought about by the release of the inhibiting influences which normally govern all psychic function. Various terms as hypomania, acute mania, delirious mania, etc., have been used to differentiate the different degrees in which the symptoms appear.
In the milder types we find the following symptoms present. There is a marked feeling of well being. The patient, having lost sight of his personal limitations, feels a consequent exalted opinion of himself. His conduct is often rather boisterous, he talks a great deal, often swearing and using obscene language. He is inconsiderate of others and tries to impose his will upon those about him. There goes with this a certain unstability of the emotional tone as manifested by the quickly changing feeling of good humor, irritability and anger. There is a rapid flow of ideas with a marked loss in the ability to concentrate and direct thought. The ideas which pass through the mind do not coordinate themselves toward a definite goal, but deviate from the course of consecutive thinking by any passing association. Again there is a restlessness and activity beyond all normal bounds. The individual feels strong physically and mentally. The appetite is unusually good and if activity is not too extreme there may be a gain in weight. The period of sleep is diminished and the feeling of fatigue is reduced.
In the more exaggerated cases the flight of ideas becomes more marked, the associations are more rapid and superficial and the attention is focused but momentarily. Illusions and delusions may be present due to the imperfect preceptions from inability to concentrate attention and from abnormal associations. Rhyming speech, disconnection of phrases and even apparent incoherence are often present. The state of mind may be such that the patient tears his clothing, breaks up furniture, jumps, dances and shouts and often will not take time to eat. The most extreme cases which refuse food over some period of time progress rapidly to exhaustion and measures to conserve strength become imperative.
Depressive Phase.—In this phase of the disorder are encountered manifestations which are in direct contrast to those presented in the manic phase. In place of the exalted emotional state there is a depression. There is a tendency to worry over trivial matters of the daily routine and of instances in past life. Introspection is the predominant mental attitude and the whole outer world is colored by the inner feeling of worry and uncertainty. Replacing the rapidity of thought in the manic phase there is a distinct slowing of mental processes in the depressive phase. Thinking is more difficult and labored, questions are answered slowly and with an apparent effort and there is usually a tendency to avoid social life.
Again replacing the excessive activity in mania the depressions show a retarded action. There is disinclination or disability toward any effort either motor or mental. The patient feels weak and incapable of effort, the body assumes a bent attitude and the facial expression is one of despondency. The appetite is usually impaired with resultant loss of weight, the bowels are sluggish, the period of sleep reduced.
In the more exaggerated cases the retardation may be complete. Introspection is carried to the degree where the patient tries to take unto himself the responsibility for all the sin in the world. He himself is the arch sinner and he feels himself the subject of punishment by divine wrath in a manner in which no other individual was ever punished. Also the introspection tends to produce various hypochondriacal ideas. The patient may feel that he has contracted some incurable disease and that certain bodily functions have ceased operating.
Mental processes become not only retarded and difficult, but actually painful, a symptom which has been termed psychalgia. Suicidal tendencies are also quite frequently present.
In extreme conditions the patient may become so retarded in thought and activity that he apparently receives no stimulus from the outer world. He lives in a more or less stuporous state, even requiring that food be administered by tube.
Circular Insanity and Mixed Forms.—In addition to the conditions in which simply mania or melancholia are manifest there are certain cases which show variations and combinations of these forms. A common type is that in which there is an alternation of the manic and depressed conditions. The patient may pass directly from one state into the other, or there may be an intervening period of lucidity. The term circular insanity has been applied to this type. Other variations are those in which there are recurrences of the manic or depressive attacks often at more or less regular intervals, each recurrence being a practical repetition of the preceding.
There is also possible a considerable intermingling of the characteristics of the two types. In the manias may occur difficulty of thinking, passing feelings of depression and even almost stuporous conditions. In depressions there can exist a marked degree of restlessness and activity and a rapidity in the flow of ideas.
Prognosis.—The outlook for recovery from the individual attack is good. The attack may last from a period of days to one of a number of months and recovery comes with rarely any evidence of mental deterioration. There is a tendency to recurrence of the trouble. In fact recurrence is the rule rather than the exception. In the osteopathic handling of these cases it has been the endeavor to demonstrate that the correction of lesions had a tendency to lessen the duration of the individual attack and reduce the tendency to recurrence. Judging from the experience thus far gained in the observation of cases under treatment during the attack and the comparative few recurrences reported both of these aims have been attained.
Treatment.—The osteopathic measures are aimed at the correction of the spinal lesions, especially those located in the upper dorsal and the cervical regions. Some reflex effects from lesions in more remote areas may have their influence so that it is wise to look to the correction of any other structural variations when present.
Remarks by Dr. Hildreth
The mental disorders of this type are purely functional and may cover a broad scope as to causes; however, from the osteopathic viewpoint a great majority of them seem to have as their specific exciting cause, lesions in the upper dorsal and upper cervical regions. The treatment should be applied specifically to the cause which may range anywhere from the 1st to the 8th dorsal, or from the 1st to the 3d cervical, covering the nutritional and circulatory centers and thus controlling the nutrition and circulation to the brain. There can be no question but what the osteopathic theory of adjustment of physical defects forms the basis of permanent cure, since many of our recoveries had been previously under other methods of treatment without results. Our records cover over 200 cases with recovery in more than two-thirds, and very few recurrences up to the present.
Involutional Psychosis
In the mid years of life, between forty and sixty, a decline begins, which in the older years results in decay; it is especially true at this period of the sexual life and the organs underlying it. While these organs undergo a very definite change constituting the so-called climacteric period in women, it is not at first sight so evident in men; however, the evidence is that a somewhat similar process, though much slower, tends to occur in the male. Associated with the decay of the sexual organs is a disturbance presumably of the internal secretions; if this latter disturbance takes place slowly and evenly the body may not notice any marked changes; on the other hand, if it takes place more quickly, or unevenly, it may give rise to distinct symptoms which indicate a disturbance of the nervous system in general and often even of the mentality. Hence, the significance of the term, Involutional Psychosis. In a large majority of cases the mental disorder is marked by the dominance of depression and is frequently referred to as melancholia. For a long time it was considered that this represented a special mental disorder having little or nothing in common with other psychoses. In recent times Dumas has studied this group very carefully and shown that it in reality has very much in common with the depressed phases of the Manic Depressive Group of psychoses. Kraepelin himself, who was the first to demonstrate the unity of the Manic Depressive Group, has accepted the conclusions of Dumas and incorporated the Involutional Depressions as a sub type of his Manic Depressive Psychosis. Among etiologic factors have been mentioned hereditary elements, which have been claimed to have been found in at least fifty per cent of all cases, forming presumably a predisposition; it is also stated that a predisposition may be acquired through various debilitating causes. Exciting factors are claimed to be present, such as mental shock, grief, worry and the like. The disease would then seem to occur when we have a combination of exciting factors and predisposition. Careful consideration will show, however, that no such mental disturbance occurs at this age in many people who show evidences of such predisposition and of exciting factors, therefore it would seem that still other causes were necessary; if we consider the suggestion above mentioned that there are atrophic processes taking place in the sexual glands leading to a loss of the internal secretions and if we further consider that this may take place unevenly and in an unbalanced way, thus aiding in giving rise to the symptoms, we will find a definite point of contact for the osteopathic conception. Osteopathically considered, we may say that the spinal lesions lead to a disturbance of innervation and nutrition to the ductless glands, and therefore produce disordered secretions in those patients developing the disease, whereas such a condition may not be present in others who at the same age period do not develop the psychosis.
Symptomatology
The emotional tone of depression dominates the picture. Associated symptoms are anxiety, fears, particularly of impending danger, the loss of interest in the external world, with a concentration of attention upon self; psychic distress is usually present, often to an extreme degree, leading apparently to real mental pain, so-called psychalgia. Delusions are usually present and manifold in variety; they mainly refer to the patient himself and are of a self-accusatory nature; they frequently refer to notions of sins having been committed, also unworthiness of the patient, of poverty, nihilistic ideas, either about his own body or external things. He may claim for example that he has no stomach or kidney, or heart, that the external world is unreal and the like. His motor reactions become retarded, or even in the more extreme cases inhibited, producing a form of stupor. The inefficiency which results along with the psychic pain and distress may determine suicidal tendencies which are very frequent. Orientation is usually good, the patient remaining aware of his own identity and that of his surroundings; the judgment of course is impaired so that the patient is unable to appreciate the unreality of his delusions; as a result he sees no hope in the future and on account of present sufferings prefers death to life. The patient may remain in a perfectly passive mood, giving the appearance of extreme depression, paying no attention to the surroundings, possibly mute, giving no regard to the necessity of the toilet, paying no attention to his clothing and the like. This may continue for hours or days. Food often has to be forced on him, possibly even by the tube; the result is usually more or less emaciation and may result in marked malnutrition; similarly the sleep may be seriously interfered with, even though the patient is quiet. The resulting loss of sleep and malnutrition sometimes lead to the death of the patient. On the other hand, the patient may moan and wring his hands in anguish, walking up and down, crying out that he is a sinner and that he wants to die and the like. This is the so-called melancholia agitata.
The physical symptoms of importance are sleep disturbances, poor appetite, with emaciation, cyanosis, often a subnormal temperature, low blood pressure, slowed heart action and weakened circulation. The hair may become gray, the skin dry and harsh and indeed any of the signs of senile decay may appear.
Diagnosis and Prognosis.—These depend partly upon the mental symptoms, partly upon the physical. On the mental side is to be emphasized marked depression, with the relatively clear orientation, resembling the depressed phase of Manic Depressive insanity; also the dominance of the self-accusatory delusions. On the physical side the age period, and the evidence of previous attacks, even though very slight. The prognosis from the study of the mental symptoms depends on the presence or absence of signs of defect, or deterioration, as for example foolish and silly delusions. On the physical side the presence or absence of conditions like kidney or arterial disease; in general, it may be said if the physical findings are negative and the mental symptoms show no deterioration there should be a good outlook, particularly if the condition has not become too chronic.
A favorable outlook is always possible if the disease is treated early and the lesions disturbing the activities of the glands and of nutrition and the circulation are corrected and if the other physical findings are negative and signs of deterioration absent.
Since this is probably only a sub-group of the Manic Depressive Psychoses, as has been mentioned above, the results obtained under osteopathic treatment are noted under the Manic Depressive group.
Remarks by Dr. Hildreth
Our experience with this class of cases invariably lead us to the nerve centers which regulate and control the process of nutrition and circulation; it is a matter of keeping up normal equilibrium of all organic life and especially the circulation to the brain. The basis of the treatment therefore is to be found in the nutritive centers, as well as those centers which control the circulation to the brain, the ductless glands, etc.
Senile Dementia
Senile Dementia may be defined as an abnormal weakening of the mind arising in old age. As the word dementia implies, the intellectual change is quantitative rather than qualitative, the prime characteristic of the disease being mental loss rather than mental perversion.
It is commonly stated that a most important cause of the disease is the general malnutrition incident to age. Since only a small proportion of the aged develop dementia, this is probably only a cooperating factor. Other causes mentioned are overwork, emotional strain, traumatisms, intoxications (especially alcoholism), cerebral arteriosclerosis and perhaps heredity.
Pathologic Anatomy.—The disease is organic, the brain exhibiting definite pathological tissue changes. There is an atrophy of many nerve cells and a proliferation of neuroglia fibers, so that the cerebrum becomes shrunken and hard, with thickened meninges and thinned cortex, and shows a loss of weight. The cerebral arteries may or may not exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant areas of softening. The cells show pigmentary degeneration and many of the association fibers have disappeared.
Onset.—The onset of this dementia is usually very gradual, the condition not being recognized until rather marked. It occurs mainly in the seventies and later and in the late sixties, being rare before sixty. It often follows financial reverses, emotional shock, or various diseases. The earliest symptoms are a change in the person’s disposition, slight disorders of memory, and trivial lapses of various sorts.
As the disease progresses the symptoms become more marked and fundamental, involving not only the intellectual but also the emotional and volitional phases of consciousness. Interest in the outside world begins to flag, attention to wander, perception to be incomplete and inaccurate, association of ideas to be slow, memory to weaken and judgment to be impaired. Memory of the most recent incidents is the first to be lost, of recent years next, and then of middle age so that the patient may not recognize his own children or know, for example, that his wife is dead; finally the memory even of youth is lost and the patient is to all intents and purposes a child, his condition being an exaggeration and aggravation of that commonly known as “second childhood.”
Several forms of Senile Dementia exist, of which the most common is probably the simple or non-delusional type. Other forms are fundamentally the same as the simple, but with certain superimposed symptoms. Fairly early in this type it becomes unsafe for the patient to continue in business. Due to impairment of memory and judgment he is apt to lose his property. Soon his work is poorly done or neglected entirely. He becomes garrulous and annoys his associates with tiresome repetitions of childish reminiscences, continually wandering from one subject to another. His speech becomes incoherent and his sentences fragmentary. He grows untidy and indifferent to the ordinary niceties and conventions of life. His appetite is either poor or voracious; in the latter case the weight may keep up fairly well. He may be either apathetic or turbulent. If the former, he seems stupid, indifferent, and sleepy. He is credulous, docile, and very suggestible. Patients of the turbulent type are restless and always moving about, either depressed or elated, giving unreasonable orders and then contradicting them. Sleeping poorly, they are apt to get up and wander about the house at night. In men, prostatic disease may cause a recrudescence of sexual feeling. Patients of either type eventually become filthy, soiling their clothing, etc. Even in well advanced cases, however, senile dements are often able to perform well certain habitual activities, such as signing their names, or playing certain games, such as checkers or dominoes.
Confusional Type.—Another form of Senile Dementia, which may in severe cases usher in the attack, but which usually, when present, is sequent to the simple form, of which it is a more severe grade, is the confusional. The additional symptoms of this type are probably due to defective elimination and the consequent toxicity. Usually unsystematized delusions, and sometimes hallucinations are present. Except for a possible occasional period of remission the confusion is continuous. It varies greatly in degree, now being mild and passive and again active, perhaps developing into delirium. Orientation as to both time and place may be lacking. Such patients may ask for dinner a few minutes after a meal, go to bed at noon, be unable to find their own room, or to recognize their own children. They are apt to be obstinate and peevish. Delusions vary in type but both these and the hallucinations are usually painful and, being referred to the patient’s associates, give rise to the thought that they are trying to kill or otherwise harm him.
Delusional Type.—A third type of Senile Dementia is the paranoid form. Dements of this type, owing to delusions of persecution and auditory hallucinations are sensitive and suspicious. Such cases may sometimes show good orientation, apparently unclouded minds, and little evidence of senility, requiring careful study to differentiate the condition from true paranoia. A patient may, on account of hallucinations of taste and smell, refuse food in the belief that it is poisoned. Members of his family who are devotedly caring for him are suspected of designs on his money, and this suspicious attitude frequently leads to unjust wills. The delusions and suspicions may be entirely concealed from the family. Wealthy paranoid elements are peculiarly apt to become the prey of scheming adventuresses, particularly in case of the above mentioned sexual recrudescence, and marry them. Opposition of the family is regarded as part of their general persecution or as due merely to their desire to get the estate. Some patients merely appear odd, suspicious, untidy, peevish, and childish. Some have expansive delusions and exhibit the euphoria so frequently found in syphilitic dements.
Senile Delirium.—A fourth type has been described by some psychiatrists under the title of senile delirium. This may appear as the initial form of the disease or as an acute attack in one of the above forms. It is characterized by great incoherence and restlessness, entire absence of orientation, and numerous rapidly changing delusions and hallucinations, the condition resembling delirium tremens. It is probably due to some somatic cause, such as nephritis, pneumonia, or cystitis, which is often fatal.
Complications may arise in Senile Dementia, such as apoplectic strokes, hemiplegia, epileptiform seizures and aphasias.
Prognosis.—It is evident from the pathology of the conditions that the prognosis is not at all good when the disease is well advanced. It is a chronic disease and usually progressive until death, which is due to one of the complications, malnutrition, or especially pneumonia. However, many cases have shown improvement, and in incipient stages recovery. A cure of advanced cases being impossible, the important consideration is prevention or arrest in its incipiency.
It is evident that this can be done only by preventing, or removing as far as possible, the predisposing causes. A glance at the list of these shows that much depends upon the cooperation of the patient by regulating his habits of life. Physical and mental overstrain must be avoided, deleterious habits, such as the use of intoxicants or narcotics given up. Much can be done by osteopathy to eliminate the effects of these upon the organism. Cardio-vascular and renal symptoms are very important and should be watched for in order that early treatment may check the process initiated. To this end the patient’s habits and diet must be regulated and treatment instituted to relieve toxicity and promote elimination. Lesions must be corrected, special attention being given to the lower dorsal that affect the kidneys, the upper dorsal that affect blood pressure, and both the upper cervical and upper dorsal that affect the blood supply and nutrition of the brain.
Arteriosclerotic Dementia.—This is a mental enfeeblement arising sometimes in the fourth, but chiefly in the fifth, decade of life, and associated with symptoms of arterial hardening.
The cause is arteriosclerosis, which may be secondary to some form of nephritis. The arterial hardening may be general or may be confined to the arteries of the cerebrum. It is likely that the arterioles supplying the cortical cells are especially involved in an atheromatous condition. The disease is organic, chronic and progressive. Hemorrhage, embolism, or thrombosis may occur, producing focal lesions and areas of softening, with hemiplegia, aphasia, etc.
The earliest symptoms may be headaches and dizziness. The blood pressure is usually found to be high but not invariably. An atheromatosis may be present in some one of the palpable peripheral arteries, such as the radials. Further symptoms on the physical side are quick fatigue, loss of energy, numbness and paresthesias of the extremities, and somnolence in the daytime or perhaps insomnia at night. Strokes may occur, usually slight and temporary, probably due to spasm in a degenerating artery or perhaps to serous effusion. Toxic symptoms appear, due to disorder in kidneys, liver, and other organs. Epileptiform seizures are possible. Mentally the patient shows impairment of memory, and perhaps some confusion and hallucinations. Rarely stupor occurs. He may be agitated and irritable or melancholy and depressed. Suspicious and persecutory ideas of the paranoid type may appear; also hypochondriacal ideas.
Osteopathic Theory.—In these psychoses of the older years of life the termination is usually dementia, which means mental enfeeblement, and which results from degenerative changes in the brain substance. As has been shown it is largely a nutritional question and the nutritional condition varies tremendously in different elderly people; it is well known that many old people preserve their brain powers fairly well to the end; on the other hand others fail relatively early, some even in the fifties; these cases of earlier failure are referred to as the “presenile type.” The osteopathic conception would be to find out the source productive of the nutritional disorder and correct it at the very outset, therefore making it quite possible to prevent the disease process from taking place. The prognosis then in the earlier stages is very good.
Remarks by Dr. Hildreth
While many cooperating factors may be found in the causation of the mental disorder of elderly people, our experience shows there is always very definite disturbance of nutrition and the nutritional centers. We find chief physical interference between the 3d and 8th dorsal vertebræ, most definite as a rule at the 4th, 5th and 6th, with the corresponding ribs on the right side. Contributing causes may be found in other areas, associated with the disturbances of the heart and circulation and of the kidney. In the cardio circulatory disorders we find abnormal spinal conditions in the upper dorsal region and especially the 5th rib on the left side. In the kidney disorders we find the lesions usually at the 10th, 11th and 12th dorsal. The above mentioned areas in general represent the centers of control of the splanchnic nerves and therefore the important processes of digestion, metabolism and assimilation. Specific treatment applied to these points is very helpful and results in marked improvement and indeed in relieving the patient’s symptoms completely when in the earlier stages of the disease.